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NTSB Annual Report to Congress 2024
Reproduced for study. Always verify against the official GACAR at gaca.gov.sa.
2024 Annual Report to Congress National Transportation Safety Board
National
Transportation
Safety Board
Annual Report to Congress2024
2024 Annual Report to Congress National Transportation Safety BoardOur Core Values
• Integrity
• Transparency
• Independence
• Excellence
On the Cover
The cargo vessel Dali, which struck
the Francis Scott Key Bridge in
Baltimore, Maryland, on March 26,
2024. The inset (below) shows an
NTSB investigator examining portions
of the collapsed bridge.Who We Are and What We Do
The National Transportation Safety Board (NTSB) is an independent
federal agency charged by Congress with investigating every civil aviation accident
in the United States and significant events in the other modes of transportation—
railroad, transit, highway, marine, pipeline, and commercial space. We determine
the probable causes of the accidents and events we investigate, and issue safety
recommendations aimed at preventing future occurrences.
In addition, we conduct transportation safety research studies and offer
information and other assistance to family members and survivors for each
accident or event we investigate.
We also serve as the appellate authority for enforcement actions involving
aviation and mariner certificates issued by the Federal Aviation Administration
(FAA) and US Coast Guard, and we adjudicate appeals of civil penalty actions
taken by the FAA.
Our Mission
Making transportation safer. We carry out our mission by—
• Maintaining our congressionally mandated independence.
• Conducting objective, thorough investigations and safety studies.
• Deciding fairly and objectively appeals of enforcement actions by the FAA and
US Coast Guard and certificate denials by the FAA.
• Advocating for implementation of safety recommendations.
• Assisting victims and survivors of transportation disasters and their families.
2024 Annual Report to Congress National Transportation Safety BoardChairwoman’s Message
The Honorable
Jennifer L. Homendy
I am honored to present the 2024 Annual Report to Congress for the NTSB.
In 2024, we continued our agency’s tradition as the world’s leading accident
investigation agency through relentless focus on our strategic goals: keeping
pace with emerging transportation technologies and systems, improving
processes and products, and optimizing organizational effectiveness and
efficiency to meet our mission.
In the past year, we:
• Adopted more than 1,200 investigative reports.
• Issued more than 130 new safety recommendations, including four urgent
safety recommendations.
• Initiated more than 190 safety actions to stakeholders and industry within
the transportation safety community.
• Continued accident investigations across all modes. Major milestones
include the following:
»Our August 2024 investigative hearing to find facts related to the ongoing
Alaska Airlines Flight 1282, inflight mid-exit door plug separation investigation.
»Our investigation of a fatal crash in Tishomingo, Oklahoma, between a teen
driver and a truck that claimed 6 lives. The crash highlighted the issues of
distracted and cannabis-impaired driving and the inexperience of young
drivers. This led to a safety alert as well as a public webinar on “Preventing
Drugged Driving Among Youth.” This investigation was completed in May 2024.
»Our final board meeting and two community meetings in East Palestine,
Ohio, for residents impacted by the February 3, 2023, train derailment and
hazardous material release. The community events provided the public an
opportunity to engage with the Board and staff and learn more about our
investigative process. This investigation was completed in June 2024.
»Our ongoing investigation into the Dali containership collision with the
Francis Scott Key Bridge in Baltimore, Maryland. We are working with
stakeholders to assess the need for improved pier protection and consider
lessons learned from past marine vessel strikes and bridge collapses.
• Launched or supported 18 international aviation investigations as the
US-accredited representative.
• Provided comments on seven international investigations where the
United States had significant involvement.• Established the Capital Planning and Investment Control (CPIC) Investment
Review Board to oversee and streamline IT spending, align technology
investments with agency priorities, and replace aging applications with scalable,
cost-effective solutions.
• Improved timely access to transportation safety information by launching
dashboards for pending publications on our website, automating notifications to
investigation parties and international representatives, and expanding tracking
and analysis of safety recommendation implementation.
• Implemented a risk-assessment tool that helps investigators identify hazards,
share mitigation strategies, and address equipment needs for all potentially
hazardous investigative activities.
• Launched new internal dashboards that display real-time data on staffing levels,
labor costs, and hiring progress, enabling supervisors to make more informed,
data-driven decisions about team structure and budget management.
• Developed a new “ Safety Issues ” section on ntsb.gov to highlight key safety
recommendations that require further action to improve transportation safety.
In previous reports, we highlighted the railroad and transit accident investigations
that we were unable to conduct due to our agency’s limited resources. These are
contained in Appendix D. I am grateful to Congress for the increased flexibility
provided by the 2024 reauthorization of the NTSB, contained in Title XII of the FAA
Reauthorization Act of 2024 (P.L. 118-63), which allows us to focus our resources on
investigating grade crossing and trespasser accidents and incidents that offer the
greatest safety benefits.
Thank you for your continued support of the NTSB. We hope this report provides a
clear and informative overview of our agency’s 2024 accomplishments, which would
not have been possible without the dedication and expertise of our highly skilled
workforce. Thanks to their hard work, the NTSB continues to be better positioned
than ever to continue making transportation safer for all.
Sincerely,
Jennifer L. Homendy
NTSB Chairwoman
2024 Annual Report to Congress National Transportation Safety BoardContents
Who We Are and What We Do .......................................... 2
Our Mission ......................................................... 2
Our Core Values ..................................................... 2
On the Cover ........................................................ 2
Chairwoman’s Message 3
Abbreviations, Acronyms, and Initialisms ................................ 5
Figures ............................................................ 5
Tables ............................................................. 6
About the NTSB 7
History ............................................................. 7
Role in Transportation Safety .......................................... 7
Strategic Goals and Objectives ......................................... 8
Organization and Program Structure .................................... 8
Office of Aviation Safety 12
Investigation Reports ................................................ 13
Ongoing Significant Aviation Investigations and Incidents ................. 17
Investigative Hearing ............................................... 18
International Investigations ........................................... 18
US Comments on Foreign Accident Reports ............................. 19
Safety Alerts ....................................................... 21
Safety Actions ..................................................... 21
Other Significant Achievements ....................................... 22
Office of Highway Safety 23
Investigation Reports ................................................ 24
Ongoing Significant Highway Accident Investigations ..................... 30
Safety Alert ........................................................ 31
Safety Actions ..................................................... 31
Other Significant Achievements ....................................... 32
Office of Marine Safety 33
Investigation Reports ................................................ 34
Ongoing Significant Marine Investigations .............................. 38
Investigative Hearings ............................................... 39
International Investigations ........................................... 39
Safety Alert ........................................................ 40
Safety Action ...................................................... 40
Other Significant Achievements ....................................... 40Office of Railroad, Pipeline and Hazardous Materials 41
Investigation Reports ................................................ 42
Ongoing Significant Railroad, Pipeline, or Hazardous Materials Investigations ..47
Safety Alert ........................................................ 48
Safety Actions ..................................................... 48
Other Significant Achievements ....................................... 49
Office of Research and Engineering 51
Safety Research Division ............................................. 52
Materials Laboratory Division ......................................... 52
Vehicle Recorder Division ............................................ 53
Vehicle Performance Division ......................................... 53
Program Area — Medical Investigations ................................ 53
Ongoing Safety Research Report ...................................... 54
Other Significant Achievements ....................................... 54
Office of Safety Recommendations and Communications 55
Safety Recommendations Division .................................... 55
Media Relations Division ............................................. 58
Government and Industry Affairs Division ............................... 59
Safety Advocacy Division ............................................ 59
Digital Services Division ............................................. 61
Office of Administrative Law Judges 62
Transportation Disaster Assistance Division 63
Appendices
A: Report of 2024 Recommendations Closed in an
Unacceptable Status to the US DOT and the US Coast Guard 65
B: NTSB Safety Recommendations Identified for
Classification Change 70
C: Outreach 73
D: Accident Investigations Not Completed 80
E: Accident Investigations Taking Longer than 12 Months 100
2024 Annual Report to Congress National Transportation Safety BoardAbbreviations, Acronyms, and Initialisms
ACs advisory circulars
AAL American Airlines
AAMVA American Association of Motor
Vehicle Administrators
AASHTO American Association of State
Highway and Transportation
Officials
AC advisory circular
AGL Aero Global Logistics
ARFF Aircraft Rescue and Firefighting
AUS Austin-Bergstrom International
Airport
CFR Code of Federal Regulations
CVR cockpit voice recorder
CVSA Commercial Vehicle Safety
Alliance
DAL Delta Air Lines
FAA Federal Aviation Administration
FedEx Federal Express
FHWA Federal Highway
Administration
FMCSA Federal Motor Carrier Safety
Administration
FRA Federal Railroad Administration
FTA Federal Transit Administration
GHSA Governors Highway Safety
Association
HAI Helicopter Association
International
HF SITOR high-frequency simplex
teletype over radio
HF VOBRA high-frequency voice broadcast
ICAO International Civil Aviation
Organization
IDSS Impact-Based Decision Support
Services
IMO International Maritime
Organization
ITA vessel registration code for
Italy MAIIF Marine Accident Investigators’
International Forum
MBTA Massachusetts Bay
Transportation Authority
MOA memorandum of agreement
mph miles per hour
NAVTEX navigational TELEX
NHTSA National Highway Traffic Safety
Administration
NS Norfolk Southern Railway
NTSB National Transportation Safety
Board
NWS National Weather Service
OMB Office of Management and
Budget
PAN vessel registration code for
Panama
PennDOT Pennsylvania Department of
Transportation
PHMSA Pipeline and Hazardous
Materials Safety Administration
POV privately owned vehicle
PTC positive train control
SEPTA Southeastern Pennsylvania
Transportation Authority
SGP vessel registration code for
Singapore
SMS safety management system
TAWS terrain awareness and warning
system
TRB Transportation Research Board
Triton Triton Logistics Incorporated
UP Union Pacific
US United States
U.S.C. United States Code
US DOT US Department of
Transportation
VCM vinyl chloride monomer
VDR voyage data recorderFigures
1. In 1966, President Lyndon Johnson
signed the Department of
Transportation Act that created the
NTSB. .......................... 7
2. NTSB Board members ............. 8
3. NTSB organization chart ........... 9
4. NTSB regions .................... 10
5. Boeing B-17G and Bell P-63F shown in
flight. ......................... 13
6. Aerial view of the B-17G and Bell P-63F
before the air show collision. ...... 13
7. Raytheon Aircraft Company Hawker
800XP airplane shown at the end of a
runway. ........................ 14
8. The cockpit and cabin wreckage of a
Bell Helicopter UH-1B, N98F. ...... 14
9. The accident scene and wreckage of a
Bell Helicopter UH-1B, N98F. ...... 15
10. Two of the accidents cited in the
special investigation report, Safety
and Industry Data Improvements for
Part 135 Operations. ............. 15
11. Exemplar aircraft involved in runway
incursion and overflight of Southwest
Airlines flight 708, and runway
position of flight 708 when crew
reported the incident. ........... 16
12. Satellite image of the taxiway J/
runway 4L intersection at John F.
Kennedy International Airport. .... 16
13. Final position of RED Air flight 203
following collapse of its landing
gear. ......................... 17
14. Investigative hearing on the Alaska
Airlines flight 1282 door plug
accident. ...................... 1815. Annotated diagram of box truck
centerline crossover collision with
bus. .......................... 24
16. Eastbound SR-37 showing area of
impact and roadway scar. ........ 25
17. Truck at rest off eastbound shoulder
of SR-37. ...................... 25
18. Postcrash view of the work zone
and the opening in the concrete
barriers. ....................... 25
19. Southbound lanes of Cotton Lane
Bridge, showing the final rest
positions of the pickup and some of
the involved bicycles. ............ 26
20. Postimpact paths of travel
of combination vehicle and
medium-size bus. ............... 26
21. Passenger car following a crash with
a truck-tractor. .................. 27
22. Graphical depiction of passenger
car speeds and movement in the
5 seconds before the crash, based
on event data recorder. .......... 27
23. View of the burned transit bus from
the left rear corner of the bus. .... 28
24. West-looking view of collapsed Fern
Hollow Bridge. ................. 28
25. The two vehicles postcrash at the
scene of the collision. ........... 29
26. Passenger vessel Spirit of Boston
after the fire. ................... 34
27. Cindy B and St. John underway after
contact with the Beaver Dock. .... 35
28. John 3:16 underway on an unknown
date before the contact. ......... 35
2024 Annual Report to Congress National Transportation Safety BoardFigures (continued)
29. Evacuation of passengers
from the Sandy Ground to the
Franklin Delano Roosevelt . ........ 36
30. Barges against the lower dam gates
receiving methanol through a cargo
transfer hose. .................. 36
31. Damage to starboard side of
Bow Triumph . ................... 36
32. Mark E Kuebler aground following the
collision. ...................... 37
33. Tanker Nisalah in 2018. .......... 37
34. Crude oil in the Pacific Ocean off the
California coast. ................ 37
35. Safer Seas Digest 2024 cover. ..... 40
36. Aerial view of the Union Pacific
Railroad train collision wreckage. ..42
37. Overview of the SEPTA trolley
derailment area. ................ 43
38. Resting place of a dump truck and
Norfolk Southern Railway train. .... 43
39. Burning tank cars at the Norfolk
Southern Railway train derailment. .44
40. Aerial view of accident scene after a
Union Pacific Railroad conductor was
killed during a shoving movement. .45
41. Gondola car and protruding angle iron
section immediately before impact. 45
42. Illustration of construction vehicles'
location following collision. . . . . . . . 46
43. Ilustrated Digest cover. ........... 50
44. Materials Laboratory Division staff
examine door plug hardware with
a 3-D laser scanner and a digital
microscope. .................... 5245. Animation created by Vehicle
Performance Division staff depicts
the sequence of events in a runway
incursion and overflight. .......... 53
46. Media Relations staff supported
media briefings involving the
midflight departure of a door plug
on a Boeing 737-9 MAX passenger
airplane. ....................... 59
47. Students signed a safe driver pledge
during the Interactive Traffic Safety
Lab.. . . . . . . . . . . . . . . . . . . . . . . . . . . 60
48. The Safety Issues page available at
ntsb.gov. ...................... 61
49. Office of Administrative Law Judges
staff presents to students at
George Mason University. ........ 62Tables
1. 2024 NTSB Safety Statistics
at a Glance ..................... 11
2. Office of Aviation Safety Statistics ..12
3. Ongoing Significant Aviation
Investigations .................. 17
4. Office of Highway Safety Statistics 23
5. Ongoing Highway Safety
Significant Investigations ........ 30
6. Office of Marine Safety
Statistics ..................... 33
7. Ongoing Significant Marine
Investigations ................. 38
8. Office of Railroad, Pipeline and
Hazardous Materials Safety
Statistics ...................... 41
9. Ongoing Significant Railroad,
Pipeline or Hazardous Materials
Investigations .................. 47
10. Office of Research and
Engineering Safety Statistics ...... 51
11. Office of Safety Recommendations
and Communications Safety
Statistics ..................... 55
12. Safety Recommendations Issued
to the US DOT, Modal Agencies,
and the US Coast Guard Closed and
in Open Unacceptable Response
Status in 2024 ................. 57
13. Open Safety Recommendations
Referenced in NTSB Responses
to Federal Register Notices from
Federal Agencies in 2024 ........ 58
14. NTSB Media Products ........... 59
15. Safety Advocacy Division
Social Media Followers,
Connections, and Subscribers .... 6016. Safety Advocacy Division
Products and Events ............ 60
17. Office of Administrative Law
Judges Safety Statistics .......... 62
18. Transportation Disaster Assistance
Division Safety Statistics ........ 63
19. Recommendations to the US DOT
and the US Coast Guard Classified
Closed—Unacceptable Action in
2024 ......................... 65
20. NTSB Safety Recommendations
Identified for Classification Change .70
21. Required Pipeline Accident
Investigations Not Completed .... 79
22. Required Railroad Accident
Investigations Not Completed .... 81
23. FRA Fatal Railroad Accidents ..... 81
24. FRA Nonfatal Railroad Accidents
with Damage Over Reporting Limit
(Freight) ...................... 82
25. FRA Nonfatal Railroad Accidents
with Damage Over Reporting Limit
(Passenger) ................... 93
26. FTA Transit Fatal Accidents
(Passenger, Customer, or
Employee) ..................... 95
27. FTA Transit Fatal Accidents
(Not a Passenger, Customer, or
Employee) .................... 96
28. FTA Transit Nonfatal Accidents
(Passenger Train) .............. 96
29. Ongoing Investigations That Have
Exceeded the Expected Time
Allotted for Completion .......... 99
2024 Annual Report to Congress National Transportation Safety BoardAbout the NTSB
History
The NTSB’s origins can be traced to the Air Commerce Act of 1926, in which
Congress charged the US Department of Commerce with investigating the causes
of aircraft accidents. That responsibility was transferred to the Civil Aeronautics
Board’s Bureau of Aviation Safety when it was created in 1940.
In 1967, Congress consolidated all US transportation agencies into a new Department
of Transportation (US DOT) and established the NTSB as an independent agency
within the US DOT. In creating the NTSB, Congress envisioned that a single
organization with a clearly defined mission could more effectively promote a higher
level of safety in the transportation system than the individual modal agencies could
working separately.
Figure 1.
In 1966, President Lyndon Johnson signed the US Department of
Transportation Act that created the NTSB. SOURCE: US DOT
Since 1967, the NTSB has investigated accidents, crashes, and other events in the
aviation, highway, marine, pipeline, and railroad transportation modes, as well as
those related to the transportation of hazardous materials. In 2022, the investigation
of accidents in commercial space transportation was added to our mission.In 1974, Congress reestablished the NTSB as a separate
entity outside the US DOT, reasoning that “no federal
agency can properly perform such [investigatory]
functions unless it is totally separate and independent
from any other…agency of the United States.”
Because the US DOT has broad operational and regulatory responsibilities that affect
the safety and efficiency of the transportation system, and transportation accidents
may suggest deficiencies in that system, the NTSB’s independence was deemed
necessary to provide objectivity in its investigations and recommendations.
Role in Transportation Safety
Since our inception in 1967, the NTSB has investigated more than 153,000 aviation
accidents and thousands of significant events in other modes of transportation—
railroad, transit, highway, marine, pipeline, hazardous materials, and commercial
space. On call 24 hours a day, 365 days a year, our investigators travel throughout the
country and to every corner of the world in response to transportation disasters.
The NTSB investigates accidents to determine their probable cause, examines safety
issues, and develop recommendations to prevent the occurrence of similar accidents
and events in the future. We have issued more than 15,500 safety recommendations
to more than 2,470 recipients in all transportation modes. The recommended action
has been implemented for 82 percent of the over 13,000 recommendations that have
been closed. The agency also develops safety research studies focused on broader
safety questions and topics, enabling us to better perform our mission.
Additionally, we serve as the appellate authority for enforcement actions involving
aviation and mariner certificates issued by the FAA and the US Coast Guard, and we
adjudicate appeals of civil penalty actions taken by the FAA.
2024 Annual Report to Congress National Transportation Safety BoardAbout the NTSB
Strategic Goals and Objectives
1. Ensure our preparedness
for investigations involving
emerging transportation
technologies and systems
Objective:
• Prepare the agency for new
transportation technologies and
systems
2. Improve processes and
products
Objectives:
• Improve enterprise data governance
• Enhance enterprise risk management
• Improve information technology
planning
• Improve the effectiveness of agency
processes and products
3. Optimize organizational
effectiveness and efficiency
Objectives:
• Strengthen human capital planning
• Engage, connect, and protect the
workforce
• Develop model supervisors and
leadersOrganization and Program Structure
The NTSB’s organizational structure is designed around sound business and management
principles.
The NTSB has five Board members, each nominated by the president and confirmed by the
Senate to serve 5-year terms. The president designates a Board member as chairman and
another as vice chairman for 3-year terms. The chairman requires separate Senate confirmation.
When there is no designated chairman, the vice chairman serves in an acting capacity.
Our current Board members are pictured below in figure 2. The position of vice chairman is
currently vacant.
Figure 2. NTSB Board members.
Honorable
Jennifer L. Homendy
Chairwoman
Honorable
Michael E. Graham
Board Member
Honorable
Thomas B. Chapman
Board Member
Honorable
J. Todd Inman
Board Member
2024 Annual Report to Congress National Transportation Safety BoardAbout the NTSB
Figure 3 shows our organizational
structure. For more information
about our offices and their
functions, please visit the
Organization page of our website.Figure 3. NTSB organization chart.
2024 Annual Report to Congress National Transportation Safety BoardAbout the NTSB
The NTSB is headquartered in
Washington, DC, where most of
our staff work, within the Eastern
Region. Others work remotely
throughout the country or are
assigned to one of the regional
offices in Anchorage, Alaska;
Federal Way, Washington; or
Aurora, Colorado.
The map in figure 4 depicts
the four NTSB regions. Figure 4. NTSB regions.
RIMANH
AK
HIWA
ORIDMT
WY
UTNV
CACO
AZNM
TXKS
OKND
SD
NEMN
IA
MOILWI
MI
INOH
KY
TN
MS AL
LA
FLSC
GANCVA
ARWVMDDENJNY
PACTVT ME
Alaska Region
Anchorage, Alaska
Alaska
HawaiiWestern Pacific Region
Federal Way, Washington
Arizona
California
Idaho
Montana
Nevada
New Mexico
Oregan
Utah
Washington
WyomingAmerican Samoa
Guam
Northern Mariana
IslandsCentral Region
Aurora, Colorado
Arkansas
Colorado
Indiana
Illinois
Iowa
Kansas
Louisiana
MichiganMinnesota
Missouri
Nebraska
North Dakota
Oklahoma
South Dakota
Texas
WisconsinEastern Region
Washington, DC
Alabama
Connecticut
Delaware
Florida
Georgia
Kentucky
Maine
Maryland
Massachusetts
North Carolina
New Hampshire
New Jersey
New YorkOhio
Pennsylvania
Rhode Island
South Carolina
Tennessee
Vermont
Virginia
Washington, DC
West Virginia
Puerto Rico
US Virgin Islands
2024 Annual Report to Congress National Transportation Safety BoardAbout the NTSB
Table 1 below provides a snapshot of the agency’s activities over the past year and highlights key office and division accomplishments across
the NTSB from January 1 through December 31, 2024.
1 In this report, each recommendation issued is reported as one recommendation, regardless of the number of recipients. Because some recommendations are issued to more than one recipient, however, recommendations
closed are reported by the number of recipients for whom a recommendation was closed during the year. Recommendations closed in an acceptable status include those classified Closed—Acceptable Action , Closed—
Acceptable Alternate Action , and Closed—Exceeds Recommended Action . Recommendations closed in an unacceptable status include those classified Closed—Unacceptable Action and Closed—Unacceptable Action/
No Response Received . Please note that recommendations closed in 2024 may have been issued in previous calendar years. If the Board determines that a recommended course of action requires immediate attention to
avoid imminent loss of life from a similar accident, the safety recommendation is designated “urgent.”
2 A safety action is a positive change within the transportation environment brought about by an NTSB investigation or study without our issuing a formal safety recommendation. Safety actions may be initiated either
because of an NTSB investigation or independent of one.
3 If the NTSB decides to launch a Board member with the investigation team to the accident site as the on-scene spokesperson, the Safety Research Division (of the Office of Research and Engineering) and the Safety
Recommendations Division (of the Office of Safety Recommendations and Communications) provide a 1- to 2-page summary of background information to support the investigation team during the initial stages of the
launch. These “rapid reports” typically include publicly available information related to relevant safety data and statistics on similar crashes and crash trends; a summary of relevant NTSB investigations, studies, or other
products; and a summary of relevant safety recommendations.
4 See Appendix C for additional details about NTSB outreach.
5 This is an approximate total and may not reflect the total number conducted.TABLE 1. 2024 NTSB Safety Statistics at a Glance
Safety Recommendations1
Issued ............................................................... 132
Closed in Acceptable Status .............................................. 79
Closed in Unacceptable Status ............................................ 20
Urgent Issued ........................................................... 4
Reports and Products
Board-Adopted Investigation Reports ...................................... 15
Delegated Investigation Reports ........................................ 1,212
Public Hearings, Meetings, Roundtables, and Webinars ........................ 91
Safety Alerts and Videos .................................................. 8
Safety Actions2 ........................................................ 193
Accident and Event Launches
Major Launches ................................................................ 12
Field or Limited Launches ...................................................... 584
International Accident Launches ................................................... 7
Family Assistance
Family Members and Victims Assisted .......................................... 3,517Research and Engineering/Laboratory
Safety Research Products Completed ............................................... 2
Safety Data Analyses Completed ................................................ 234
Readouts of Vehicle Recorders and Other Electronic Devices Completed ................ 476
Materials Laboratory Exam Reports Completed ..................................... 183
Vehicle Performance Reports and Animations Completed ............................. 60
Medical Investigation Reports Completed ......................................... 188
Rapid Reports Completed3 ........................................................ 8
Aviation Certificate Appeals
Total Cases Received .......................................................... 470
Total Cases Closed ........................................................... 293
Emergency Cases Received ..................................................... 111
Emergency Cases Closed ........................................................ 84
Hearings Scheduled ............................................................ 94
Hearings Held . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Outreach4
Publications .................................................................... 2
Testimony or Legislative Support to State Legislative Committees ...................... 23
Board Member External Outreach Presentations and Events5 .......................... 93
Outreach Presentations and Events ............................................... 375
2024 Annual Report to Congress National Transportation Safety BoardOffice of Aviation Safety
6 One recommendation was adopted in our December 28, 2023, Hiles, Wisconsin, investigation report, but was not
issued until January 2024.TABLE 2. Office of Aviation Safety Statistics
Recommendations Issued6 ................................ 37
Urgent Recommendations Issued ........................... 4
Recommendations Closed in an Acceptable Status ............ 22
Recommendations Closed in an Unacceptable Status .......... 10
Board-Adopted Investigation Reports ........................ 7
Delegated Investigation Reports ......................... 1,173
Investigative Hearing ..................................... 1
Safety Alerts ............................................ 5
Safety Actions ......................................... 178
Major Investigation Launches ............................... 5
Field Investigation Launches ............................. 522
International Accident Launches ............................ 7
Outreach .............................................. 45The mission of the Office of Aviation Safety
is to—
»Investigate all air carrier, commuter, and
air taxi accidents and certain serious
incidents; fatal and nonfatal general
aviation accidents and serious incidents;
uncrewed aircraft systems, advanced
air mobility, and public aircraft accidents
and serious incidents; and commercial
space launch/reentry accidents.
»Participate in the investigation of aircraft
accidents that occur in foreign countries
involving US carriers, US-manufactured or
-designed equipment, or US-registered
aircraft to fulfill US obligations under
International Civil Aviation Organization
(ICAO) agreements.
»Investigate safety issues that extend
beyond a single accident to examine
specific aviation safety problems from a
broader perspective.
The Office of Aviation Safety conducts
investigative activities through five specialty
divisions based in Washington, DC, and a
regional investigation management structure
consisting of four regions. Investigators are
located throughout the country. International
aviation activities are coordinated from the
Washington, DC office.
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardInvestigation Reports
7 All times stated are local time.During 2024, the Office of Aviation Safety issued or developed for adoption by the Board a total
of 1,180 investigation reports; 7 of these reports were adopted by the Board and involved
safety issues that led to the issuance of 36 safety recommendations, including 4 recommendations
that were designated urgent.
Below are summaries of some of the aviation investigation reports completed during this period.
In-Flight Collision During Air Show,
Commemorative Air Force Boeing B-17G,
and Bell P-63F
Dallas, Texas, November 12, 2022
On November 12, 2022, about 1:22 p.m. local time, a
Boeing B-17G and a Bell P-63F collided in flight during
a performance at the Commemorative Air Force’s
Wings Over Dallas air show at Dallas Executive Airport
in Dallas, Texas.7 The pilot, copilot, flight engineer,
and two scanners on board the Boeing B-17G and the
pilot of the Bell P-63F were fatally injured, and both
airplanes were destroyed. No injuries to people on the
ground were reported.
We determined that the probable cause of this
accident was the air boss’s and event organizer’s
lack of an adequate, prebriefed aircraft separation
plan for the air show performance, relying instead on
the air boss’s real-time deconfliction directives and
the see-and-avoid strategy for collision avoidance,
which allowed for the loss of separation between the Boeing B-17G and the Bell P-63F airplanes. Also
causal were the following:
• diminished ability of the accident pilots
to see and avoid the other aircraft due to
flight path geometry,
• out-the-window view obscuration by
aircraft structures,
• attention demands associated with the
air show performance, and
• inherent limitations of human performance
that can make it difficult to see another
aircraft.
Contributing to the accident were the lack of FAA
guidance for air bosses and event organizers on
developing plans and performing risk assessments
that ensure the separation of aircraft that are not
part of an approved maneuvers package, and the
lack of FAA requirements and guidance for recurrent
evaluations of air bosses and direct surveillance of
their performance.
Figure 5. Left to right: Boeing B-17G and Bell P-63F shown in flight. SOURCE: COMMEMORATIVE AIR FORCE
Figure 6.
Aerial view of the B-17G and Bell P-63F
before the air show collision.
SOURCE: DYLAN PHELPS, COMMEMORATIVE AIR FORCE
We identified the following safety issues during
this investigation:
(1) the air boss’s and event organizer’s lack of an
adequate, prebriefed aircraft separation plan for the
performance;
(2) the factors that limited the ability of the Boeing
B-17G pilot and the Bell P-63F pilot to see and avoid
each other’s aircraft;
(3) the lack of adequate guidance provided by the
FAA and the International Council of Air Shows to
better mitigate the collision risks associated with
air boss-directed performances involving multiple,
dissimilar aircraft;
(4) the need for administrative controls and
documented safety risk assessments; and
(5) the Commemorative Air Force’s lack of a strong,
clearly defined safety risk assessment plan, which
resulted in air show production decisions that were
not systematically developed to determine acceptable
levels of risk and were susceptible to influences
unrelated to safety.
As a result of this investigation, we issued safety
recommendations to the FAA, the International Council
of Air Shows, and the Commemorative Air Force.
»Recommendations: 7 new
»Report date: December 4, 2024
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardMitigate Safety Concerns Involving
Boeing 737 Airplanes with Collins Aerospace
SVO-730 Rudder Rollout Guidance Actuators
Newark, New Jersey, February 6, 2024
On February 6, 2024, about 3:55 p.m., the flight crew of
United Airlines flight 1539, a Boeing 737-8, experienced
a rudder pedal anomaly while landing at Newark
Liberty International Airport. The pilot and passengers
on board were not injured.
We identified the following safety issues during
this ongoing investigation:
(1) the potential for a jammed or restricted rudder
control system on affected Boeing 737 airplanes
due to incorrectly manufactured Collins Aerospace
SVO-730 rudder rollout guidance actuators that allow
moisture to enter and freeze;
(2) the potential for uninformed flight crews of
affected Boeing 737 airplanes to apply rudder pedal
force in an attempt to clear a jammed or restricted
rudder control system that results in a large, sudden,
and undesired input to the rudder and loss of airplane
control; and
(3) the need to determine and disseminate guidance
on appropriate flight crew responses if the affected
Collins actuators on certain Boeing 737 airplanes
become jammed or restricted in flight or during
landing.
As a result of this investigation, we issued urgent
safety recommendations to The Boeing Company and
the FAA.
»Recommendations: 4 new (urgent)
»Report Date: September 26, 2024Collision with Powerlines and Terrain During
Forced Landing, MARPAT Aviation, Bell
Helicopter UH-1B
Amherstdale, West Virginia, June 22, 2022
On June 22, 2022, about 4:45 p.m., a Bell Helicopter
UH-1B helicopter was destroyed when, about
15 minutes after the flight departed, the helicopter
impacted two powerlines and a rock face during
a forced landing in Amherstdale, West Virginia.
A postcrash fire ensued, and the pilot and five
passengers were fatally injured.
Figure 7.
The cockpit and cabin wreckage of a Bell
Helicopter UH-1B in Amherstdale, West Virginia.
We determined that the probable cause of this
accident was the operator’s failure to adequately
inspect the former military turbine-powered helicopter,
which allowed an engine issue to progress and result in
a loss of engine power and a subsequent loss of control
after the helicopter struck powerlines during forced
landing.
We identified the following safety issues during
this investigation:
(1) insufficient inspection requirements for the UH-1B
and other former military turbine-powered aircraft,
(2) inadequate operator maintenance of the accident
helicopter,
(3) inadequate management of the helicopter’s
experimental airworthiness certificate, (4) lack of FAA oversight of the accident helicopter’s
airworthiness certificate,
(5) lack of guidance for FAA inspectors to perform
routine surveillance of operators with experimental
exhibition airworthiness certificates, and
(6) the need for a method to ensure that operators
of experimental exhibition aircraft meet their annual
obligation to submit program letters to the appropriate
FAA flight standards district office.
As a result of this investigation, we issued
safety recommendations and reiterated a safety
recommendation to the FAA.
»Recommendations: 6 new, 1 reiterated
»Report Date: August 14, 2024
Figure 8.
The accident scene and wreckage of
a Bell Helicopter UH-1B, N98F, in Amherstdale,
West Virginia.
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardDefine the Meaning and Operational Use of
Instantaneous Wind Reports
Aspen, Colorado, February 21, 2022
On February 21, 2022, a Raytheon Aircraft Company
Hawker 800XP airplane overran the end of runway 33
after the flight crew aborted the takeoff in gusting
tailwind conditions at Aspen-Pitkin County Airport in
Aspen, Colorado. The pilot and passengers on board
were not injured.
Figure 9.
Raytheon Aircraft Company Hawker 800XP
airplane shown at the end of a runway at Aspen-Pitkin
County Airport.
SOURCE: ASPEN-PITKIN COUNTY AIRPORT OPERATIONS
We determined that the probable cause of the
accident was the flight crew’s decision to take off in
tailwind conditions that were consistently above the
airplane’s tailwind limitation, which resulted in a runway
overrun following an aborted takeoff. Contributing was
the flight crew’s use of the instantaneous wind report
for the decision to attempt the takeoff.
We identified the following safety issue during
this investigation: the lack of an official definition
for “instantaneous wind” and guidance on its use
during flight operations in potentially hazardous wind
conditions.
As a result of the investigation, we issued a safety
recommendation to the FAA.
»Recommendations: 1 new
»Report Date: August 20, 2024Safety and Industry Data Improvements
for Part 135 Operations
Special Investigation Report
Historically, accident rates for Title 14 Code of Federal
Regulations (CFR) Part 135 operations have remained
higher than those for Part 121 operations, which are
subjected to more stringent FAA requirements. In
December 2022, we initiated a special investigation
of 14 CFR Part 135 operations after our investigations
of several accidents in recent years highlighted
similar deficiencies, suggesting a need for a more
comprehensive review of the industry.
Completed in 2024, the special investigation
identified 116 fatal accidents and 460 nonfatal
accidents involving flights operated under Part 135 that
occurred from 2010 to 2022. We sought to identify any
trends or similarities in the types of deficiencies that
led to the accidents; evaluate the circumstances of
each accident in the context of applicable regulations
and potential mitigations that could prevent similar
accidents; and review accident and flight activity data
to determine whether those data could support an
assessment of any trends in the historic accident rates
for different industry segments based on certificate
type, operating authority, and scope.
We identified the following safety issues during
this special investigation:
(1) the need for certificated dispatchers for all Part
135 operators except single pilot and single-pilot-in-
command operators;
(2) the need for aircraft load manifest and
recordkeeping requirements to apply to all aircraft
operated under Part 135;
(3) the need for safety management system (SMS)
and flight data monitoring program requirements for all
Part 135 operators;
(4) the need for guidance to help small operators
scale an SMS, as appropriate for their operations;
(5) the need for accident and incident data
collection improvements related to Part 135 certificate information for operators involved in accidents or
incidents; and
(6) the need for accurate flight activity data for the
various segments of Part 135 operations.
As a result of this special investigation, we issued
and reiterated safety recommendations to the
FAA. We also classified previously issued safety
recommendations to the FAA.
»Recommendations: 3 new, 2 reiterated, and
1 classified in this report
»Report Date: July 24, 2024
Figure 10.
Two of the accidents cited in the special
investigation report, Safety and Industry Data
Improvements for Part 135 Operations .
From top: AS350-B3 helicopter crash in Palmer,
Alaska, and Mitsubishi MU2B airplane crash in
Sioux Falls, South Dakota.
SOURCES (FROM TOP): ALASKA STATE TROOPERS, FAA
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardRunway Incursion and Overflight, Southwest
Airlines Flight 708, Boeing 737-700, and
Federal Express Flight 1432, Boeing 767-300
Austin, Texas, February 4, 2023
On February 4, 2023, about 6:40 a.m., Southwest
Airlines flight 708, a Boeing 737-700, and Federal
Express (FedEx) flight 1432, a Boeing 767-300, were
involved in a runway incursion at Austin-Bergstrom
International Airport (AUS), Austin, Texas. The
128 occupants aboard the Southwest airplane and
the 3 occupants aboard the FedEx airplane were not
injured, and neither airplane sustained damage.
Figure 11.
Top: The FedEx 767 is shown during a
takeoff, and a Southwest 737 is pictured in flight
(both not the incident flight). Bottom: Diagram
showing the position of Southwest Airlines flight 708
when the flight crew reported that the airplane was
short of runway 18L. SOURCES: JETPHOTOS.COM (TOP);
GOOGLE EARTH (BOTTOM), ANNOTATED BY NTSB
We determined that the probable cause of this
incident was the local controller’s incorrect assumption
that the Southwest airplane would depart from the
runway before the FedEx airplane arrived on the same
runway, which resulted in a loss of separation between
both airplanes. Contributing to the controller’s incorrect
assumption were his expectation bias regarding the SWA airplane’s departure, his lack of situational
awareness regarding the SWA airplane’s position when
the flight crew requested takeoff clearance, and the
air traffic control tower’s lack of training (before the
incident) on low-visibility operations. Contributing
to the incident was the SWA flight crewmembers’
failure to account for the traffic that was on short final
approach and to notify the controller that they would
need additional time on the runway before the takeoff
roll. Also contributing to the incident was the Federal
Aviation Administration’s failure to require surface
detection equipment at Austin-Bergstrom International
Airport and direct alerting for flight crews.
We identified the following safety issues during
this investigation:
(1) the lack of surface detection equipment at AUS to
alert controllers about potential conflicts on a taxiway
or runway surface;
(2) the need for flight deck technology to alert flight
crews about potential conflicts on an airport surface;
(3) the need to ensure, especially during low-visibility
conditions, that controllers are aware when pilots, after
receiving takeoff clearance, might need extra time on
the runway;
(4) the lack of training on the AUS airport’s Surface
Movement Guidance and Control System plan;
(5) the need for low-visibility operations training at
all airports; and
(6) the need for 25-hour cockpit voice recorders
(CVRs).
As a result of this investigation, we issued and
reiterated safety recommendations to the FAA.
»Recommendations: 7 new, 5 reiterated
»Report Date: June 6, 2024Runway Incursion and Rejected Takeoff
American Airlines Flight 106, Boeing 777-200
and Delta Air Lines Flight 1943, Boeing 737-900
Queens, New York, January 13, 2023
On January 13, 2023, about 8:44 p.m., American
Airlines (AAL) flight 106, a Boeing 777-223, crossed
runway 4L on taxiway J without air traffic control
clearance at John F. Kennedy International Airport,
Queens, New York, causing Delta Air Lines (DAL)
flight 1943, a Boeing 737 900ER, to abort its takeoff roll
on runway 4L. None of the 6 crew and 153 passengers
on DAL1943, nor the 12 crew and 137 passengers on
AAL106, was injured, and there was no damage to
either aircraft.
Figure 12.
Satellite image of the taxiway J/runway 4L
intersection at John F. Kennedy International Airport
indicating runway lights and markings.
SOURCE: GOOGLE EARTH, ANNOTATED BY NTSB
We determined that the probable cause of the
incident was the AAL106 flight crew’s surface
navigation error due to distractions caused by their
performance of concurrent operational tasks during
taxi, which resulted in a loss of situational awareness.
We identified the following safety issues during
this incident investigation:
(1) the need for additional risk mitigation strategies
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety Boardto prevent flight crew surface navigation errors that
result in runway incursions;
(2) the need for a procedural crosscheck that
requires flight crews to verbalize the number of a
runway they are about to cross as indicated by runway
signs; and
(3) the lack of flight deck technology to detect
potential traffic conflicts.
Because the incident data on the 2-hour CVRs on
both airplanes were overwritten, we also reiterated the
need for CVRs with a 25-hour recording capability.
As a result of this investigation, we issued
safety recommendations and reiterated a safety
recommendation to the FAA.
»Recommendations: 8 new, 1 reiterated
»Report Date: May 29, 2024
Landing Gear Collapse RED Air Flight 203
McDonnell Douglas MD-80
Miami, Florida, June 21, 2022
On June 21, 2022, about 5:38 p.m., RED Air flight 203,
a Boeing MD-82, overran the end of runway 9 at Miami
International Airport, Miami, Florida, after the left main
landing gear failed shortly after landing. Of the 140
occupants aboard the airplane, 4 passengers sustained
minor injuries.
Figure 13.
Final position of RED Air flight 203 following
collapse of its landing gear.
SOURCE: GOOGLE EARTH, ANNOTATED BY NTSBWe determined that the probable cause of the
accident was the structural failure of the left main
landing gear downlock following ineffective shimmy
dampening during the landing roll, which caused the
collapse of the left main landing gear, resulting in a
runway excursion and postflight fire.We identified the following safety issue during this
investigation: the failure of landing gear components.
»Recommendations: None
»Report Date: April 25, 2024
Ongoing Significant Aviation Investigations and Incidents
At the close of 2024, the Office of Aviation Safety had seven open investigations involving
significant safety issues. We are devoting significant resources to these investigations and
anticipate producing a report upon the completion of each one.
TABLE 3. Ongoing Significant Aviation Investigations
Location Event Date Description Fatalities2025
Report Date
Houston, Texas 10/20/2024Robinson R44 collision with
communication tower4
St. Mary’s, Alaska 9/15/2024Cessna 207 controlled flight into
terrain4
Halloran Springs, California 2/9/2024 Airbus EC130 helicopter crash 6 5/6/2025
Westwater, Utah 2/7/2024Hawker Beechcraft 900XP loss of
control in flight2
Newark, New Jersey 2/6/2024 Boeing 737-8 rudder system anomaly 0
Portland, Oregon 1/5/2024Boeing 737-9 door plug separation and
rapid decompression0 6/24/2025
Stagecoach, Nevada 2/24/2023 Loss of control during departure 5 6/4/2025
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety Board
Investigative Hearing
During 2024, the Office of Aviation Safety
held one investigative hearing;
a summary is provided below.8
Alaska Airlines Flight 1282
In-flight Mid Exit Door Plug Separation
August 6–7, 2024
The NTSB convened an investigative hearing in August
2024 to gather sworn testimony about the January 5,
2024, accident involving Alaska Airlines flight 1282.
The accident occurred when a left mid exit door plug
departed the airplane at an altitude of about 16,000 feet
shortly after departing Portland, Oregon, on a flight
destined for Ontario, California; following the loss of the
door plug, which led to a rapid decompression, the flight
crew returned to Portland, where the airplane landed
safely. During the hearing, we received information on
the B737-9 manufacturing and inspection processes,
including events related to the opening and closing
of the mid exit door plug. Key topics included
production practices, mechanic training and retention,
documentation of part removals and installations,
the lack of records regarding the mid exit door plug ʼs
handling, and post-accident process changes. We
will use the information gathered to complete the
investigation, determine probable cause, and make
recommendations to improve transportation safety.
Figure 14.
Investigative hearing to gather testimony on
the Alaska Airlines flight 1282 door plug departure.
8 Investigative hearings are public hearings related to investigations in
which the agency is authorized to obtain testimony under oath.International Investigations
The United States is a signatory to the Chicago Convention on International
Civil Aviation, which is administered by ICAO. The NTSB is charged with
fulfilling the US obligation for accident and incident investigations in accordance
with Annex 13 of this agreement in full coordination with the US Department of State.
The international investigative process is critical to maintaining aviation safety in the United States
and throughout the world. When an aircraft operated by—or designed, manufactured, or registered
to—a US company has been involved in an accident in a foreign state, NTSB participation in that
investigation enables the United States to ensure the airworthiness and operation of its aircraft
operated here and overseas. ICAO Annex 13 protocols also define the agency’s engagement
with international authorities whose products or operations are involved in accidents within the
United States. This international process of collaboration plays an important role in enabling us to
identify safety concerns and issue appropriate recommendations. We have issued numerous safety
recommendations that have resulted in safety improvements worldwide as a direct result of our
participation in these foreign investigations.
During 2024, the Office of Aviation Safety was notified of 448, and assisted with 50, international
investigations. Of these, investigators launched to or traveled in support of 18 investigations. The
following required significant US involvement.
Boeing 737 Crash Following Gear-Up Landing
Muan County, South Korea, December 29, 2024
On December 29, 2024, Jeju Air flight 2216, a
Boeing 737-800, landed well beyond the touchdown
zone on the arrival runway at Muan International
Airport, Muan County, South Korea, without the
landing gear having deployed. The airplane overran
the runway, impacted the approach lighting system
then an embankment, and a postimpact fire ensued.
All but 2 of the 181 occupants were fatally injured.
As the US-accredited representative of the state of
design and manufacture of the airframe and engines,
NTSB staff traveled to South Korea to assist the
Aviation and Railway Accident Investigation Board in its
investigation.Boeing 737 Crash During Approach and
Landing
Vilnius, Lithuania, November 25, 2024
On November 25, 2024, a SwiftAir Boeing 737-746,
operated by DHL, on an international cargo flight
from Leipzig, Germany, to Vilnius Airport, Vilnius,
Lithuania, impacted the ground short of the arrival
runway (near a house) while on approach to the airport.
Of the four occupants on board (two pilots and two
passengers), one pilot sustained fatal injuries, and the
other occupants were injured. No one on the ground
was injured. As the US-accredited representative of
the state of design and manufacture of the airframe,
NTSB staff traveled to Lithuania to assist the Transport
Accident and Incident Investigation Division of the
Ministry of Justice of Lithuania in its investigation.
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardBombardier CL600 2B19 Crash After Takeoff
Kathmandu, Nepal, July 24, 2024
On July 24, 2024, a Saurya Airlines Bombardier
CL-600-2B19 carrying 16 passengers and
3 crewmembers crashed and caught fire while taking
off from Tribhuvan International Airport, Kathmandu,
Nepal. All 16 passengers and 2 crewmembers
sustained fatal injuries; the captain survived with
non-life-threatening injuries. As the US-accredited
representative of the state of design and manufacture
of the engines, NTSB staff traveled to Singapore’s
Transport Safety Investigation Bureau facilities
to assist Nepal’s Aircraft Accident Investigation
Commission investigation in downloading and
interpreting data recovered from the flight data
recorder and CVR.
Boeing 787 In-flight Upset
enroute over the r epublic of Türkiye,
May 26, 2024
On May 26, 2024, a Qatar Airways Boeing 787-900
flying from Doha, Qatar, to Dublin, Ireland, experienced
an in-flight upset while flying through Turkish airspace.
Following initial reports of injuries to 6 passengers
and 6 crew members, a total of 12 people received
hospital treatment, of whom 8 were passengers. As the
US-accredited representative of the state of design and
manufacture of the airframe and engines, NTSB staff
traveled to the Republic of Ireland to support the Air
Accident Investigation Unit’s investigation.
Boeing 777 Turbulence Encounter
irrawaddy Basin, Burma, May 21, 2024
On May 21, 2024, a Singapore Airlines Boeing 777
carrying 211 passengers and 18 crew members
encountered severe turbulence at an altitude of
about 37,000 feet. One passenger died, likely from a
heart attack, and dozens of others sustained serious
injuries. The flight made an emergency landing at Suvarnabhumi Airport, Bangkok, Thailand. As the
US-accredited representative of the state of design
and manufacture of the airframe, NTSB staff traveled
to Bangkok to assist in the Singapore Transport Safety
Investigation Bureau’s investigation.
Boeing 767 Landing with Nose Gear Retracted
istanbul, Türkiye, May 8, 2024
On May 8, 2024, a FedEx Boeing 767 landed at
Istanbul Airport, Istanbul, Türkiye, without its nose
gear extended. No injuries were reported. As the
US-accredited representative of the state of design and
manufacture of the airframe and engines, NTSB staff
traveled to Türkiye to support the Transport Safety
Investigation Center’s investigation.
Sikorsky S-92 Crash into Sea
Near Bergen, Norway, February 28, 2024
On February 28, 2024, a Sikorsky S-92 helicopter
carrying six passengers and two pilots conducting a training exercise crashed into the sea off the coast
of Norway. One occupant sustained fatal injuries,
and one occupant sustained serious injuries. As the
US-accredited representative of the state of design
and manufacture of the airframe, the NTSB assigned
staff to support the Norwegian Safety Investigation
Authority’s investigation.
Airbus A350 and DHC-8 Runway Incursion
Tokyo, Japan, January 2, 2024
On January 2, 2024, a Japan Airlines A350-900 and
a Japanese Coast Guard de Havilland DHC-8 collided
on the runway at Haneda Airport in Tokyo, Japan.
Of the six crew on the DHC-8, five sustained fatal
injuries; the captain survived with serious injuries.
All 379 occupants of the A350 survived, 17 of whom
received medical attention. The Japan Transport
Safety Board requested US assistance to coordinate
readout of the A350’s Honeywell-manufactured
flight data recorder.
US Comments on Foreign Accident Reports
We completed comments on behalf of the United States on several international investigations
in which the United States had significant involvement under Annex 13, including the following.
Boeing 787 Nose Gear Failure
Incheon, South Korea, June 18, 2023
On June 18, 2023, a Scoot Boeing 787-900 experienced
a failure of its nose gear during departure from
Incheon International Airport, Seoul, South Korea.
Officials at Incheon International Airport found nose
wheel parts, including tire fragments, along one of
the airport’s taxiways; about the same time, while the
airplane was reaching the top of its climb, the flight
crew discovered that pressure readings for both nose
landing gear tires were not available. The airplane landed without incident at its intended destination,
Taiwan Taoyuan International Airport, Taipei, Taiwan.
As the US-accredited representative of the state of
design and manufacture of the Boeing 787 airframe,
the NTSB provided comments on a draft report to the
Singapore Transport Safety Investigation Bureau. The
final report was issued in July 2024.
Boeing 777 Altitude Deviation
Muscat, Oman, January 13, 2024
On January 13, 2024, a controller in Muscat, Oman,
noticed Singapore Airlines flight 306, a Boeing 777,
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety Boarddepart its assigned altitude into the path of crossing
traffic. The controller attempted several times to call
the airplane’s pilots on the radio, but the crew did
not respond. The airplane climbed to 32,500 feet, at
which point contact was established between the
flight crew and controller. When asked why the crew
had climbed to an unassigned altitude, the crew
responded that it was an autopilot error and that they
would have to manually descend. As the US-accredited
representative of the state of design and manufacture
of the airframe, the NTSB provided comments on a
draft report to the Oman’s Civil Aviation Authority. The
final report is pending.
Boeing 777 and Airbus A330
Ground Collision During Taxi
Paris, France, August 30, 2023
On August 30, 2023, an Air France Boeing 777-328ER
and a DAL Airbus A330-941 were involved in a ground
collision accident at Paris Charles de Gaulle Airport
in Paris, France. After arrival, as the Airbus A330 was
taxiing, its right winglet collided with the tail of the
Boeing 777, which was holding on an adjacent runway.
No injuries to occupants on either airplane were
reported. As the US-accredited representative of the
state of design and manufacture of the Boeing 777
airframe and one of the operators involved, the NTSB
provided comments on a draft report to the Bureau
d’Enquêtes et d’Analyses in April 2024. The final report
was issued in May 2024.Boeing 767 Contained Engine Failure
glasgow, u nited Kingdom, February 10, 2023
On February 10, 2023, a DAL Boeing 767-332-ER
suffered a failure of its right engine on takeoff from
Edinburgh Airport and experienced airframe vibration
and engine indications resulting in the aircraft diverting
to Glasgow’s Prestwick Airport. During the diversion,
fuel escaping from the wing was ignited by the hot
engine exhaust, but the flames extinguished before
the landing. All 211 passengers and 10 crew members
safely disembarked without injury. As the US-accredited
representative of the state of design and manufacture
of the Boeing 767 airframe and the Pratt and Whitney
PW4060 engines, as well as the state of the operator,
the NTSB provided comments on a draft report to the
United Kingdom’s Air Accidents Investigation Branch.
The final report was issued in July 2024.
Boeing 737 Brazzaville Landing Gear Collapse
Democratic Republic of the Congo, February 9, 2023
On February 9, 2023, the tire on the left main landing
gear of an Allied Air Cargo 737 burst on landing, and
the gear collapsed. No injuries were reported. As the
US-accredited representative of the state of design
and manufacture of the airframe, the NTSB provided
comments on a draft report to the Democratic
Republic of the Congo in March 2024. The final report
is pending.Airbus A330 Runway Excursion
Amsterdam, the Netherlands, January 12, 2023
On January 12, 2023, a DAL Airbus A330-300 landed
short of the runway at Amsterdam Airport Schiphol,
Amsterdam, the Netherlands. No injuries were reported
to the airplane occupants. The airplane sustained
minor damage, and the runway pavement and
runway lights were damaged. As the US-accredited
representative of the state of the operator, the NTSB
provided comments on the draft report to the Dutch
Safety Board in February 2024. The final report was
issued in July 2024.
Airbus A320 In-flight Fire
Mediterranean Sea, May 19, 2016
On May 19, 2016, an Airbus A320-200 operating as
Egypt Air flight 804 from Paris Charles de Gaulle,
France, to Cairo, Egypt, was en route at 37,000 feet
over the Mediterranean Sea when the airplane’s
transponder signal ceased at 2:33 am. Postaccident
analysis determined that the airplane experienced an
in-flight fire. As the US-accredited representative of
the state of manufacture of the engines, the NTSB
provided comments on a draft report to the Egyptian
Ministry of Civil Aviation. The final report was issued in
October 2024.
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety BoardSafety Alerts
During 2024, the Office of Aviation Safety developed the following safety alerts
for issuance by the Board.9
9 Safety alerts are brief information sheets that pinpoint a particular safety issue. They contain information based on investigation findings and
enhance the dissemination of safety information to the traveling public. They are primarily used to alert the transportation safety community,
which may not otherwise be reached through safety recommendations, of safety issues identified during multiple investigations. Safety alerts
provide information on the problem, examples of accidents, what pilots can do to avoid making the same mistakes, and references for pilots to
find additional information. These alerts are posted on the NTSB website, and brochures are distributed at outreach events that staff attends
throughout the year.Flying in Icing Conditions? » SA-097
This safety alert, which replaced a 2008 safety alert
on the same subject, was derived from multiple
investigations involving flight in icing conditions in
which pilots had not followed their pilot’s operating
handbooks or aircraft flight manuals, which led to
in-flight loss of control.
Wake Turbulence: Helicopters and
Small General Aviation Aircraft
Also Pose a Risk » SA-096
This safety alert was derived from multiple
investigations involving small aircraft encountering
wake turbulence from helicopters and other small
general aviation aircraft. These encounters have led to
serious damage to the aircraft and have also caused
fatal injuries to the occupants.
Mechanics: Check the
Engine Control Cables! » SA-092
This safety alert was derived from multiple
investigations involving the failure of worn throttle
and/or mixture cables that resulted in partial or
total loss of engine power.Know When to Feather Your Propeller: If One
Engine Loses Power Don’t Get Locked Out
» SA-091 » Companion video: SA-091
This safety alert and accompanying video were
derived from multiple accident investigations in which
twin-engine airplanes experienced partial loss of
engine power. The investigations described highlight
scenarios in which delayed propeller feathering of an
aircraft compromised control and safety, leading to
aircraft damage and fatalities.
Aluminum Propeller Blades: Prevent
Fractures with Proper Inspections and
Maintenance » SA-090
This safety alert was derived from multiple accident
investigations involving the failure of aluminum
propeller blades. The investigations described highlight
scenarios in which fatigue cracking and fractures
were not detected before takeoff, resulting in propeller
blades fracturing during takeoff or flight, causing
forced landings and aircraft damage.
Explore more than 50 aviation safety
alerts sorted by topic, available at
ntsb.gov/advocacy/safety-alertsSafety Actions
During 2024, the Office of Aviation Safety
documented 178 safety actions.10 The
following are summaries of a sampling of
these actions.
• As a result of our ongoing investigation of an
August 2023 fatal accident involving a total loss
of power in the right engine of a twin-engine
experimental amateur-built airplane , the engine
manufacturer made several changes to the engine
installation manual in April 2024. These changes
included reorganizing and adding additional links and
important warnings to the manual’s electrical system
section and to installation videos. The addition of
warnings included a red box warning stating “All wires
are critical to engine functions.”
• As a result of our investigations of two fatal
accidents that occurred within months of each other
under similar circumstances at Venice Municipal
Airport, Venice, Florida , the airport authority took
mitigating action concerning the airport operating
environment in April 2024. Both accidents involved
departures at night under visual flight rules, over
water, and with no discernable horizon. Following
conversations with NTSB investigators, the airport
authority placed signage on the end of every runway
alerting pilots departing under visual flight rules
to the potential visual loss of the horizon after
departure, added a warning with similar information
to the airport’s automated weather observing system
notifications, and added a permanent entry concerning
this information to the airport’s notices to airmen.
10 A safety action is a positive change within the transportation
environment brought about by an NTSB investigation or study
without our issuing a formal safety recommendation.
OFFICE OF AVIATION SAFETY
2024 Annual Report to Congress National Transportation Safety Board• As a result of our investigation of an accident
involving an Air Tractor AT-802 that drifted right
and impacted a ditch during landing , the airplane
manufacturer issued a service letter to operators
about the identified safety issue, including correction
action. Postaccident examination of the airplane found
movement of the rudder/brake pedal was restricted
by the spray valve control pushrod. This condition
prevented the simultaneous application of full left
rudder and left brake when operated from the rear
seat. Following issuance of the manufacturer’s service
letter and at the NTSB’s suggestion, the FAA agreed
to follow up with a standard airworthiness information
bulletin in April 2024.
• As a result of our investigation of a Hughes 369D
helicopter accident in which an object became
loose from a backpack while in flight, exited the
helicopter, and impacted the tail rotor , the helicopter
operator made several operational changes in February
2024. These changes included revising its general
operations manual to establish standards for carry
on items, requiring pilots to visually ensure that all
carry-on items are properly secured and meet the
standards described in the manual before every
takeoff, requiring that all safety briefings address and
describe the company standards for carry-on items,
and implementing a policy that customers are notified
via email before flight that no objects are allowed to be
strapped or stored on the exterior of carry-on items.Other Significant Achievements
Regulatory Correspondence
We provided feedback and guidance on four regulatory efforts related to the following rulemakings:
• FAA’s airworthiness directives for various helicopters
• 25-hour CVR requirements
• Supplemental restraint systems
• Final rule on SMSs11
Loss of Separation/Runway Incursions
During 2024, the NTSB investigated several events involving commercial airlines and losses of separation or
runway incursions. These investigations were a top priority because of the potential catastrophic consequences.
As summarized in the Investigation Reports section, the NTSB issued 15 recommendations to reduce the risk of
recurrence as a result of findings in two runway incursion investigations. These recommendations, if acted upon,
will result in improved technology in aircraft cockpits to alert pilots to other aircraft that could become a collision
risk, improved procedures for crossing runways, support for more effective use of SMS programs, updated airport
runway lighting systems, required airport surface detections systems, and improved air traffic control procedures.
Project to Optimize Regional Investigator Launch Coverage
During the first half of fiscal year 2024, the office formed a working group to evaluate the various duty schedules
among the regional offices and recommend a single unified duty rotation schedule. The objectives of this project
were to use limited launch resources more efficiently while maintaining launch readiness and to provide seasonally
appropriate launch depth by leveraging cross-regional support. The working group completed its evaluation and
delivered recommendations to office management in March 2024.
2024 ICAO Audit
The Office of Aviation Safety provided extensive support during a July 2024 audit of the US civil aviation system
conducted by ICAO under its Universal Safety Oversight Aviation Programme. The Office of Aviation Safety led
efforts demonstrating the US implementation of the program’s critical elements and protocols related to aviation
accident and incident investigation. The US achieved an effective implementation score of 94 percent for that
portion of the audit—well above the global average and reflective of the comprehensive system and capabilities in
place at the NTSB for accident investigation.
11 See Congressional and Regulatory Correspondence for more information on NTSB responses to regulatory actions and requests for comment.
2024 Annual Report to Congress National Transportation Safety BoardOffice of Highway Safety
12 Eight recommendations were adopted in our November 14, 2023, North Las Vegas, Nevada, investigation report,
but were not issued until January 2024.TABLE 4. Office of Highway Safety Statistics
Recommendations Issued12 ............................... 44
Recommendations Closed in an Acceptable Status ............ 18
Recommendations Closed in an Unacceptable Status ........... 3
Board-Adopted Investigation Reports ........................ 4
Delegated Investigation Reports ............................ 4
Public Webinars ......................................... 2
Safety Alert ............................................. 1
Safety Actions ........................................... 5
Major Investigation Launches ............................... 4
Field Investigation Launches ............................... 8
Outreach .............................................. 30The Office of Highway Safety investigates
crashes that have significant safety
implications nationwide, highlight national
safety issues, involve the loss of numerous
lives, or generate high interest because of
emerging technologies or the circumstance
of the crash. Such investigations may focus
on collapses of bridges spanning roadways or
tunnel structures, mass casualties and injuries
on public transportation vehicles (such as
motorcoaches and school buses), and collisions
at highway–railroad grade crossings.
This office also investigates crashes that involve
new safety issues or technologies (such as
automated vehicles and alternatively fueled
vehicles), and develops reports based on trends
emerging from NTSB investigations and from
research and data that identify common risks or
the underlying causes of crashes, injuries, and
fatalities.
The NTSB is the only US organization that
performs independent, comprehensive, and
transparent multidisciplinary investigations
to determine the probable causes of
highway crashes, with the goal of making
recommendations to prevent similar events
and to reduce injuries and fatalities. Our
investigations result in recommendations that
provide policymakers with unbiased analysis and
that, if implemented, would reduce or eliminate
the safety risks identified in the investigations.
OFFICE OF HIGHWAY SAFETY24
2024 Annual Report to Congress National Transportation Safety BoardThe Office of Highway Safety comprises
the Investigations Division and the
Report Development Division. The
Investigations Division is further divided
into the Multidisciplinary Branch East, the
Multidisciplinary Branch West, and the Special
Investigations Branch. The multidisciplinary
investigation branches conduct major highway
investigations through a multidisciplinary team
comprising an investigator-in-charge and five
other investigators with expertise in vehicle,
highway, human performance, survival, and
motor carrier factors. The Special Investigations
Branch performs focused investigations by
specific subject matter experts on targeted
safety issues.Investigation Reports
During 2024, the Office of Highway Safety issued a total of eight investigation reports;
four of these reports involved safety issues that led to the issuance of 36 new
safety recommendations.
Below are summaries of the highway investigation reports completed during this period.
13 All times stated are local time.Box Truck Centerline Crossover Collision
with Bus
Louisville, New York, January 28, 2023
On Saturday, January 28, 2023, about 6:00 a.m., a bus
was traveling west on New York State Route 37 (SR-37)
at a speed of 53–54 miles per hour (mph) in Louisville,
New York.13 The bus was operated by LBFNY and
transporting 14 workers to a solar farm construction
site. At the same time, a box truck, operated by Aero
Global Logistics (AGL), was traveling east on SR-37 about 59 mph. SR-37 is a two-lane roadway with one
lane in each direction and a posted speed limit of 55
mph. The roadway was wet and there was light snow in
the area. As the two vehicles approached each other,
the truck crossed over the highway centerline and
collided with the driver’s side of the bus. As a result, six
bus passengers died in the crash, two were seriously
injured, five had minor injuries, and one was uninjured.
The bus driver sustained minor injuries, and the truck
driver was seriously injured.
Figure 15. Diagram denoting gouge marks at area of impact in westbound lane of State Route 37 (SR-37),
final areas of rest of truck and bus, and locations of scrape marks and tire scuffs left by truck after impact
(marked in blue). SOURCE: NEW YORK STATE POLICE; ANNOTATED BY NTSB
OFFICE OF HIGHWAY SAFETY25
2024 Annual Report to Congress National Transportation Safety BoardWe determined that the probable cause of the crash
was the truck driver’s fatigue due to insufficient sleep
and circadian disruption, which lowered his level
of alertness to the driving task and resulted in the
truck crossing the centerline of the roadway into the
opposing lane of travel and colliding with the oncoming
bus. Contributing to the crash were the failure of the
truck motor carrier, AGL, to effectively manage driver
fatigue and monitor unsafe driving, and the failure of
the bus motor carrier, LBFNY, to operate in compliance
with Federal Motor Carrier Safety (FMCSA) regulations
and a federal out-of-service order. Also contributing
was the FMCSA’s ineffective oversight of AGL during
the New Entrant Safety Assurance Program and
subsequent compliance reviews to ensure that the
carrier had appropriate safety management controls in
place to mitigate its high crash rate and driver fatigue.
Contributing to the severity of the injuries was the
failure of the bus motor carrier, LBFNY, to ensure that
seat belts were readily accessible and worn, which
resulted in multiple bus occupants being displaced from
their seats and injured during the collision sequence.
We identified the following safety issues during
this investigation:
(1) lack of seat belt use by the bus occupants,
(2) inadequate safety practices of AGL for managing
fatigue and crash risk, and
(3) deficient motor carrier oversight by the FMCSA.
As a result of this investigation, we issued safety
recommendations to the following:
• FMCSA
• State of Montana
• American Trucking Associations
• National Private Truck Council
• Amalgamated Transit Union
• International Brotherhood of Teamsters
• Owner-Operator Independent Drivers Association
• Transport Workers Union of America
• American Association of Motor Vehicle
Administrators (AAMVA)• LBFNY
• AGL
We also reiterated safety recommendations to
the FMCSA, the National Highway Traffic Safety
Administration (NHTSA), and the State of New York.
»Recommendations: 12 new, 3 reiterated,
2 classified in this report
»Report Date: November 19, 2024
Figure 16.
Eastbound SR-37 showing area of impact
and roadway scar extending to truck’s damaged
left front wheel assembly.
SOURCE: NEW YORK STATE POLICE; ANNOTATED BY NTSB
Figure 17.
Truck at rest off eastbound shoulder of
SR-37. SOURCE: NEW YORK STATE POLICEHigh-Speed Vehicle Collision with Workers
in a Highway Work Zone
Woodlawn, Maryland, March 22, 2023
On Wednesday, March 22, 2023, about 12:36 p.m., six
highway workers were struck by a passenger vehicle in
a work zone along northbound (inner loop) Interstate
695 near Woodlawn, Maryland. The work zone was
a long-term closure of the left shoulder, and all six
workers were behind a series of concrete barriers
in place to isolate workers from vehicles operating
in the travel lanes. The crash occurred when a 2017
Acura TLX, traveling at a vehicle-recorded speed of
121 mph, moved from the right lane, across the two
middle lanes and toward the left lane, and struck
a 2017 Volkswagen Jetta, which was traveling at a
vehicle-recorded speed of 122 mph. The Acura driver
lost control, and the vehicle entered the work zone
through an opening in the concrete barrier that was
intended for work zone access. After striking the
center concrete median barrier inside the work zone,
the vehicle began to overturn. While overturning, the
Acura struck construction materials and equipment
and the six workers, who were standing in the work
zone. The Volkswagen made a controlled stop in the
left lane. All six workers were fatally injured, and the
Acura driver was seriously injured.
Figure 18.
Postcrash view of the work zone and the
opening in the concrete barriers through which the
Acura entered.
SOURCE: MARYLAND STATE POLICE; ANNOTATED BY NTSB
OFFICE OF HIGHWAY SAFETY26
2024 Annual Report to Congress National Transportation Safety BoardWe determined that the probable cause of the crash
between a passenger vehicle and highway workers in a
work zone was the excessive speed of two vehicles and
unsafe lane change by the Acura driver, resulting in a
collision with the Volkswagen and subsequent loss of
control, entry into the work zone, rollover, and collision
with the workers.
We identified the following safety issue during this
investigation: excessive speeding.
»Recommendations: None
»Report Date: October 9, 2024
Pickup Collision with a Group of Bicyclists
Goodyear, Arizona, February 25, 2023
On February 25, 2023, about 7:55 a.m., a group of
bicyclists was struck by a 2019 Ford F-250 pickup truck
while traveling south over the Cotton Lane Bridge near
Goodyear, Arizona. The pickup truck, which was also
traveling south, departed the left lane and crossed the
right southbound lane and shoulder before striking the southbound bridge barrier. Following the impact, the
pickup truck veered left, struck the bicyclists, crossed
over both southbound travel lanes, and stopped in the
center median of the roadway. As a result of the crash,
2 bicyclists were fatally injured and 14 received injuries
ranging from serious to minor. Two were not injured.
The driver was wearing a lap/shoulder belt and was
also uninjured.
We determined that the probable cause of the crash
was the pickup driver’s diminished state of alertness,
likely due to fatigue. Contributing to the severity of the
bicyclists’ injuries was the pickup driver’s speed and
lack of response once the crash sequence began.
We identified the following safety issues during
this investigation:
(1) the pickup truck driver’s fatigue, and
(2) the lack of adequate protections for vulnerable
road users, including bicyclists.
»Recommendations: None
»Report Date: September 20, 2024
Figure 19.
View of the southbound lanes of Cotton Lane Bridge, showing the final rest positions of the pickup and
some of the involved bicycles.Rear-End Collision Between Combination
Vehicle and Medium-Size Bus
Williamsburg, Virginia, December 16, 2022
On Friday, December 16, 2022, about 1:36 a.m., a
truck-tractor in combination with a semitrailer, operated
by Triton Logistics Incorporated (Triton), was traveling
east on Interstate 64 near Williamsburg, Virginia, when
it crashed into the rear of a slower-moving medium-size
bus, operated by Futrell’s Party Adventures, LLC. The
bus was traveling about 20–25 mph, while the truck
was traveling about 65–70 mph. The truck driver did
not brake or take any evasive action while approaching
the slower-moving vehicle. As a result of the crash,
3 bus occupants died, 9 sustained serious injuries,
and 11 sustained minor injuries. The truck driver also
sustained serious injuries.
Figure 20.
Depiction of the postimpact paths of travel
for the truck and bus relative to physical evidence as
overlaid atop the scene (orthomosaic image).
We determined that the probable cause of the crash
was the truck driver’s fatigue, due to excessive driving
time and limited sleep opportunity, which resulted in
his lack of response to the slow-moving bus ahead.
OFFICE OF HIGHWAY SAFETY27
2024 Annual Report to Congress National Transportation Safety BoardContributing to the truck driver’s fatigue was the motor
carrier, Triton, which created fictitious driver accounts
in the electronic logging device system and enabled
drivers to operate their vehicles for hours in excess of
federal regulations. Contributing to the severity of the
crash was the operation of the bus at a significantly
slower speed than other highway traffic.
We identified the following safety issues during
this investigation:
(1) the inadequate safety culture of the truck motor
carrier,
(2) the need for federal requirements for commercial
vehicle collision avoidance systems, and
(3) the inadequate safety management and oversight
of the bus carrier.
As a result of this investigation, we issued safety
recommendations to the FMCSA, the Commonwealth
of Virginia, Triton, and the Commercial Vehicle
Safety Alliance (CVSA). We also reiterated safety
recommendations to NHTSA and the FMCSA.
»Recommendations: 6 new, 3 reiterated
»Report Date: August 12, 2024
Intersection Crash Between Passenger Car
and Combination Vehicle
Tishomingo, Oklahoma, March 22, 2022
On the afternoon of March 22, 2022, at 12:19 p.m., a
2015 Chevrolet Spark four-passenger car, occupied
by a 16-year-old driver and five teen passengers,
was traveling east on Oklahoma State Highway 22
(SH-22) approaching US Highway 377 (US-377)
in Tishomingo, Oklahoma. The flow of traffic on
SH-22 was controlled by a stop sign, and vehicles
on US-377 had no traffic controls. At the same time,
a 1994 Peterbilt truck-tractor in combination with a
2017 Travis semitrailer (combination vehicle) was
traveling south on US-377 at a calculated speed of
51–53 mph and approaching the intersection with
SH-22. The car driver slowed her vehicle in advance of the intersection (behind another vehicle) but did not
come to a complete stop at the stop sign or yield to the
oncoming combination vehicle. Instead, the car driver
sped up to make a left turn in front of the combination
vehicle. The combination vehicle driver applied braking
and steered to try to avoid the collision, but the
combination vehicle struck the driver’s side of the car;
all six occupants in the car were fatally injured. The
combination vehicle driver was not injured in the crash.
Figure 21.
Damage to passenger car where six teens
died following a crash with a truck-tractor.
SOURCE: OKLAHOMA DEPARTMENT OF PUBLIC SAFETY
We determined that the probable cause of the
collision was the teen driver’s acceleration through the
intersection after briefly slowing without stopping, due
to distraction from having five teen passengers in the
car, limited driving experience, and likely impairment
from cannabis.
We identified the following safety issues during
this investigation:
(1) the car driver’s distraction from transporting
multiple teen passengers, inexperience with driving,
and likely impairment due to recent cannabis use; and
(2) the need for public awareness, effective communication, and access to resources about the
impairing effects of cannabis use on driving.
As a result of this investigation, we issued safety
recommendations to the following:
• Oklahoma State Department of Education
• Service Oklahoma
• Governors Highway Safety Association
(GHSA)
• National Conference of State Legislatures
• National Association of State Boards of
Education
• AAMVA
We also reiterated previously issued safety
recommendations to Oklahoma, 19 states, the District
of Columbia, and the Commonwealth of Puerto Rico.
»Recommendations: 7 new, 2 reiterated
»Report Date: May 30, 2024
Figure 22.
Graphical depiction of passenger car
speeds, acceleration statuses, and locations in
the 5 seconds before the crash, based on event
data recorder.
SOURCE: OKLAHOMA DEPARTMENT OF PUBLIC SAFETY
OFFICE OF HIGHWAY SAFETY28
2024 Annual Report to Congress National Transportation Safety BoardFire on Battery Electric Transit Bus
Hamden, Connecticut, June 23, 2022
On Saturday, July 23, 2022, about 3:39 a.m., a battery
electric transit bus, owned by the Connecticut
Department of Transportation and operated by public
transit system CTtransit, began emitting smoke
while parked inside a CTtransit maintenance facility
in Hamden, Connecticut. The bus had been placed
out of service 2 days earlier due to an error in the
bus charging system. Responding fire department
personnel did not observe any visible flames, and the
bus was pushed to an outdoor, isolated parking area.
In the process, two CTtransit maintenance workers
suffered smoke inhalation and were treated at an area
hospital. Later that same morning, the bus was again
emitting smoke, and fire was observed coming from
the rear of the vehicle. Fire personnel returned to the
site and the incident commander decided to let the bus
burn in the controlled environment. The fire remained
active for several hours and fully consumed the vehicle.
Following the departure of fire personnel, the bus
continued to smolder while remaining isolated in the
parking lot. On Monday, July 25, 2022, smoke and an
orange glow were observed emanating from the right
rear wheel well of the burned bus. Fire department
personnel responded for a third time and applied water
to the smoking battery compartment. No additional
injuries were reported. We investigated two additional
battery electric transit bus fires, one that occurred at an
IndyGo facility in Indianapolis, Indiana and another at
a Southeastern Pennsylvania Transportation Authority
(SEPTA) facility in Philadelphia, Pennsylvania, that we
summarized in this report.
We determined that the probable cause of the fire
was moisture in the high-voltage lithium-ion battery
system, which led to battery damage resulting
in the fire. Contributing to the injuries to facility
personnel was the lack of a safety plan by CTtransit
for mitigating risks associated with high-voltage
lithium-ion battery fires during emergency response. Figure 23.
View of the burned transit bus from the
left rear corner of the bus.
We identified the following safety issue during
this investigation: inadequate emergency responder
safety and emergency response guides that provide
vehicle-specific information about safely extinguishing
fires, mitigating reignition events, and transporting and
storing damaged vehicles. Following the investigation,
the Federal Transit Administration (FTA) issued
additional guidance.
»Recommendations: None
»Report Date: March 4, 2024
Collapse of the Fern Hollow Bridge
Pittsburgh, Pennsylvania, January 28, 2022
On Friday, January 28, 2022, about 6:37 a.m., the
Fern Hollow Bridge, which carried Forbes Avenue
over the north side of Frick Park in Pittsburgh,
Pennsylvania, experienced a structural failure. As a
result, the 447-foot-long bridge fell about 100 feet
into the park below. The collapse began when the
transverse tie plate on the southwest bridge leg failed
due to extensive corrosion and section loss. The
corrosion and section loss resulted from clogged
drains that caused water to run down bridge legs and
accumulate along with debris at the bottom of the legs, which prevented the development of a protective
rust layer or patina. Although repeated maintenance
and repair recommendations were documented in
many inspection reports, the City of Pittsburgh failed
to act on them, leading to the deterioration of the
fracture-critical transverse tie plate and the structural
failure of the bridge. At the time of the collapse, a 2013
New Flyer articulated transit bus, operated by the
Port Authority of Allegheny County, and four passenger
vehicles were on the bridge. A fifth passenger vehicle
drove off the east bridge abutment after the collapse
began and came to rest on its roof on the ground below.
As a result of the collapse, the bus driver sustained
minor injuries, and two bus occupants were uninjured.
Of the six passenger vehicle occupants, two sustained
serious injuries, one sustained a minor injury, two were
uninjured, and the injury status of one was unknown.
Figure 24.
West-looking view of collapsed Fern Hollow
Bridge.
We determined that the probable cause of the
collapse was the failure of the transverse tie plate
on the southwest leg of the bridge, a fracture-critical
member (nonredundant steel tension member), due
to corrosion and section loss resulting from the City
of Pittsburgh’s failure to act on repeated maintenance
OFFICE OF HIGHWAY SAFETY29
2024 Annual Report to Congress National Transportation Safety Boardand repair recommendations from inspection reports.
Contributing to the collapse were the poor quality
of inspections, the incomplete identification of the
bridge’s fracture-critical members (nonredundant
steel tension members), and the incorrect load rating
calculations for the bridge. Also contributing to the
collapse was insufficient oversight of Pittsburgh’s
bridge inspection program by the Pennsylvania
Department of Transportation (PennDOT). Also
contributing to the collapse was insufficient oversight
by the Pennsylvania Department of Transportation of
the City of Pittsburgh’s bridge inspection program.
We identified the following safety issues during
this investigation:
(1) the lack of action on repeated recommendations
from bridge inspection reports, including the City of
Pittsburgh’s failure to maintain and repair the Fern
Hollow Bridge and PennDOT’s failure to ensure that
the city of Pittsburgh completed the maintenance and
repairs specified in the recommendations from the
bridge inspection reports;
(2) PennDOT’s ineffective bridge inspection program,
which used bridge inspection methods and measures
that did not comply with guidance from the Federal
Highway Administration (FHWA) and the American
Association of State Highway and Transportation
Officials (AASHTO), that failed to identify all of the
bridge’s fracture-critical members, and that produced
inaccurate bridge load rating calculations; and
(3) insufficient oversight by the city, PennDOT, and
the FHWA, which led to their failure to carry out their
responsibilities within the bridge inspection program to
detect and prevent bridge failures.
As a result of this investigation, we issued safety
recommendations to the FHWA, PennDOT, the City
of Pittsburgh, and AASHTO. We also classified a
previously issued safety recommendation to the FHWA.
»Recommendations: 11 new, 1 classified in this
report
»Report Date: February 21, 2024 Intersection Crash between a Medium-Size
Bus and a Combination Vehicle
Dermott, Arkansas, June 6, 2022
On June 6, 2022, about 2:41 p.m., a crash occurred
between a medium-size bus and a truck-tractor
combination vehicle at an intersection of US Highway
65 (US-65) and State Highway 35 (SH-35) near
Dermott, Arkansas. The bus was traveling westbound
on SH-35 and, without yielding, began crossing the
southbound lanes of US-65, where it was struck by the
combination vehicle. Five bus passengers died, and
three bus passengers sustained serious injuries; both
drivers were seriously injured.We determined that the probable cause of the
crash was the failure of the bus driver to yield to the
combination vehicle, likely as the result of fatigue.
We identified the following safety issues during
this investigation:
(1) the lack of onboard video recorders on the bus,
and
(2) insufficient oversight of the driver’s fitness for
duty by the bus operator.
»Recommendations: None
»Report Date: February 5, 2024
Figure 25.
The two vehicles postcrash at the scene of the collision.
SOURCE: ARKANSAS STATE POLICE, ANNOTATED BY NTSB
OFFICE OF HIGHWAY SAFETY30
2024 Annual Report to Congress National Transportation Safety BoardOngoing Significant Highway Accident Investigations
At the close of 2024, the Office of Highway Safety had 17 open investigations involving significant safety issues. We are devoting significant
resources to these investigations and anticipate producing a report upon the completion of each one.
TABLE 5. Ongoing Significant Highway Safety Investigations
Location Event Date Description Fatalities2025
Report Date
Vicksburg, Mississippi 8/31/2024 Motorcoach roadway departure and overturn 7
Swanton, Ohio 8/15/2024 Rear-end collision and subsequent multivehicle collisions near toll plaza on Interstate 80 4
Belle Glade, Florida 8/5/2024 Sport utility vehicle (SUV) roadway departure and overturn 9
Kenly, North Carolina 7/24/2024 Multivehicle work zone collision and postcrash fire 5
Rushville, Illinois 3/11/2024 School bus collision with combination vehicle and postcrash fire 5
Millstone, West Virginia 3/4/2024 School bus roadway departure and overturn 0
Philadelphia, Pennsylvania 3/3/2024Rear-end collision between an SUV operating with partial driving automation and
two stationary passenger vehicles2
San Antonio, Texas 2/24/2024Rear-end collision between an SUV operating with partial driving automation and
a stationary SUV1
Wilmington, California 2/15/2024 Compressed natural gas-powered truck-tractor fire and explosion 0
Etna, Ohio 11/14/2023 Multivehicle collision including motorcoach transporting students and postcrash fire 7
Teutopolis, Illinois 9/29/2023Cargo tank combination vehicle roadway departure crash and subsequent release of anhydrous
ammonia5
Wawayanda, New York 9/21/2023 Motorcoach roadway departure and overturn 2 7/10/2025
Highland, Illinois 7/12/2023 Crash between motorcoach and combination vehicles parked along rest area ramp 3 5/20/2025
Philadelphia, Pennsylvania 6/11/2023 Combination vehicle overturn, fire, and Interstate 95 overpass collapse 1 3/19/2025
Excelsior Township, Wisconsin 5/12/2023 Vehicle collision with stopped school bus and student pedestrian 1 6/4/2025
OFFICE OF HIGHWAY SAFETY31
2024 Annual Report to Congress National Transportation Safety BoardPublic Webinars
Preventing Drugged Driving Among Youth:
Understanding the Issue and Advocating
for Change
October 24, 2024
During this webinar, experts in youth traffic safety and
drug-use prevention explored the risks associated with
drug-impaired driving among youth and highlighted
effective advocacy strategies for preventing
drug-impaired driving.Back-to-School Safety
August 21, 2024
Our panel of NTSB experts highlighted pertinent
safety recommendations and crash investigations for
returning to school safely and provided examples from
personal back-to-school safety stories.
Safety Alert
During 2024, the Office of Highway Safety developed the following safety alert for
issuance by the Board:
Parents: Protect Your Teen from
Marijuana-Impaired Driving » SA-93
Educating drivers about the risks of marijuana-impaired driving is essential for preventing fatal crashes like the one
that occurred in Tishomingo, Oklahoma. As states continue to legalize marijuana and thereby remove barriers to
its access and use, it becomes even more important to provide accurate information about marijuana’s impairing
effects and the continued illegality of driving under its influence. The NTSB’s safety alert focuses on parents’ role
in protecting their teen drivers from marijuana-impaired driving.
Safety Actions
During 2024, the Office of Highway Safety documented five safety actions.
The following are summaries of these actions.
• The CVSA’s roadside inspection protocols for
commercial vehicles lacked a step to compare
commercial motor vehicles’ gross vehicle weight
rating to driver’s license class. NTSB staff
petitioned the CVSA to amend the inspection
procedures to ensure that roadside inspectors
were properly comparing vehicle gross vehicle weight ratings with the driver’s license to ensure
compliance with regulations. On September 21,
2022, the CVSA voted and confirmed the
suggested changes to the inspection procedures.
The current procedures now require the inspector
to verify the gross vehicle weight rating and
compare it to the license for proper license class.• Mid-State Systems Inc. did not keep files for
driver performance and qualification in the same
place, which resulted in poor oversight of driver
safety. As a result of our investigation of a crash
in Etna, Ohio, Mid-State Systems Inc. now keeps
records of all driver notices, such as those related
to inspections, traffic violations, and outside
communications, in the driver’s file, and keeps
a master list of all such documents. Drivers
are interviewed, coached, and informed of the
ramifications of any policy breaches. The driver
signs and dates a receipt of the information.
• Our investigation into a single-vehicle fatal crash
in Belle Glade, Florida, found there was no warning
signage for the curve at the crash site. At our
urging, the Palm Beach County Department of
Transportation installed the warning signage on
August 9, 2024.
• As a result of our investigation into the crash in
Tishomingo, Oklahoma, the Oklahoma Department
of Transportation proposed a redesign of
the crash intersection to improve safety and
submitted a project initiation report.
• Also as a result of our investigation into the
crash in Tishomingo, Oklahoma, school officials
reported that they had established policies
regarding students driving off campus for lunch.
These new policies included the terms of the
state’s graduated driver’s license restrictions
(including passenger limits), limiting the number of
passengers to the number of seat belts available
in a vehicle, and prohibiting students from
traveling beyond town limits for lunch.
OFFICE OF HIGHWAY SAFETY32
2024 Annual Report to Congress National Transportation Safety BoardOther Significant Achievements
14 See Congressional and Regulatory Correspondence for more information on NTSB responses to regulatory actions and requests for comment.Regulatory Correspondence
We provided feedback and guidance on six regulatory
efforts, including, but not limited to the following
rulemakings:
• FMCSA’s Safety Fitness Determinations,
• NHTSA’s Federal Motor Vehicle Safety
Standards Occupant Crash Protection and
Seat Belt Reminder Systems,
• NHTSA’s Federal Motor Vehicle Safety
Standards for Pedestrian Head Protection,
and
• NHTSA’s Federal Motor Vehicle Safety
Standards, “FMVSS No. 305a Electric-Powered
Vehicles: Electric Powertrain Integrity Global
Technical Regulation No. 20.”14Investments in Technology
The Office of Highway Safety invested time and
resources to train multiple investigators within the
office and those in other modal offices on the use
of drone technology to accurately and completely
document our investigations. We invested in software
to better visualize drone data and in tablets to expand
the investigators’ on-scene capabilities during
drone flights.
Office of Highway Safety Manager Training
In September, the office coordinated in-person
manager training focusing on communicating for
employee engagement and performance.
2024 Annual Report to Congress National Transportation Safety BoardOffice of Marine Safety
TABLE 6. Office of Marine Safety Statistics
Recommendations Issued ................................. 13
Recommendations Closed in an Acceptable Status ............. 8
Recommendations Closed in an Unacceptable Status ........... 7
Board-Adopted Investigation Reports ........................ 3
Delegated Investigation Reports ........................... 35
Safety Alert ............................................. 1
Safety Action ........................................... 1
Major Investigation Launches ............................... 1
Field Investigation Launches .............................. 33
Outreach .............................................. 18The Office of Marine Safety investigates
and determines the probable cause of
major marine casualties in US territorial waters,
major marine casualties involving US-flagged
vessels worldwide, and accidents involving
both US public (federal) and nonpublic
vessels in the same casualty. In addition, the
office investigates select catastrophic marine
accidents and events of a recurring nature.
The US Coast Guard conducts preliminary
investigations of all marine accidents and
notifies the NTSB when an event qualifies as a
major marine casualty, which includes any one
of the following:
»The loss of six or more lives.
»The loss of a mechanically propelled vessel
of 100 or more gross tons.
»Property damage initially estimated to be
$500,000 or more.
»A serious threat, as determined by the
commandant of the US Coast Guard and
concurred with by the NTSB chairman,
to life, property, or the environment by
hazardous materials.
The office is also responsible for the overall
management of the NTSB’s international
marine safety program, under which the office
investigates major marine casualties involving
foreign-flagged vessels in US territorial waters
and those involving US-flagged vessels
anywhere in the world. Accidents involving
foreign-flagged vessels accounted for
OFFICE OF MARINE SAFETY34
2024 Annual Report to Congress National Transportation Safety Board29 percent of NTSB marine casualty
investigations over the past 5 years. Under the
International Maritime Organization (IMO) Code
of International Standards and Recommended
Practices for a Safety Investigation into a
Marine Casualty or Marine Incident , the office
also participates with the US Coast Guard as a
substantially interested state in investigations
of serious marine casualties involving
foreign-flagged vessels in international waters.
The international program involves reviewing
US administration position papers related to
marine investigations and participating in select
IMO subcommittee meetings.
As part of the international program, the office
coordinates with other US and foreign agencies
to ensure consistency with IMO conventions.
We also cooperate with other accident
investigation organizations worldwide at annual
meetings held both virtually and in person,
such as the Marine Accident Investigators’
International Forum (MAIIF), which has status as
a nongovernmental organization with IMO, with
Europe MAIIF, and with MAIIF Americas. MAIIF
tracks developments related to marine casualty
investigations and prevention.
The NTSB is the only federal organization that
performs independent, comprehensive, and
transparent multidisciplinary investigations
to determine the probable cause of marine
accidents, with the goal of making safety
recommendations to prevent similar
events from occurring in the future. The thoroughness and independence of these
investigations maintain public confidence in
marine transportation systems and provide
policymakers with unbiased analysis.
15 All times stated are local time.The Office of Marine Safety comprises the
Marine Investigations Division and the Product
Development Division.
Investigation Reports
During 2024, the Office of Marine Safety issued a total of 38 investigation reports; three of these
reports involved safety issues that led to the issuance of 13 new safety recommendations.
Below are summaries of some of the marine investigation reports completed during this period.
Fire aboard Passenger Vessel
Spirit of Boston
Boston, Massachusetts, March 24, 2023
On March 24, 2023, about 10:52 p.m., a fire broke
out in the wait station on deck 1 of the passenger
vessel Spirit of Boston while it was moored at the
Commonwealth Pier in Boston Harbor, Boston,
Massachusetts.15 All 16 persons aboard evacuated the
vessel to the pier. The local fire department responded
and extinguished the fire. There were no injuries, and
no pollution was reported. Damage to the vessel was
estimated at $3.1 million.
We determined that the probable cause of the
fire was the improper extinguishing and disposal of
a chafing fuel heating canister due to City Cruises
US’s lack of documented procedures for handling
open-flame devices, which led to the ignition of a
plastic glassware rolling rack. Contributing to the
growth and spread of the fire was City Cruises US
not requiring a marine crewmember—designated
and trained to execute City Cruises US’s emergency
response plan for a fire aboard a vessel—to remain aboard the vessel until all hospitality staff and other
noncrew personnel departed the vessel.
Figure 26.
Passenger vessel Spirit of Boston after
the fire.
We identified the following safety issues during
this investigation:
(1) the absence of marine crewmembers aboard
the vessel during an emergency while hospitality staff
were still aboard,
(2) improper handling of open-flame devices, and
(3) the lack of established mechanisms for City
Cruises US to identify unsafe practices and fire risks.
OFFICE OF MARINE SAFETY35
2024 Annual Report to Congress National Transportation Safety BoardAs a result of this investigation, we issued safety
recommendations to the Passenger Vessel Association
and to City Cruises US. We also reiterated a previously
issued safety recommendation to the US Coast Guard.
»Recommendations Issued: 4 new; 1 reiterated
»Report Date: December 13, 2024
Contact of Cindy B Tow with Dock
Clatskanie, Oregon, November 12, 2023
On November 12, 2023, about 5:52 a.m., the towing
vessel Cindy B was pushing the loaded deck barge
St. John upbound on the Columbia River at mile 53
near Clatskanie, Oregon, when the tow gradually
moved to starboard out of the navigation channel
and struck the Port Westward Beaver Dock. The
three crewmembers aboard the Cindy B were
uninjured. During the cleanup, about 2 gallons of
renewable diesel fuel leaked onto the dock from
a damaged pipe on the dock, with about 1 gallon
going into the river; a portion of the spilled fuel
was recovered. Damage to the St. John and the
Beaver Dock was estimated to be about $6 million.
Figure 27.
Cindy B and St. John underway after
contact with the Beaver Dock.
SOURCE: COLUMBIA PACIFIC BIO-REFINERY
We determined that the probable cause of the
contact was the deckhand falling asleep at the helm due to fatigue that he did not perceive, which
occurred during a night watch, at a low point in his
circadian rhythm, and following a change in his
awake/sleep cycle. Contributing to the casualty
was the pilothouse alerter system not alarming
to wake the incapacitated deckhand at the helm
because a swinging very high frequency radio
microphone in the motion sensors’ field of view
defeated the system.
»Recommendations Issued: None
»Report Date: September 23, 2024
Contact of Towing Vessel John 3:16
with Pier
Saint Rose, Louisiana, September 12, 2023
On September 12, 2023, about 6:41 a.m., the towing
vessel John 3:16 was transiting the Lower Mississippi
River near Saint Rose, Louisiana, when the vessel
contacted an industrial cargo pier. No pollution or
injuries were reported. The final cost to repair the
damages to the towing vessel and pier was $285,441.
Figure 28.
John 3:16 underway on an unknown date
before the contact. SOURCE: MARQUETTE TRANSPORTATION
We determined that the probable cause of the
contact was the pilot falling asleep while navigating
due to an accumulated sleep debt. Contributing to the pilot’s fatigue was cell phone use during
off-watch time, which significantly limited the pilot’s
opportunity for sleep.
»Recommendations Issued: None
»Report Date: August 1, 2024
Engine Room Fire on board Passenger
Ferry Sandy Ground
Staten i sland, New York, December 22, 2022
On December 22, 2022, about 4:54 p.m., an engine
room fire broke out aboard the passenger ferry
Sandy Ground while the vessel was underway in
New York Harbor near Staten Island, New York,
with 884 persons aboard. The crew extinguished
the fire by activating the engine room’s fixed fire
extinguishing system. The vessel lost propulsion
and electricity, and the crew deployed both anchors.
Most of the passengers transferred to responding
Good Samaritan vessels; the Sandy Ground
was towed to the St. George Ferry Terminal in
Staten Island, where the remaining persons on
board disembarked. There were no injuries, and no
pollution was reported. Damage to the vessel was
estimated at $12.7 million.
We determined that the probable cause of the
engine room fire was the design of the vessel’s
diesel engine fuel oil return system, which included
isolation valves that could be regularly adjusted
by the crew and, when closed, stopped return fuel
oil flow from all operating engines, resulting in the
overpressurization of the fuel oil system and the
ignition of fuel oil spraying from ruptured fuel oil
filters onto the exhaust manifold of a running engine.
Contributing to the overpressurization was the
operator’s inadequate training program on fuel oil
system operation, which did not provide follow-on
instruction after the installation of fuel oil return
isolation valves at the day tanks.
OFFICE OF MARINE SAFETY36
2024 Annual Report to Congress National Transportation Safety BoardFigure 29.
Evacuation of passengers from the
Sandy Ground to the Franklin Delano Roosevelt .
SOURCE: NEW YORK CITY DEPARTMENT OF TRANSPORTATION
FERRY DIVISION
We identified the following safety issues during
this investigation:
(1) engineering crewmembers’ ineffective
management of fuel oil day tank levels on the
Sandy Ground ,
(2) inadequate training for engineering
crewmembers on the use of fuel oil return isolation
ball valves in the fuel oil system,
(3) the need for a requirement to maintain
unimpeded return flow in diesel engine fuel oil return
systems, and
(4) the need for additional regulatory and
classification society guidance on fuel oil return
system design.
As a result of this investigation, we issued safety
recommendations to the US Coast Guard and to the
American Bureau of Shipping.
»Recommendations Issued: 5 new
»Report Date: July 9, 2024 Contact of Queen City Tow with Vane Dike
Louisville, Kentucky, March 28, 2023
On March 28, 2023, about 2:24 a.m., the towing
vessel Queen City was downbound on the Ohio River
in high-water conditions, pushing an 11-barge tow,
when the tow struck the Vane Dike at the arrival
point for the McAlpine Locks and Dam in Louisville,
Kentucky, and broke apart. No pollution or injuries
were reported. Total damages to the barges and
cargo were estimated to be $1.98 million.
We determined that the probable cause of the
contact was the pilot not effectively compensating
for the strong outdraft while navigating toward the
lock channel entrance during a period of high-flow
conditions.
»Recommendations Issued: None
»Report Date: May 7, 2024
Figure 30.
Barges IN995423 and IB1938 against the
lower dam gates. IB1913 is receiving methanol from
IB1938 through a cargo transfer hose.
SOURCE: US COAST GUARDContact of Tank Vessel Bow Triumph
with Pier
Charleston, South Carolina, September 5, 2022
On September 5, 2022, about 4:02 p.m., the
600-foot-long tanker Bow Triumph was transiting
outbound on the Cooper River near Naval Weapons
Station, Joint Base Charleston, South Carolina, when
the vessel struck Naval Weapons Station Pier B. The
vessel’s bow sustained significant damage, and a
300-foot section of the pier collapsed. No pollution
or injuries were reported. Damage to the vessel and
pier was estimated at $29.5 million.
Figure 31.
Bow Triumph at the Odfjell Terminal in
Charleston on September 8, 2022, showing damage to
the vessel’s starboard side. SOURCE: US COAST GUARD
We determined that the probable cause of the
contact was the pilot’s decision to maneuver the
vessel close to the left bank while approaching the
turn immediately before the pier, exposing the tanker
to bank effect, which the pilot’s subsequent rudder
and engine orders could not overcome.
»Recommendations Issued: None
»Report Date: April 15, 2024
OFFICE OF MARINE SAFETY37
2024 Annual Report to Congress National Transportation Safety BoardCollision between Tugboat Mark E
Kuebler and Tanker Nisalah
Port Aransas, Ingleside, Texas, January 22, 2023
On January 22, 2023, about 3:30 p.m., the tugboat
Mark E Kuebler and the tanker Nisalah collided
while the tanker was transiting inbound in the
Corpus Christi Ship Channel near Ingleside, Texas.
The tugboat’s hull was breached, and the tanker’s
propeller was damaged in the collision. The captain
of the Mark E Kuebler grounded the tugboat to
prevent it from sinking, and, while aground, a
small sheen of hydraulic oil was observed near
the tugboat. The oil was recovered with absorbent
pads. No injuries were reported. Damage to the
Mark E Kuebler was estimated at $3 million; damage
to the Nisalah was estimated at $3.9 million.
Figure 32.
Mark E Kuebler aground following the
collision. SOURCE: G & H TOWING
Figure 33.
Tanker Nisalah in 2018.
SOURCE: PATRICK DEENIKWe determined that the probable cause of the
collision was the mate maneuvering the tugboat
near the starboard quarter of the tanker, which
resulted in the tugboat being drawn in toward the
tanker by hydrodynamic forces that the tugboat had
insufficient reserve power to counteract due to the
transit speed of the vessels.
»Recommendations Issued: None
»Report Date: February 21, 2024
Anchor Strike of Underwater Pipeline and
Eventual Crude Oil Release
San Pedro Bay near Huntington Beach, California,
October 1, 2021
On October 1, 2021, at 4:10 p.m., San Pedro Bay
Pipeline controllers received the first of a series of
leak detection system alarms for their underwater
pipeline located in San Pedro Bay, 4.75 nautical
miles off the coast of Huntington Beach, California.
Over the next 13 hours, the controllers conducted
seven pipeline shutdowns and restarts to identify
the problem. At 6:04 a.m. on October 2, controllers
shut down the pipeline for the eighth and final time.
A pipeline contractor vessel crew visually confirmed
a crude oil release at 8:09 a.m. and Beta Offshore,
the pipeline operator, initiated an oil spill response.
An estimated 588 barrels of oil leaked from the
pipeline. Damage, including clean-up costs, was
estimated at $160 million. There were no injuries. A
postaccident underwater examination of the pipeline
found a crack along the top of the pipeline within a
section of the pipeline that had been displaced from
its originally installed location. Additionally, scarring
consistent with anchor dragging was identified on
the seafloor near the crack location. Postaccident
investigation determined that the containerships
MSC Danit and Beijing had dragged anchor near
the pipeline months before the oil release, on
January 25, 2021.Figure 34.
Crude oil in the Pacific Ocean off the
California coast on October 3, 2021. Oil spill removal
organization vessels are towing a skirted oil boom to
contain the oil spill. SOURCE: US COAST GUARD
We determined that the probable cause of the
damage to and subsequent crude oil release from
the pipeline was the proximity of established
anchorage positions to the pipeline, which resulted
in two containerships’ anchors striking the pipeline
when the ships dragged anchor in high winds and
seas. Contributing to the crude oil release was the
undetected damage to the pipeline, which allowed
fatigue cracks to initiate and grow to a critical
size and the pipeline to leak nearly 9 months later.
Contributing to the amount of crude oil released
was Beta Offshore’s insufficient training of its
pipeline controllers, which resulted in the failure
of the controllers to appropriately respond to leak
alarms by shutting down and isolating the pipeline.
Contributing to the pipeline controllers’ inappropriate
response to the leak alarms was the water buildup in
the pipeline, an incorrect leak location indicated by
Beta Offshore’s leak detection system, and frequent
previous communication-loss alarms.
OFFICE OF MARINE SAFETY38
2024 Annual Report to Congress National Transportation Safety BoardWe identified the following safety issues during
this investigation:
(1) an insufficient distance between anchorage
locations and the pipeline,
(2) the need for notification of potential pipeline
damage to the pipeline operator,
(3) the need for improvements to vessel traffic
services vessel monitoring systems, (4) the incorrect response by pipeline controllers
to leak alarms,
(5) the lack of postaccident alcohol and other drug
testing for pipeline controllers, and
(6) the need for pipeline operators to implement
pipeline SMSs.
As a result of this investigation, we issued safety
recommendations to the US Coast Guard, the Marine Exchange of Southern California, and the Pipeline
and Hazardous Materials Safety Administration
(PHMSA).
»Recommendations Issued: 6 new
»Report Date: January 2, 2024
Ongoing Significant Marine Investigations
At the close of 2024, the Office of Marine Safety had 67 open domestic investigations. The following ongoing investigations involved significant
safety issues. We are devoting significant resources to these investigations and anticipate producing a report upon the completion of each one.
TABLE 7. Ongoing Significant Marine Investigations
Location Event Date Description Fatalities2025
Report Date
La Salle, Michigan 8/10/2024 Collision between recreational vessel and uncrewed surface vessel (US) 0
Baltimore, Maryland 3/26/2024Contact of containership Dali (SGP) with Francis Scott Key Bridge and
subsequent bridge collapse6
Goose Creek, South Carolina 1/14/2024Contact of bulk carrier Hafnia Amessi (SGP) with Joint Base Charleston—
Naval Weapons Station Pier B0 3/24/2025
La Porte, Texas 1/8/2024 Engine room fire aboard cargo vessel Stride (PAN) 2 1/29/2025
Dutch Harbor, Alaska 12/27/2023 Fire aboard cargo vessel Genius Star XI (PAN) 0
Newark, New Jersey 7/5/2023 Fire aboard roll-on/roll-off containership Grande Costa D’Avorio (ITA) 2 4/15/2025
Atlantic Ocean, 900 nautical miles east
of Cape Cod, Massachusetts6/18/2023 Hull failure of submersible Titan (US) 5
OFFICE OF MARINE SAFETY39
2024 Annual Report to Congress National Transportation Safety BoardInvestigative Hearings
US Coast Guard Marine Board
of Investigation: Hull Failure of
Submersible Titan
September 16–27, 2024
From September 16 to September 27, 2024, the
US Coast Guard held a Marine Board of Investigation
hearing in Charleston, South Carolina, regarding the
hull failure of the submersible Titan , which occurred
on June 22, 2023, about 900 nautical miles east of
Cape Cod, Massachusetts. The Titan had submerged
at 8:00 a.m. that day with five people on board and was
scheduled to surface in the afternoon after viewing
the wreckage of the Titanic , but the research vessel
Polar Prince lost contact with the submersible about
1 hour and 45 minutes into its voyage. On June 22,
about 3:00 p.m., the US Coast Guard announced that
the Titan ’s tail cone and additional debris had been
found. All five people on board are presumed dead.
One representative from the Office of Marine Safety
and another from the Office of Research and
Engineering participated in the hearing. The
Marine Board of Investigation, the highest level of
marine casualty investigation conducted by the
US Coast Guard, is tasked with examining the causes
of the marine casualty and making recommendations
to improve maritime safety.US Coast Guard Formal Investigation
Hearing: Fire aboard the Roll-on/Roll-off
Cargo Vessel Grande Costa D’Avorio
January 10–18, 2024
From January 10 to January 18, 2024, the US
Coast Guard held a formal investigation public
hearing in Newark, New Jersey, into the fire aboard
the roll-on/roll-off cargo vessel Grande Costa D’Avorio ,
which occurred at the Port of Newark during cargo
loading operations on July 5, 2023. The 692-foot
Italian-flagged vessel was on a regular run, loading
containerized cargo and used vehicles in ports along
the US East Coast and delivering them to ports in
West Africa. The vessel was loading used vehicles in
Newark when a vehicle fire broke out. Crewmembers
were unable to extinguish the fire and evacuated the
cargo space. Shoreside firefighters responded to
assist, and two firefighters were fatally injured. The fire
was finally extinguished on July 11, 2024.
One representative from the Office of Marine Safety
and another from the Office of Research and
Engineering participated alongside the US Coast Guard
in questioning witnesses. The hearing detailed the
condition of the Grande Costa D’Avorio prior to and
at the time of the fire, including the cargo loading
process for vehicles at the Port of Newark, initial
response actions by the ship’s crew, and subsequent
response and recovery efforts by local land-based
fire departments.International Investigations
Given the international nature of the marine
transportation system and the number
of foreign-registered (-flagged) cruise and
cargo ships operating from US ports, the
NTSB’s investigation of accidents involving
both domestic and foreign-registered vessels
promotes marine safety worldwide.
Capsizing and Sinking of Yacht Bayesian
Sicily, Italy, August 19, 2024
On August 19, 2024, at 6:14 a.m., the 184-foot
recreational yacht Bayesian capsized and sank off
the coast of Sicily, Italy, during a severe weather
event. There were 22 people aboard the vessel
(10 crewmembers and 12 passengers); 7 were fatally
injured (1 crewmember and 6 passengers) and 15
were rescued. The US Coast Guard (Coast Guard
Activities Europe) and the NTSB are participating in the
investigation of this casualty with the United Kingdom
(Marine Accident Investigation Branch) under the IMO
Code of International Standards and Recommended
Practices for a Safety Investigation into a Marine
Casualty or Marine Incident .
Weather-Related Damage to
Passenger Vessel Viking Polaris
Cape Horn, Chile, November 29, 2022
On November 29, 2022, the 665-foot-long passenger
vessel Viking Polaris was transiting Drake Passage
near Cape Horn, Chile, when the vessel experienced
weather-related damage, causing passenger cabin
windows to shatter. One passenger was fatally injured,
and eight passengers sustained injuries. The NTSB
and the US Coast Guard represented the United States,
which was invited to participate in this investigation as
a substantially interested state, and we produced an
investigation close-out memorandum.
OFFICE OF MARINE SAFETY40
2024 Annual Report to Congress National Transportation Safety BoardSafety Alert
In 2024, the Office of Marine Safety developed
one safety alert for issuance by the Board.
Reducing the Risk of Diesel Engine
Fuel Return System Overpressurization
» SA-094
We urged vessel owners and operators to mitigate
the risk of engine room fires resulting from the
overpressurization of diesel engine fuel systems by
eliminating isolation valves in return lines or using one
of three other alternatives: installing a check valve
in the return line, a locked-open isolation valve, or a
pressure relief valve in the return line.
Safety Action
During 2024, the Office of Marine Safety
documented one safety action.
• In 2024, the National Oceanic and
Atmospheric Administration’s Ocean
Prediction Center released the Freezing Spray
Guidance web page in response to the NTSB’s
recommendations and investigation of the
2019 capsizing and sinking of the commercial
fishing vessel Scandies Rose near Sutwik
Island, Alaska. This new web page shows
estimates of ice accumulation in centimeters
per hour on a vessel moving through the
region at an average speed of about 20 knots.
It also provides icing hazard information
from three forecast models and better user
interface and imagery, and it covers both the
Alaska and north Atlantic marine regions.Other Significant Achievements
Safer Seas Digest 2023 :
Annual Publication
The Safer Seas Digest 2023 was released in
May 2024. The digest comprises concise summaries
of the previous year’s casualty investigations and
represents the NTSB’s continuing commitment to
sharing the lessons that we learn through our marine
investigations to inspire safety improvements. Some
of the safety issues examined in the 2023 edition
included the following:
• Detecting small vessels
• Communicating effectively
• Inspecting equipment proactively
• Mitigating fatigue
• Anticipating fire hazards
• Improving firefighting training
• Conducting timely hull maintenance and repair
• Maintaining an effective watch
• Avoiding nonoperational cell phone use
• Reporting chart changes and hazards
• Avoiding excessive speed during bow-to-bow
harbor-assist operations
• Preventing vessel damage from the risk of
thermal runaway of lithium-ion batteries
• Reporting potential damage from dragging
anchorsFigure 35.
Safer Seas Digest 2023 cover.
Congressional and
Inter-Agency Briefings
• On September 17, 2024, the acting director
of the Office of Marine Safety presented
information regarding the ongoing Dali
investigation at the US Committee on the
Marine Transportation System Coordinating
Meeting and answered questions from
committee members.
• On May 23, 2024, office staff briefed
congressional authorizing committee
members and staff regarding the Dali-Francis
Scott Key Bridge investigation and the
preliminary findings.
2024 Annual Report to Congress National Transportation Safety BoardOffice of Railroad, Pipeline
and Hazardous Materials
Investigations
16 Two pipeline safety recommendations were issued from the San Pedro Bay near Huntington Beach, California
investigation, and two railroad safety recommendations were issued from the Arlington, Virginia investigation,
which were adopted in 2023 and released on January 5, 2024.TABLE 8. Office of Railroad, Pipeline and Hazardous Materials
Investigations Safety Statistics
Recommendations Issued16 ............................... 38
Recommendations Closed in an Acceptable Status ............ 31
Board-Adopted Investigation Reports ........................ 1
Safety Alert ............................................. 1
Safety Actions ........................................... 9
Major Investigation Launches ............................... 2
Field Investigation Launches .............................. 21
Publication ............................................. 1
Outreach .............................................. 63The Office of Railroad, Pipeline and
Hazardous Materials Investigations
investigates accidents involving railroads,
pipelines, and hazardous materials, and
evaluates the associated emergency response.
Based on the findings of these investigations,
the NTSB may issue safety recommendations to
federal and state regulatory agencies; unions,
industry, and safety standards organizations;
carriers and pipeline operators; equipment
and container manufacturers; producers
and shippers of hazardous materials; and
emergency response organizations. The NTSB
may also issue safety alerts to industry.
The Office of Railroad, Pipeline and Hazardous
Materials Investigations comprises four
divisions: Railroad, Pipeline and Hazardous
Materials, System Safety, and Report
Development.
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS42
2024 Annual Report to Congress National Transportation Safety BoardInvestigation Reports
During 2024, the Office of Railroad, Pipeline and Hazardous Materials Investigations issued a
total of 12 investigation reports; 1 of these involved safety issues that led to the issuance of
34 safety recommendations.
Below are summaries of seven of the railroad, pipeline, or hazardous materials investigation
reports completed during this period.
17 All times stated are local time.Union Pacific Railroad Train Collision
Chico, Texas, April 16, 2023
On April 16, 2023, about 6:44 p.m., a southbound
Union Pacific Railroad (UP) train crossed a main track
switch lined toward yard track C-4 and collided with a
parked UP train in Chico Yard in Chico, Texas.17 As a result of the collision, 12 loaded hopper railcars
and 2 locomotives from the southbound train derailed,
and 1 empty gondola railcar and 2 locomotives from
the parked train derailed. Two crewmembers from the
southbound train were seriously injured. UP estimated
damages to equipment and track infrastructure to be
about $4.9 million.
Figure 36. Aerial view of the Union Pacific Railroad train collision wreckage in Chico, Texas.
SOURCE: UP, ANNOTATED BY NTSBWe determined that the probable cause of the
collision was the lining of the C-yard main track switch
to yard track, a human error made by the conductor
of the parked train. Contributing to the collision was
the inability of the dispatcher and the crew of the
southbound train to determine the position of the main
track switch in nonsignaled territory in time to prevent
the collision.
We identified the following safety issues during
this investigation:
(1) failure to comply with operating procedures,
(2) insufficient training, and
(3) insufficient administrative controls related to
switching operations.
After the collision, on May 9, 2023, the Federal
Railroad Administration (FRA) issued a safety bulletin
to railroad employees and contractors to increase
awareness of safe operations of hand-operated main
track switches in nonsignaled territory. The bulletin
described the circumstances of the collision and
provided best practices, such as visually verifying
that hand-operated switches are properly lined for the
intended route and guarding against complacency
derived from repetitive task performance (such as the
repetition associated with relining main track switches)
by using multiple methods to confirm that safety
critical tasks are complete.
Following the collision, UP issued an incident alert
reminding employees of applicable rules, including
the General Code of Operating Rules 8.2 and 8.3,
and Special System Instructions Item 10-K. UP also
updated Duncan Subdivision General Order No. 5
to include a head-end speed restriction of 20 mph
throughout Chico Yard.
»Recommendations: None
»Report Date: November 13, 2024
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS43
2024 Annual Report to Congress National Transportation Safety BoardSoutheastern Pennsylvania Transportation
Authority Trolley Derailment
Philadelphia, Pennsylvania, July 27, 2023
Figure 37.
Overview of the SEPTA trolley derailment
area in Philadelphia, Pennsylvania.
On July 27, 2023, about 10:18 p.m., a SEPTA trolley
derailed at the intersection of Island Avenue and
Woodland Avenue in Philadelphia, Pennsylvania,
and struck an SUV and the Blue Bell Inn. Shortly
before the derailment, an electronics specialist had
started operating the trolley from SEPTA’s Elmwood
maintenance facility toward an adjoining yard for
storage. As the trolley left the facility, the electronics
specialist attempted to apply the air brakes to stop
the trolley from moving downhill into Island Avenue,
but the brakes had been rendered inoperable during
maintenance and did not activate. The electronics
specialist jumped out of the trolley before it derailed,
sustaining minor injuries. The sport utility vehicle
was occupied by four people, two of whom were
transported to a local hospital with minor injuries. The
Blue Bell Inn was occupied by one resident, who was
not injured. SEPTA estimated equipment damage to be about $500,000. Damage to the Blue Bell Inn was
estimated to be about $300,000.
We determined that the probable cause of the
derailment was the trolley’s movement with inoperable
brakes, of which the electronics specialist operating
the trolley was unaware because of insufficiently
documented maintenance procedures. Contributing
to the likelihood of the accident were inadequate
training resources for maintenance employees and a
maintenance shift turnover process that lacked clear
communication about the condition of the brakes.
We identified the following safety issues during
this investigation:
(1) insufficient maintenance procedures for replacing
air compressors,
(2) inadequate training of maintenance employees,
and
(3) the lack of clear communication during shift
turnovers.
»Recommendations: None
»Report Date: October 22, 2024
Norfolk Southern Railway Conductor Fatality
Cleveland, Ohio, March 7, 2023
On March 7, 2023, about 1:08 a.m., a Norfolk Southern
Railway (NS) conductor on an NS train was killed
when the train collided with a dump truck as it entered
a private highway–railroad grade crossing in the
Cleveland-Cliffs Incorporated steel plant in Cleveland,
Ohio. The conductor was riding the lead railcar during a
shoving movement when the collision caused him to be
pinned between the railcar and the dump truck.
We determined that the probable cause of the
employee fatality was the crew not following NS
Operating Rule 120, which requires a member of the
crew to be on the ground at the private highway–
railroad grade crossing to warn traffic. Contributing
to the accident was the design of the intersection at
the private highway–railroad grade crossing, which prevented adequate sight distance for the driver to
determine if it was safe to cross the tracks.
Figure 38.
Final resting place of a dump truck and
NS train after they collided in Cleveland, Ohio.
SOURCE: FRA
We identified the following safety issues during
this investigation:
(1) failure to adhere to operating rules, and
(2) grade crossing safety.
»Recommendations: None
»Report Date: July 22, 2024
Norfolk Southern Railway Derailment and
Hazardous Materials Release
East Palestine, Ohio, February 3, 2023
On February 3, 2023, about 8:54 p.m., an eastbound NS
train derailed 38 mixed freight railcars at milepost 49.5
on the NS Fort Wayne Line of the Keystone Division
in East Palestine, Ohio. Three tank cars carrying
flammable and combustible hazardous materials were
mechanically breached during the derailment. A fire
ignited during the derailment and grew to involve lading
released from these three mechanically breached
tank cars, additional derailed tank cars carrying both
hazardous and nonhazardous materials, and freight
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS44
2024 Annual Report to Congress National Transportation Safety Boardcars. Emergency responders established a 1-mile
evacuation zone that affected about 2,000 residents.
The derailed equipment included five hazardous
materials tank cars carrying vinyl chloride monomer
(VCM), a compressed liquified flammable gas. These
five cars had not been mechanically breached during
the derailment, but over the next day, four of them
were exposed to fires and released material from
pressure relief devices. Acting on information provided
by NS and its contractors that a dangerous chemical
reaction was occurring within a VCM tank car, the
incident commander managing the response, who
was unaware of dissenting opinions the shipper had
provided to NS and its contractors, chose to expand
the evacuation zone and perform a vent and burn (a
deliberate breach of a tank car) on all five derailed VCM
tank cars. A contractor hired by NS breached the five
tank cars on February 6, releasing and igniting their
lading. No injuries were reported during the derailment
or emergency response.
Figure 39.
Overhead view of derailment and early fire.
SOURCE: ERIC'S TRAIN YARD, ANNOTATED BY NTSBWe determined that the probable cause of the
derailment was the failure of the L1 bearing on the
23rd railcar in the consist that overheated and caused
the axle to separate, derailing the train and leading to
a postderailment fire that had likely began with the
release of a Class 3 flammable liquid from a DOT-111
tank car punctured during the derailment.
Contributing to the postderailment fire and the
severity of the hazardous materials release was the
continued use of DOT-111 tank cars in hazardous
materials service. Also contributing to the severity of
the hazardous materials release were the failure of NS
and its contractors to communicate relevant expertise
and dissenting opinions to the incident commander and
the inaccurate representation by NS and its contractors
that the tank cars were at risk of catastrophic failure
from a polymerization reaction, which created
unwarranted urgency and led to the unnecessary
decision to vent and burn the five VCM tank cars to
prevent a polymerization-induced tank car rupture.
Contributing to the exposure of emergency responders
and the public to postderailment hazards were NS’s
delay in transmitting the train consist information to
emergency responders and Ohio’s insufficient training
requirements for volunteer firefighters.
We identified the following safety issues during
this investigation:
(1) the failure of systems intended to identify failing
wheel bearings;
(2) inadequate training of volunteer first responders;
(3) the delayed transmittal of train consist
information to first responders;
(4) the illegibility of fire-damaged placards;
(5) the use of tank cars with documented poor
derailment performance;
(6) a tank car certification process that could not
ensure that tank car fittings are compatible with
approved commodities, misleading written guidance
and information about chemical hazards; and
(7) the flawed communication and decision-making process leading up to the deliberate breach of five tank
cars containing VCM.
As a result of this investigation, we issued safety
recommendations to the following:
• US DOT
• FRA
• PHMSA
• State of Ohio
• Columbiana County Emergency Management
Agency
• Association of American Railroads (AAR)
• International Association of Fire Chiefs
• International Association of Fire Fighters
• National Volunteer Fire Council
• The Chlorine Institute
• American Chemistry Council
• NS
• Oxy Vinyls, LP
We also reiterated a safety recommendation
to the Class I railroads and classified safety
recommendations to the Secretary of Transportation,
PHMSA, and the FRA.
»Recommendations: 34 new, 1 reiterated,
3 classified in this report
»Report Date: June 25, 2024
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS45
2024 Annual Report to Congress National Transportation Safety BoardUnion Pacific Railroad Employee Fatality
El Paso, Texas, August 29, 2022
On August 29, 2022, about 9:14 p.m., the conductor of
a UP train was killed during a shoving movement when
two railcars of the train derailed in UP’s Alfalfa Yard in
El Paso, Texas. The conductor was riding on the lead
end of the first railcar when the train encountered a
derail that had been placed on the yard lead earlier
in the day to protect maintenance-of-way employees
during an upcoming installation project. As the train
entered the yard, it encountered the derail device, and
two railcars derailed. One of these railcars overturned,
landing on its side, then sliding into a residential property where it struck a natural gas line owned by
Texas Gas Service. The railcar’s contact with the gas
line did not result in a gas leak.
We determined that the probable cause of the
employee fatality was the failure of personnel to
contact the employee-in-charge before granting the
train permission to enter the yard lead track.
We identified the following safety issue during
this investigation: inadequate protection for
maintenance-of-way employees performing shoving
movements.
»Recommendations: None
»Report Date: April 25, 2024
Figure 40.
Aerial view of accident scene showing derailed railcars after a UP conductor was killed during a
shoving movement at UP’s Alfalfa Yard in El Paso, Texas.
SOURCE: UNION PACIFIC RAILROAD (DRONE IMAGE), ANNOTATED BY NTSBNorfolk Southern Railway Employee Fatality
Bessemer, Alabama, December 13, 2022
Figure 41.
Gondola car and protruding angle iron
section immediately before impact.
SOURCE: NORFOLK SOUTHERN RAILWAY, ANNOTATED BY NTSB
On December 13, 2022, about 12:01 a.m., the lead
locomotive of a northbound NS freight train struck a
length of steel angle iron protruding from a gondola
car on a stationary NS freight train on the Alabama
Great Southern South Subdivision in Bessemer,
Alabama. The northbound train was traveling about
54 mph on main track 2; a second NS train was
stopped on main track 1. The gondola car was part of
a block of 21 railcars recently added to the stopped
train from a yard track near a US Pipe recycling
facility. The section of angle iron was protruding
from the top edge of the gondola car on its east
side, fouling main track 2. As the lead locomotive of
the northbound train passed the gondola car on the
adjacent track, the section of angle iron penetrated
the locomotive’s left-front door window, continued
into the operating cab, and struck the conductor
trainee, who was fatally injured. The conductor was
transported to a local hospital for minor injuries.
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS46
2024 Annual Report to Congress National Transportation Safety BoardWe determined that the probable cause of the
employee fatality was the hazardous condition of a
gondola car known to personnel at a US Pipe facility
but not communicated to NS nor identified by NS
personnel during required predeparture inspections.
We identified the following safety issue during this
investigation: inadequate visual inspections.
»Recommendations: None
»Report Date: April 3, 2024
Caltrain Passenger Train Collision with
Hi-Rail Construction Vehicles
San Bruno, California, March 10, 2022
On March 10, 2022, about 10:31 a.m., a southbound
Caltrain train struck three hi-rail construction vehicles
in San Bruno, California. The train’s locomotive derailed,
and all three construction vehicles were destroyed.
Released fuel from the construction vehicles fed a
fire that spread to one of the passenger railcars, and eight people were transported to local hospitals. One
railroad construction employee sustained serious
injuries. One train crewmember was treated and
released from the hospital. Six passengers who
were treated for minor injuries were also released.
Caltrain estimated that the property damage exceeded
$1.4 million.
We determined that the probable cause of
this accident was the roadway worker-in-charge
releasing exclusive track occupancy protection,
leaving workers and construction equipment
unprotected on the main track due to his degraded
performance from excessive workload.
We identified the following safety issues during
this investigation:
(1) inadequate hours-of-service requirements,
(2) the lack of a fatigue risk management plan, and
(3) inadequate roadway worker protections.
»Recommendations: None
»Report Date: February 27, 2024
Figure 42.
Illustration of the collision.
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS47
2024 Annual Report to Congress National Transportation Safety BoardOngoing Significant Railroad, Pipeline, or Hazardous Materials Investigations
At the close of 2024, the Office of Railroad, Pipeline and Hazardous Materials Investigations had 30 open investigations; 13 of which involve
significant safety issues. The office is devoting significant resources to these investigations and anticipates producing a report upon the
completion of each one.
TABLE 9. Ongoing Significant Railroad, Pipeline or Hazardous Materials Investigations
Location Event Date Description Fatalities2025
Report Date
Avondale, Louisiana 12/2/2024 Explosion of natural gas resulting in destruction of a home 1
Rocky Mount, North Carolina 11/19/2024 Serious injury of Carolina Coastal Railway train conductor 0
South Jordan, Utah 11/6/2024 Explosion of natural gas resulting in destruction of a home 1
Bel Air, Maryland 8/11/2024 Explosion of natural gas resulting in destruction of a home 2
Melrose Park, Illinois 7/6/2024 Fatality of UP conductor 1
Youngstown, Ohio 5/28/2024 Explosion of natural gas in a mixed use commercial and residential building 1
McNeil, Arkansas 4/11/2024 Union Pacific Railroad employee fatality 1 4/3/2025
Jackson, Mississippi 1/24/2024 Explosion of natural gas resulting in destruction of three homes 1
Manhattan, New York 1/4/2024 Collision of two New York City transit trains 0
Manhattan, New York 11/29/2023 Fatality of New York City transit employee 1
Great Barrington, Massachusetts 8/4/2023 Fatality of railroad employee 1
Baltimore, Maryland 6/26/2023 Fatality of CSX Transportation conductor trainee 1
West Reading, Pennsylvania 3/24/2023Explosion of natural gas resulting in destruction of commercial and residential
buildings7 3/18/2025
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS48
2024 Annual Report to Congress National Transportation Safety BoardSpecial Investigation into Norfolk Southern
Railway’s Safety Practices and Culture
Following the NS train derailment and subsequent
hazardous material release and fires in East Palestine,
Ohio, on February 3, 2023, and several other significant
NS accidents being investigated by the NTSB, in
March 2023, we initiated a special investigation into
NS’s organization and safety culture. The Railroad
Division and Office of Aviation Safety’s Human
Performance and Survival Factors Division are leading
the investigation.
As part of this special investigation, we surveyed
the NS workforce to gather real-time information from
NS employees across its entire network about the
organization’s safety culture. The survey allows us to
gather valuable insights directly from NS employees to
assess its safety practices and culture. The final report
is pending.Special Inquiry into Railroad Trespassing at
Lake Accotink Park, Springfield, Virginia
On June 5, 2024, about 8:20 p.m., an eastbound NS
train encountered two adults and one child trespassing
on a trestle bridge in Lake Accotink Park in Springfield,
Virginia. The bridge was 65 feet tall and 1,120 feet
long, had two main tracks, and was designed only for
rail traffic. The train crew sounded the train horn at
the whistle post 1,433 feet from the bridge. Shortly
afterward, when the crew saw people on the bridge,
they began an emergency braking application. The
three people fell from the bridge into a shallow creek
and were fatally injured.
We initiated a special inquiry into the accident and,
as a result, met with NS, the Fairfax County Park
Authority, and the FRA to discuss the incident and
ways to mitigate trespasser issues in the park. As an
outcome of these meetings, several safety actions
were undertaken by the stakeholders, including
community engagement to raise awareness about the
dangers of trespassing and installation of additional
signage near the tracks.
Safety Alert
During 2024, Office of Railroad, Pipeline and Hazardous Materials Investigations developed
the following safety alert for issuance by the Board.
Pipeline Safety Management Systems:
Vital for the Safe Operation of Pipelines » SA-095
This safety alert was derived from the October 1, 2021, anchor strike of an underwater pipeline and eventual
crude oil release, off the coast of Huntington Beach, California. Our investigation found that pipeline safety would
be enhanced if pipeline companies implemented SMSs. The safety alert describes additional accident scenarios in
which the lack of a pipeline SMS contributed to the accident.Safety Actions
During 2024, the Office of Railroad, Pipeline
and Hazardous Materials Investigations
documented 17 safety actions. The following
are summaries of a sampling of these actions.
• East Palestine, Ohio
On January 19, 2024, the FRA published a report
describing the results of the FRA’s Legacy Tank Car
Focused Inspection Program, a program undertaken
in response to the East Palestine derailment that
focused inspection resources on DOT -111 tank cars
and the shippers and tank car owners that have not
yet upgraded to the DOT -117 specification.
In February 2024, NS signed an agreement with the
Brotherhood of Locomotive Engineers and Trainmen
and the International Association of Sheet Metal,
Air, Rail and Transportation Workers—Transportation
Division to develop a Close Call Confidential
Reporting pilot program.
• Cleveland, Ohio
On May 22, 2024, in response to a rail conductor
fatality in Cleveland, Ohio, Cleveland-Cliffs
Incorporated took action to improve the safety of
the accident highway–railroad grade crossing by
altering the road to increase visibility at the crossing
and adding additional stop signs, crossbucks, and
portable light towers. Before railroad operations
started back up, Stein LLC site management met
with Stein LLC employees who worked in this
area and reiterated the company’s rail safety
practices and procedures and commitment to
safety. Stein LLC also audited and surveyed all
rail crossings in the Cleveland-Cliffs steel plant
and shared its findings with Cleveland-Cliffs.
Further, Cleveland-Cliffs is exploring more robust
enhancements to the crossing and has brought in an
engineering firm to provide assistance.
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS49
2024 Annual Report to Congress National Transportation Safety Board• Folkston, georgia
On April 18, 2024, CSX published a safety alert in
response to the collision in Folkston, Georgia. The
safety alert discussed operating requirements
for dual-controlled, power-operated switches
and emphasized that all trains must approach all
switches within the limits of the signal suspension
at restricted speed until it is known they are lined for
the authorized and intended route. In addition, CSX
published a signal suspension safety bulletin that
discusses signal suspension job briefing protocols
and field management audits and testing.
• Melrose Park, i llinois
On August 21, 2024, the UP vice president of safety
emailed the general directors of safety for both
regions, along with their director-level reports, and
instructed the general directors of safety to ensure
that all yard controllers were educated and proficient
at providing a switch person or conductor a job aid
when needed per the regulation.
• Norfolk, Virginia
On September 13, 2024, NS published a serious
incident notice to its workforce discussing the
serious conductor injury and highlighting rules
that must be followed. On September 6, 2024, NS
issued a Norfolk Terminal-Lambert’s Point special
instructions bulletin modifying rules regarding
equipment spacing and securement in the yard
where the incident occurred.
• Kenosha, Wisconsin
While NTSB investigators were on scene, UP told
them that track breach protection had not been
in effect on the Kenosha subdivision per Special
Instructions-14, miscellaneous instructions in the UP
timetable. NTSB investigators asked UP to consider
updating the instructions to allow employees to
utilize track breach protection on that subdivision. On September 2, 2024, UP issued a subdivision
general order canceling the earlier instructions.
• McNeil, Arkansas
On November 19, 2024, NTSB investigators held a
conference call with B&P Enterprises and UP officials
to discuss excessive cell phone usage by the B&P
excavator operator, which violated railroad rules.
Although the operator had not been using the phone
at the time of the accident, he had used it continually
for over 3 hours, ending his last call about 15 minutes
before the accident. In response, UP implemented
increased auditing of contractors for compliance with
phone usage rules.
• Somerville, Massachusetts
On October 30, 2024, NTSB investigators informed
the Massachusetts Bay Transportation Authority
(MBTA) that the distance between the 10 mph speed warning sign and the start of the 10-mph track
segment for eastbound movement on the Green
Line prior to the Redbridge Interlocking measured
286 feet. This distance was noted to be 64 feet
shorter than the MBTA’s own minimum distance
standard for speed warning signage of 350 feet. On
November 4, 2024, the MBTA reported completing
relocating the advance warning sign for that
segment to the previous catenary pole. In doing so,
the MBTA brought the distance in compliance with
the standard found in rule LR7 as published in “MBTA
Rules for Operating Employees” dated August 2023.
On October 29, 2024, the MBTA reported that
it had reduced the maximum authorized speed
from 30 to 25 mph for the track segment between
Lechmere Station and the Red Bridge Interlocking
on the Green Line to reduce the number of speed
changes in this segment and to lessen the speed
reduction necessary to transition to 10 mph at the
Red Bridge Interlocking.
Other Significant Achievements
Adoption of Safety Recommendations
• Safety Recommendation P-19-17 –
Massachusetts Exceeds Recommended Action
Following the September 2018 natural gas-fueled
explosion in Merrimack Valley, Massachusetts, we
called on the Commonwealth of Massachusetts
Executive Office of Public Safety and Security
to develop guidance that includes a component
for effective communications when deploying
mutual aid resources within the first hours of a
multijurisdictional incident.
Our investigation of the emergency response
to the community found that the state had available and ready resources to handle the large
number of distress calls; however, the response
involved so many different jurisdictions and first
responders that the scale of the response exceeded
the existing communications interoperability
capabilities at the time. Specifically, we found
that field radio communications used across
fire departments on September 13, 2018, lacked
adequate interoperability and availability to ensure
that emergency responders had efficient means
of interdepartmental and intradepartmental
communications, making it difficult for them to
communicate and coordinate the response.
Since the Merrimack Valley pipeline accident,
OFFICE OF RAILROAD, PIPELINE AND HAZARDOUS MATERIALS50
2024 Annual Report to Congress National Transportation Safety BoardMassachusetts has invested in resources to further
the state’s emergency response communications
capabilities, including publishing a state-wide fire
mobilization plan and upgrading its interoperable
radio system, which facilitates interoperability
between any agency or discipline in the state and any
area within its coverage footprint. We determined
that Massachusetts exceeded our recommendation,
making several substantive changes to improve
its emergency response communications
and serving as a model for other states.
• Safety Recommendation R-19-22 –
Amtrak Takes Acceptable Action
Following the December 2017 Amtrak train
derailment near DuPont, Washington, we called on
Amtrak (National Railroad Passenger Corporation)
to implement a formal, systemic approach to
developing training and qualification programs to
identify the most effective strategies for preparing
crewmembers to safely operate new equipment on
new territories.
Since the derailment, Amtrak has implemented
an extensive training program for engineers and
conductors to address our safety concerns. By
increasing performance standards, formalizing an
extensive process for conducting evaluation rides
for route qualification, recording trainee evaluation
rides and refresher training rides for engineers
to demonstrate their route proficiency during
refamiliarization rides every 12 months, Amtrak has
fully implemented our recommendation.
18 See Congressional and Regulatory Correspondence for more information on NTSB responses to regulatory actions and requests for comment.Regulatory Correspondence
We provided feedback and guidance on three
regulatory efforts related to the following rulemakings:
• FTA’s state safety oversight,
• FTA’s rail transit roadway worker protection,
and
• PHMSA’s information collection.18
Illustrated Digest Publication:
Norfolk Southern Railway Derailment and
Subsequent Hazardous Materials Release
We released an illustrated digest of our investigation
into the 2023 derailment of an NS freight train
carrying hazardous materials in East Palestine, Ohio.
The illustrated digest serves as a companion to our
201-page final report, using photos and graphics to
illustrate how and why the derailment occurred as
well as explaining our safety recommendations to
prevent similar accidents in the future. Although the
final report remains our definitive publication on the
derailment, the digest highlights the depth and scope
of the 16-month investigation.
Figure 43.
Ilustrated Digest cover.Rail Communication Technology
We purchased a new spectrum analyzer for use by
investigators during rail accident investigations to
assess the efficacy and integrity of rail technology,
including positive train control systems (PTC). This
technology offers investigators the ability to measure
and record PTC radio system parameters and to
analyze PTC communication radio network parameters
and message integrity.
2024 Annual Report to Congress National Transportation Safety BoardOffice of Research and
Engineering
TABLE 10. Office of Research and Engineering Safety Statistics
Safety Research Products Completed ........................ 2
Safety Data Analyses Completed .......................... 234
Materials Laboratory Exam Reports Completed .............. 183
Readouts of Vehicle Recorders and
Other Electronic Devices Completed ...................... 476
Vehicle Performance Reports and Animations Completed ....... 60
Medical Investigation Reports Completed .................. 188
Rapid Reports Completed ................................. 8
Publication ............................................. 1
Outreach .............................................. 93The Office of Research and Engineering is
an investigative office providing scientific
and technical expertise for NTSB accident
investigations in all modes of transportation.
The office, which includes four divisions and
one program area, conducts safety research,
generates periodic statistical reviews of
aviation accidents, conducts readouts of
vehicle recorders and other electronic devices,
conducts materials failure analysis and fire
investigations, determines vehicle performance
and develops animations, and provides medical
and toxicology expertise for investigations in
all modes.
Consistent with the NTSB’s strategic goal of
improving processes and products, the office
identifies ways to enhance the effectiveness
and efficiency of its investigative activities
and products. In 2024, to improve efficiency,
effectiveness, and succession planning,
the office hired two recorder specialists in
the Vehicle Recorder Division through the
Pathways program: an aerospace engineer
with a specialty in spacecraft engineering and
a computer scientist. These recent college
graduates add new knowledge and experience
to the division’s already extensive capabilities.
OFFICE OF RESEARCH AND ENGINEERING52
2024 Annual Report to Congress National Transportation Safety BoardSafety Research Division
The Safety Research Division examines
transportation accidents, accident trends,
and technological changes to identify problems
and associated remedial actions that will
reduce risk and improve the safety of the
transportation system. Division staff includes
transportation safety researchers, data analysts,
and statisticians who conduct systematic
examinations of the following:
(1) risks or hazards in the transportation
environment that may influence
accidents or injury,
(2) the techniques and methods of
accident investigation, and
(3) the effectiveness of various safety
countermeasures, such as policies,
programs, or technologies.
The division also provides data science, data
visualization, and statistical expertise to
support accident launches and investigations;
assists in safety recommendation development;
and publishes annual statistical reviews for the
NTSB, Congress, and the public.
In 2024, the Safety Research Division published the
NTSB’s official annual review of US civil aviation
accident statistics, as well as the agency’s response
to an advance notice of proposed rulemaking
on impaired driving prevention technology from
NHTSA. In addition, division staff published a paper
on delays in blood collection and drug toxicology
results among crash-involved drivers arrested for
impaired driving. Finally, the division completed 234
data, geospatial, and statistical analysis requests to support our accident investigations in aviation,
highway, marine, rail, and pipeline, and requests
from other government agencies, Congress, and the
public. The division is currently updating a safety
research report analyzing toxicology findings among
fatally injured pilots in US aviation.
Materials Laboratory Division
The Materials Laboratory Division performs
expert multidisciplinary engineering and
scientific analyses to determine if material or
structural performance is related to the cause
or severity of an accident. Staff also analyze
wreckage to determine the causes of fires and
explosions. The division provides chemical and
forensic science expertise, as well as technical
advice and resources for experimental testing
and research in the physical sciences.
In 2024, the division completed 183 reports for
97 investigations, launched to 6 accident sites,
and supported numerous NTSB reports and
recommendations. In one example, the division
supported the investigation of the Dali collision with
the Francis Scott Key Bridge that resulted in the
partial collapse of the bridge. Staff assisted with
evidence documentation and provided materials
expertise in evaluating the shipboard electrical
terminal block that had unexpectedly opened,
causing a loss of electrical power to the ship. The
division also aided in the investigation of a natural
gas-fueled explosion and fire in Jackson, Mississippi,
that resulted in the destruction of two homes and
the death of one resident. For this investigation, we
evaluated the failed service tee and provided support
to the fire and explosion investigation. In a third example, the division assisted in the investigation
of Alaska Airlines flight 1282 that sustained a rapid
in-flight decompression caused by the separation
of the left mid exit door plug. We examined the plug
and determined that four bolts that prevent upward
movement of the plug were missing.
Figure 44.
Materials Laboratory Division staff examine
door plug hardware with a three-dimensional laser
scanner (top) and a digital microscope (bottom).
OFFICE OF RESEARCH AND ENGINEERING53
2024 Annual Report to Congress National Transportation Safety BoardVehicle Recorder Division
The Vehicle Recorder Division extracts,
formats, and analyzes data from aircraft
flight data recorders and CVRs and from
recorders installed in locomotives, large
ships, and some highway vehicles. Engineers
also examine recorded electronic audio and
video information captured by aircraft, ship,
train, and support communication systems;
provide electronic engineering expertise for
all accident investigation modes in examining
communication and control systems; provide
time synchronization to correlate voice, data,
and video recorder outputs; use advanced
digital and analog filtering and signal
representation techniques to extract critical
recorder information; and perform forensic
examinations of personal electronic devices and
other computer hardware.
In 2024, division staff received 442 devices;
completed reports, transcripts, and studies for
476 devices to support aviation, railroad, marine,
and highway investigations, and launched to support
seven investigations. Of the recorders received,
56 were from foreign accidents and one was
from US military or other US government agency
investigations. Staff downloaded and evaluated
video and voyage data recorder information from
the Dali for the Francis Scott Key Bridge collapse
investigation. Staff also assisted in foreign
investigations, launching to the Haneda Airport
runway collision in Tokyo, Japan, and hosting
international investigators from Mexico, Colombia,
India, and Sudan, among other countries.Vehicle Performance Division
The Vehicle Performance Division
provides specialized aeronautical,
mechanical, structural, and biomechanical
engineering expertise; three-dimensional
laser scanning and accident reconstruction;
photogrammetry and video analysis; and
animation and graphics development for all
modes. Engineers use computational and
visualization technology to provide accurate
time-motion histories of the sequence of
events and evaluate data from multiple sources
to determine vehicle and occupant motion
and the underlying causes of that motion.
Engineers also develop video animations of
accident scenarios, evaluate occupant injury
mechanisms, and participate in and direct
research into special projects as required.
In 2024, division staff completed 60 products in
support of investigations (aircraft and surface vehicle
performance studies, video/photograph studies,
animations, and video compilations). Staff developed
animations to support the following investigations:
• October 2021 Washington Metropolitan Area
Transit Authority train derailment in Arlington,
Virginia
• January 2022 Fern Hollow Bridge collapse in
Pittsburgh, Pennsylvania
• February 2023 runway incursion and
overflight in Austin, Texas
• November 2022 in-flight collision during an
airshow in Dallas, TexasFigure 45.
Animation created by Vehicle Performance
Division staff depicts the sequence of events in a
runway incursion and overflight. YouTube link: Runway
Incursion and Overflight, Southwest Airlines 708
Federal Express 1432 .
Program Area —
Medical Investigations
NTSB medical officers evaluate the medical
aspects of investigations, including
medical fitness, pathology, toxicology, and
injury causation. Examples of medical issues
addressed include operator incapacitation,
injury prevention, vision deficiency, hypoxia,
obstructive sleep apnea, carbon monoxide
poisoning, mental health conditions, and
impairment from the effects of medications and
illicit drugs.
In 2024, the agency’s two physicians participated
in more than 100 investigations and completed
188 reports from all transportation modes. This
included evaluating and addressing medical
issues through formal factual and analytical
reports, safety recommendations, coordination
with other agencies, and formal presentations
to the Board and external audiences.
OFFICE OF RESEARCH AND ENGINEERING54
2024 Annual Report to Congress National Transportation Safety BoardOngoing Safety Research Report
2018–2022 Update to Drug Use Trends in Aviation
This safety research report will provide the most recent 5 years of data from ongoing toxicology evaluations
among fatally injured flying pilots. Toxicology data were obtained from the FAA’s Civil Aerospace Medical Institute
for the period spanning 2018 through 2022. The final report will address data trends useful for studying the
relationship between drug use and accident risk in the United States and other safety issues.
Other Significant Achievements
• The Office of Research and Engineering’s science, technology, engineering, and math outreach events included
five laboratory tours and six university lectures.
• The State of Delaware authorized the use of automated speed enforcement in response to NTSB Safety
Recommendation H-17-32 from the 2017 safety study, Reducing Speeding-Related Crashes Involving
Passenger Vehicles (SS-17/01).
• NHTSA worked with the GHSA to revise the Model Minimum Uniform Crash Criteria to include data elements
for electric scooters and electric bicycles in response to NTSB Safety Recommendation H-22-26 from the
2022 safety research report, Micromobility: Data Challenges Associated with Assessing the Prevalence and
Risk of Electric Scooter and Electric Bicycle Fatalities and Injuries (SRR-22-01). The State of New York also
signed into law Senate Bill 9419 requiring accidents involving electric scooters and electric bicycles to be
reported by state and local authorities.
19 See Congressional and Regulatory Correspondence for more information on NTSB responses to regulatory actions and requests for comment.Regulatory Correspondence
We provided feedback and guidance on three
regulatory efforts related to the following rulemakings:
• Drug Enforcement Administration’s Schedules
of Controlled Substances: Rescheduling of
Marijuana,
• FAA’s 25-Hour Cockpit Voice Recorder
Requirement, New Aircraft Production, and
• NHTSA’s Advanced Impaired Driving Prevention
Technology.19Investments in Technology
• Our Materials Laboratory and Vehicle Recorder
divisions acquired new state-of-the-art digital
microscopes with cutting-edge, three-dimensional
capability to increase production and assist in
advanced chip recovery work.
• We purchased three new video-processing
workstations for the Vehicle Recorder Division.
The new workstations will replace older
equipment, improving our capability to process
audio and video evidence of increasing volume
and resolution.Publication
• J. Price, R. C. Smith, A. K. Miles, and T. A. Kayagil.
Delays in Blood Collection and Drug Toxicology
Results Among Crash-Involved Drivers Arrested
for Impaired Driving. Traffic Injury Prevention
(2024).
Award
• Erik Mueller, a materials engineer in the Office of
Research and Engineering’s Materials Laboratory
Division, was named an American Society for
Materials International Fellow, October 1, 2024.
2024 Annual Report to Congress National Transportation Safety BoardOffice of Safety
Recommendations and
Communications
20 Recommendations closed in an acceptable status include those classified Closed—Exceeds Recommended Action,
Closed—Acceptable Action, and Closed—Acceptable Alternate Action. In this report, each recommendation issued
is reported as one recommendation, regardless of the number of recipients. Because some recommendations are
issued to more than one recipient, however, recommendations closed are reported by the number of recipients for
whom a recommendation was closed during the year.TABLE 11. Office of Safety Recommendations and
Communications Safety Statistics
Recommendations Closed in an Acceptable Status20 ........... 79
Recommendations Closed in an Unacceptable Status .......... 20
Testimony or Legislative Support to
State Legislative Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Public Webinars and Virtual Meetings ....................... 88
Media Mentions (Print, Broadcast, and Online) ........... 657,40 0
Outreach ............................................ 135The Office of Safety Recommendations
and Communications publicly releases
information on NTSB investigations, activities,
and safety recommendations across multiple
communication channels. The office engages
a range of stakeholders, including safety
recommendation recipients; members of the
transportation industry; transportation workers;
federal, state, and local government officials;
transportation safety advocates; and the public.
Our work spans an investigation’s lifecycle,
providing transparency that supports our
independence while building public trust
and support for our mission. Following an
investigation, office staff focus on advocating
for and monitoring safety recommendation
implementation.
The office comprises five divisions:
Safety Recommendations, Media Relations,
Government and Industry Affairs,
Safety Advocacy, and Digital Services.
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS56
2024 Annual Report to Congress National Transportation Safety BoardSafety Recommendations Division
NTSB safety recommendations address specific issues uncovered during investigations
and specify actions to help prevent similar accidents and events from occurring in the
future. These safety recommendations are the agency’s most important products because they
alert government, industry, and the public to the critical changes that are needed to prevent
transportation accidents and events, reduce injuries, and save lives.
We issue recommendations to the organizations best able to take corrective action, such as the
US DOT and its modal administrations, the US Coast Guard, other federal and state agencies,
manufacturers, operators, labor unions, and industry and trade organizations. The Safety
Recommendations Division helps investigative offices craft recommendations that will encourage
recipients to take the corrective action needed.
Once the Board issues a recommendation, the Safety Recommendations Division handles the
ongoing correspondence between the agency and each recipient, tracking and analyzing the
recipient’s responses and determining a classification—Acceptable or Unacceptable—for the
Board members to consider. The division monitors the progress of action to implement each
recommendation until it is closed (which usually takes several years), maintains a database of all
recommendations, compiles monthly statistics, and responds to data queries from other offices.
In 2024, the Safety Recommendations Division
reviewed and analyzed 114 responses from
recommendation recipients and developed
recommendation classification responses for Board
review and approval. Staff generated 16 follow-up
letters for recommendation recipients who had
not responded to NTSB safety recommendations
and helped the modal offices develop and issue
132 new safety recommendations resulting from
18 investigation reports. In addition, the division
developed numerous reports and data summaries
on specific recommendation topics to support NTSB
Board members, other agency staff, the media, and
the public. Outreach activities in 2024 included meetings to
discuss open recommendations with government
and industry organizations, including the following:
• Alliance for Automotive Innovation
• AAMVA
• AAR
• AASHTO
• American Chemistry Council
• Amtrak
• Apple
• BNSF Railway
• Canadian Pacific Kansas City
• City of Pittsburgh
• The Chlorine Institute
• Consolidated Edison Company of New York, Inc.
• CSX • CVSA
• FAA
• FHWA
• FMCSA
• FRA
• FTA
• GHSA
• Impairment-related state legislators and
organizations (.05 Coalition)
• International Association of Fire Chiefs
• National Association of Charterboat Operators
• National Association of State Boards of Education
• National Conference of State Legislatures
• National Weather Service (NWS)
• NHTSA
• NS
• North Slope
• PennDOT
• PHMSA
• Runway Safety Alerting Subgroup of the
Investigative Technologies Aviation Rulemaking
Committee
• State of Oklahoma
• State of West Virginia
• Triton
• UP
• US Army Corps of Engineers
• US Department of Agriculture, Forest Service
• US DOT
• US Coast Guard
• US Senate Committee on Commerce
• Virginia Passenger Rail Authority
• Washington Metrorail Safety Commission
• Washington Metropolitan Area Transit Authority
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS57
2024 Annual Report to Congress National Transportation Safety BoardIn 2024, 79 open recommendations were closed in an acceptable status; 28 of these had been issued to
US DOT modal agencies or the US Coast Guard. In addition, 20 safety recommendations were closed in an
unacceptable status in 2024; of these, 12 were issued to US DOT modal agencies or the US Coast Guard.21
The number of open recommendations that are closed each year fluctuates for various reasons. Over the
last 5 years (2020 through 2024), the number of safety recommendations closed in an acceptable status
has averaged 199 per year. As of December 31, 2024, 199 safety recommendations issued to US DOT modal
agencies or the US Coast Guard remain in open unacceptable response status.
TABLE 12. Safety Recommendations Issued to the US DOT, Modal Agencies, and the
US Coast Guard Closed and in Open Unacceptable Response Status in 2024
AgencySafety
Recommendations
Closed in an
Acceptable StatusSafety
Recommendations
Closed in an
Unacceptable StatusSafety
Recommendations
Open–Unacceptable
Response
Department of Transportation 0 0 4
Federal Aviation Administration 18 8 60
Federal Highway Administration 1 0 0
Federal Motor Carrier Safety Administration 0 0 11
Federal Railroad Administration 0 0 38
Federal Transit Administration 0 0 4
National Highway Traffic Safety
Administration3 0 65
Pipeline and Hazardous Materials Safety
Administration3 0 6
US Coast Guard 3 4 11
Total 28 12 199
21 A summary of the recipient responses and our reasoning for closing each recommendation in an unacceptable status, as required by 49 United States Code (U.S.C.) Section 1116(c)(3), can be found in Appendix A.
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS58
2024 Annual Report to Congress National Transportation Safety BoardAlso in 2024, we referenced related open safety recommendations in our responses to several notices issued
by the US DOT and other federal agencies in the Federal Register . The table below provides a summary of
these actions.
TABLE 13. Open Safety Recommendations Referenced in NTSB Responses to
Federal Register Notices from Federal Agencies in 2024
AgencyFederal Register
NoticesOpen Safety
Recommendations
Referenced
Department of Transportation 1 11
Federal Aviation Administration 4 4
Federal Transit Administration 2 17
National Highway Traffic Safety Administration 4 12
Pipeline and Hazardous Materials Safety Administration 1 1
Department of Justice, Drug Enforcement Administration 1 9
Total 13 54
Investigation and Safety Recommendations Database Search
CAROL (Case Analysis and Reporting Online) allows you to search NTSB
investigations and safety recommendations across all modes.
For more information on CAROL, including details on the data structure,
see the CAROL help page on our website at ntsb.gov .Media Relations Division
The Media Relations Division is responsible
for providing accurate and timely
information on the NTSB’s activities to the
media and public.
The division provides information about
accident, crash, and incident investigations
and coordinates the release of investigation
reports, safety research reports, safety
recommendations, safety alerts, and other
agency investigative products. The division
provides counsel to senior leaders, responds to
media inquiries, arranges media interviews of
agency personnel, and serves as the on-scene
public affairs contact, supporting Board
members during major accident investigations.
The division also supports deployed regional
investigators and investigators-in-charge and
provides media training to agency leaders and
senior investigators.
In 2024, the Media Relations Division published
60 news releases and 14 media advisories, which
resulted in more than 3.4 million page views on
ntsb.gov and more than 657,400 separate news
articles or television and radio segments. These
mentions included information on major NTSB
investigations, such as the containership strike
and subsequent collapse of the Francis Scott Key
Bridge and the in-flight departure of a door plug on
American Airlines flight 1282 passenger airplane.
Staff also made 756 posts on X during this period,
gathering more than 16.3 million views. In addition,
staff provided remote support for every NTSB
investigation.
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS59
2024 Annual Report to Congress National Transportation Safety BoardFigure 46.
Media Relations staff provided support to
the investigation involving the in-flight departure of a
door plug on American Airlines flight 1282 passenger
airplane in Portland, Oregon.
The division provided training on media relations
and response communications to 66 NTSB
staff and more than 335 transportation industry
communicators. Venues included 2-day workshops
in Washington, DC, and Denver, Colorado; and
training sessions in Cincinnati, Ohio; Memphis,
Tennessee; and Seoul, South Korea. The division
also delivered a 90-minute webinar on NTSB
postaccident communications and media relations
to 20 staff members at Argentina’s Junta de
Seguridad en el Transporte (NTSB’s counterpart in
Argentina).
The division helped the NTSB garner more than
657,400 print, broadcast, and online news mentions
in 2024.
TABLE 14. NTSB Media Products
Media Product Total
News releases and media advisories 74
Tweets 756Government and Industry Affairs Division
The Government and Industry Affairs Division initiated outreach to congressional, federal, state,
and local officials and industry stakeholders. It arranged numerous briefings by Board members
and investigators and responded to requests for information regarding NTSB investigations and
safety recommendations.
In 2024, the division coordinated activity to support the agency’s reauthorization through fiscal year 2028. Staff
also prepared the chairwoman to testify at five congressional hearings regarding aviation safety, grade-crossing
safety, the status of all investigations, the strike and collapse of the Francis Scott Key Bridge, and rail safety.
The division supported Board member and staff testimony and legislative advocacy on impairment in the States
of California, Connecticut, Hawaii, New York, and Washington; motorcycle helmet use in Maryland; speeding
in California, Connecticut, Minnesota, New York, and Washington, DC; distracted driving in Pennsylvania; and
school bus safety in Illinois, Maryland, and Oregon.
The division supported major accident launches and general aviation regional investigations; updated Congress,
state, and local officials as these investigations continued; and served as the main point of contact for additional
outreach and inquiries.
Safety Advocacy Division
The Safety Advocacy Division leads the agency’s advocacy efforts and promotes the
implementation of safety recommendations. The division relays safety messages and
lessons learned from NTSB investigations through print, digital, and social media channels,
and delivers presentations at national conferences and meetings with state and local
lawmakers and other stakeholders.
In 2024, the division helped develop, execute, and
promote more than 239 advocacy and outreach
activities related to the NTSB’s safety priorities
and other critical safety recommendations. Major
activities included the following:
• Organized, promoted, and facilitated an NTSB
event on the 2021 Truckee, California, Challenger
aircraft crash. The event was attended by over 45 individuals from the National Business Aviation
Association Conference in Las Vegas, Nevada.
• Supported Board member and staff testimony
and legislative advocacy in collaboration with
Government and Industry Affairs Division.
• Conducted outreach to communities impacted
by high numbers of road deaths, including the
following:
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS60
2024 Annual Report to Congress National Transportation Safety Board ǡHosted a road safety webinar series that had
over 1,200 registrants and over 5,000 views.
ǡFacilitated three road safety community
engagement meetings with local council
members in Prince George’s County, Maryland.
About 200 community members attended the
meetings.
ǡOrganized and hosted the Wyoming Youth
Interactive Traffic Safety Lab on the Wind River
Reservation, with over 400 students attending.
• Created campaigns for National Distracted Driving
Awareness Month, Pedestrian Safety Month, Teen
Driver Safety Week, Child Passenger Safety Week,
Rail Safety Week, and School Bus Safety Week.
• Worked with modal offices and the NTSB’s Digital
Services Division to develop the modal safety
issues section of the agency’s website.
• Identified and promoted speaking opportunities
for Board members and modal office staff at
national conferences and industry meetings,
including the 2024 National Lifesavers Conference
on Road Safety, Helicopter Association
International (HAI) Heli-Expo, and the 33rd World
Traffic Safety Symposium.
The division used its social and digital platforms
to amplify information related to the NTSB’s
advocacy work, safety priorities, and investigative
outcomes and lessons learned. Staff sent 34 email
notifications to more than 123,000 stakeholders
and developed hundreds of social and digital media
products promoting the agency’s safety messages.
Followers increased across all platforms, reaching
more than 1,371,000 users on X, Facebook, LinkedIn,
Instagram, YouTube, and Flickr. Staff wrote or
coordinated the posting of 15 blogs and produced
four episodes of the “Behind-the-Scene @ NTSB”
podcast, which highlighted agency activities, staff,
and programs. The division also supported webinars
and virtual events on a variety of topics specific to unique audiences and recommendation recipients,
such as webinars on teen driving safety, traffic
safety thoughts from a public health lens, and
distracted driving.
Figure 47.
Students signed a safe driver pledge during the Interactive Traffic Safety Lab held at the
Wyoming Indian High School in Ethete, Wyoming.
TABLE 15. Safety Advocacy Division
Social Media Followers, Connections,
and Subscribers
Communication Product Total
X followers 171,500
Instagram followers 31,100
LinkedIn followers 37,600
Email subscribers 9,900
Facebook subscribers 59,000TABLE 16. Safety Advocacy Division
Products and Events
Advocacy Activity Total
Behind-the-Scene @ NTSB podcasts 4
YouTube videos 12
Public webinars and virtual meetings 88
Safety Compass blogs 15
Events (NTSB-led coalition meetings,
conference exhibits, presentations,
roundtables, testimony, and workshops)116
OFFICE OF SAFETY RECOMMENDATIONS AND COMMUNICATIONS61
2024 Annual Report to Congress National Transportation Safety BoardDigital Services Division
The Digital Services Division supports the NTSB’s internal and external strategic
communications goals. Staff manage agency communications on ntsb.gov and design and
develop graphics and audiovisual products that optimize the agency’s ability to communicate
investigation findings and safety messages and to facilitate employee engagement. The
division also establishes visual style and branding standards for the agency and advises internal
stakeholders on how to best use visual information to enhance their products.
In 2024, the Digital Services Division supported five Board meetings, one Board hearing, and nine other NTSB led
events. Staff completed nearly 600 graphics and illustrations for use in reports and other products; developed
eight major print publications, including the East Palestine Illustrated Digest; produced nearly 60 videos,
podcasts, and live video streams; and fulfilled more than 850 website update requests.
The division completed the next phase of the agency’s branding and design standards project, which provides
guidance on annotating and labeling images used in investigation reports and other products to optimize and
standardize those graphic elements.
The division is focusing on optimizing our website and customer service to comply with the
requirements and recommendations in Office of Management and Budget (OMB) Memorandum M-23-22,
“Delivering-a-Digital-First-Public-Experience.” These improvements cover access, content, usability, and
customer experience. To support this initiative, the division worked with the NTSB’s Office of General Counsel to
obtain generic clearance from the OMB to collect qualitative feedback on agency service delivery. This allows
the agency to fast-track user feedback surveys. We launched and conducted two user surveys on the website,
focusing on our investigation pages and safety issue pages. We will use the feedback to improve the content of
those pages in response to user needs.
The division worked closely with modal office staff to develop and manage new safety issues content for our
website, creating a way to add additional issue areas and to regularly review and update existing content.
Figure 48.
The division worked closely with modal
offices to develop and maintain new Safety Issues
content for our website.
2024 Annual Report to Congress National Transportation Safety BoardOffice of
Administrative
Law Judges
TABLE 17. Office of Administrative Law Judges
Safety Statistics
Total Cases Received ................ 470
Total Cases Closed .................. 293
Emergency Cases Received ........... 111
Emergency Cases Closed .............. 84
Hearings Scheduled .................. 94
Hearings Held ....................... 21
Outreach ........................... 12The NTSB serves as the court of appeals for airmen, aircraft mechanics,
air traffic controllers, air carriers, repair facilities, and any other
individual or entity against whom the FAA has taken a certificate
action, and for mariners against whom the US Coast Guard has taken a
certificate action.
The judges within the agency’s Office of Administrative Law Judges hear
and consider the cases of, and issue initial decisions on, administrative
appeals of FAA aviation enforcement actions. Under the Equal Access
to Justice Act, the judges also adjudicate claims from certificate holders
for legal fees and expenses incurred in defending against FAA certificate
actions and adjudicate appeals from civil penalty actions assessed
against any individual by the FAA. The certificate holder, the person
being assessed, or the FAA may appeal an administrative law judge’s
decision. The Board’s review of such an appeal is based on the record of
the proceeding, which includes the transcript of the hearing testimony,
exhibits, the judge’s decision, and appeal briefs submitted by the parties.
Marine certificate actions are heard first by US Coast Guard administrative
law judges and may be appealed to the vice commandant of the US Coast
Guard. The vice commandant’s ruling may then be appealed to the Board.
The NTSB was saddened
by the passing of our Chief
Administrative Law Judge in
July 2024, and a recruitment to
fill that position is underway.
We currently have one judge
assigned to headquarters in
Washington, DC; one assigned to
the circuit that includes Denver,
Colorado; and one assigned
to the circuit that includes
San Antonio, Texas. Judges
have the option of holding live
hearings or virtual hearings. Figure 49.
Office of Administrative Law
Judges staff discuss the role of a NTSB
Administrative Law Judge to students
at the Antonin Scalia Law School at
George Mason University.
2024 Annual Report to Congress National Transportation Safety BoardTransportation Disaster
Assistance Division
TABLE 18. Transportation Disaster Assistance Division Safety Statistics
Family Members and Victims Assisted ................... 3,517
Outreach Events ........................................ 82
Agencies/Organizations Supported ........................ 457The Transportation Disaster Assistance
Division coordinates federal government
resources to support local and state
governments, disaster relief organizations, and
transportation carriers to offer services and
information to family members and survivors
following major aviation and rail accidents.
Division staff serve as the primary source of
investigative information for family members
and survivors for any accident investigated
by the NTSB.22 Staff also provide direct
investigative support for all modal offices by
interfacing with medicolegal jurisdictions and
healthcare systems to secure evidence.
To support both our investigative and
family assistance efforts, we maintain formal
agreements with the American Red Cross; the
Departments of Homeland Security, Defense,
Health and Human Services, and State; and the
Federal Bureau of Investigation.
22 In 1996, Congress enacted the Aviation Disaster Family Assistance
Act (49 U.S.C. sections 1136 and 41113), charging the NTSB with
assisting victims of aviation disasters and their families, and
coordinating with federal agencies, domestic air carriers, and state
and local authorities to ensure that the fundamental concerns of
families are met. In 1997, the Foreign Air Carrier Family Support
Act (49 U.S.C. section 41313) required foreign air carriers operating
flights to and from the United States to meet similar victim assistance
standards as their US counterparts. The Rail Safety Improvement
Act of 2008 (49 U.S.C. sections 1139 and 24316) gave similar
responsibilities to the NTSB, Amtrak, and other interstate and
intercity high-speed passenger rail operators following rail passenger
accidents. Finally, in 2018, Congress further expanded the Board’s
responsibilities to provide information regarding NTSB investigative
processes and products to the families of individuals involved in any
accident investigated by the NTSB to the maximum extent practicable
in advance of the media (49 U.S.C. section 1140).
TRANSPORTATION DISASTER ASSISTANCE DIVISION64
2024 Annual Report to Congress National Transportation Safety BoardDuring 2024, division staff participated in
12 launches and provided nonlaunch family
assistance support for an additional 787
investigations in all modes of transportation,
interacting with 3,517 accident survivors, family
members, and family contacts.
Staff engaged with family members associated with
64 different accidents, on average, each week; these
encounters ranged from a single phone call or email
to several hours of work over multiple days with
numerous family members from a single accident.
Staff also provided fatality management subject
matter support to the Federal Emergency
Management Agency under a Stafford Act
deployment for the Hurricane Helene response in
North Carolina. During the 1-week deployment, staff
helped establish the family assistance operation and
high throughput morgue operations.In addition, staff interfaced with 457 federal,
state, and local agencies; transportation industry
organizations; and other nongovernmental
organizations that have a role in family assistance
operations, with an average of 32 engagements per
week requiring either travel or remote interaction. We
also supported a total of 82 outreach events, directly
interfacing with about 4,352 stakeholders.
Staff supported several ICAO initiatives to promote
family assistance programs globally. Staff are
actively representing the United States on ICAO’s
Facilitation Panel Working Group on Assistance to
Aircraft Accident Victims and their Families and
participated in ICAO’s Symposium on Assistance to
Aircraft Accident Victims and their Families, held
in Haarlem, the Netherlands. Staff also supported
agency participation in ICAO’s Universal Safety
Oversight Audit Programme, with a satisfactory
assessment in all areas relevant to family assistance.
2024 Annual Report to Congress National Transportation Safety BoardAppendix A:
Report of 2024 Recommendations Closed in an
Unacceptable Status to the US DOT and the US Coast Guard
We classified 12 safety recommendations to the US DOT and the US Coast Guard Closed—Unacceptable Action in calendar year 2024.23 We
have provided a summary of the recipient response and our reasoning for closing each recommendation in an unacceptable status. Full
details of each recommendation can be found via the links provided.
TABLE 19. Recommendations to the US DOT and the US Coast Guard Classified Closed —Unacceptable Action in 2024
Recommendation Recipient Recommendation Text Recipient Response NTSB Response
A-10-145 FAA Require operators to include
simultaneous dual-engine power
loss scenarios in both initial and
recurrent ground and simulator
training for pilots of dual-engine
helicopters.The FAA has reviewed its current safety management system
(SMS) risk-based decision-making protocols and determined
that current FAA guidance, policies, and industry procedures
adequately address this safety recommendation. The FAA will no
longer pursue these actions and considers its actions complete.Having an SMS is not enough to ensure that
operators provide the recommended training, and
most dual-engine helicopter operations are not
required to have an SMS. Because losing power in
both engines at once requires different responses
from losing power in one engine, pilots of these
helicopters need the recommended training. The
FAA has not taken any action to address Safety
Recommendation A-10-145 after 13 years. It is
classified CLOSED—UNACCEPTABLE ACTION.
A-11-39 FAA Require that role-playing or
simulator-based exercises that
teach first officers to assertively
voice their concerns and that teach
captains to develop a leadership
style that supports first officer
assertiveness be included as part of
the already required crew resource
management training for 14 CFR
Part 121, 135, and 91 subpart K
pilots.The FAA previously planned to revise advisory circulars (ACs)
dealing with training simulations and crew resource management
training, respectively. The Board suggested these revised ACs
should include example scenarios for first officers and captains
could roleplay appropriate crew resource management supporting
first officer assertiveness, but developing examples is the
responsibility of the air carrier instructors, not the FAA. Therefore,
the FAA no longer plans to revise this guidance. The FAA also
refers the Board to the Pilot Professional Development Final Rule
(85 Federal Register 10896) and two further ACs. This addresses
the intent of the recommendation, and the FAA considers its
actions complete. We previously told the FAA that including the
recommended role-playing exercises in the ACs
would be an acceptable alternative to requiring
these exercises, but the FAA no longer intends to
revise these ACs and states that operators should
develop the example scenarios. Because the FAA
does not intend to require this training or include
example scenarios in its training guidance, Safety
Recommendation A-11-39 is classified CLOSED—
UNACCEPTABLE ACTION.
23 As required by section 1209 of the FAA Reauthorization Act of 2024.
APPENDIX A: Report of 2024 Recommendations Closed in an Unacceptable Status to the US DOT and the US Coast Guard66
2024 Annual Report to Congress National Transportation Safety BoardRecommendation Recipient Recommendation Text Recipient Response NTSB Response
A-14-48 FAA Once the minimum staffing level
has been developed by the Aircraft
Rescue and Firefighting (ARFF)
Working Group, as requested in
Safety Recommendation A-14-60,
amend 14 CFR 139.319(j) to require
a minimum ARFF staffing level that
would allow exterior firefighting
and rapid entry into an airplane
to perform interior firefighting
and rescue of passengers and
crewmembers.ARFF services vary. Each airport develops an ARFF staffing level
base that, in combination with mutual-aid agreements, can result
in enough personnel to handle an aircraft incident or accident.
Independent organizations, such as the Airport Cooperative
Research Program, have previously evaluated minimum ARFF
staffing and failed to reach consensus. They found no conclusive
evidence suggesting that enhanced ARFF staffing standards
would make a difference in the survivability of the crashes studied.
Without data to support ARFF staffing requirements the FAA
cannot successfully pursue such rulemaking. The research on which the FAA bases its
response was conducted in response to Safety
Recommendation A-01-65. We were aware of this
research when we issued Safety Recommendation
A-14-48. In addition, in response to Safety
Recommendation A-14-60, the ARFF Working
Group created a task group that examined theories,
knowledge, methods, and techniques concerning the
creation of a minimum staffing level, which the FAA
co-chaired, and which recommended establishing
minimum ARFF staffing levels. However, the FAA
does not intend to revise section 139.319 to address
this concern, so Safety Recommendation A-14-48 is
classified CLOSED—UNACCEPTABLE ACTION.
A-14-73 FAA Require operators to develop
an annual recurrent dispatcher
resource management module
for dispatchers that includes
participation of pilots to reinforce
the need for open communication.The safety issue identified in these safety recommendations
occurred a decade ago. It is not prevalent in the current system
and predates current air carrier awareness of terrain awareness
and warning systems (TAWS) operational performance guidance.
The FAA maintains that these recommendations are best
addressed through reinforcement of flightpath and energy
management, the previously discussed changes to the required
checklist used by flightcrews and division of pilot flying (PF) and
pilot monitoring (PM) duties, in combination with FAA surveillance
and oversight of training activities and enroute procedures, and the
use of the FAA’s Safety Assurance System data collection tools.
The FAA has effectively addressed Safety Recommendations
A-14-73, -81, -83, and -84 and considers its actions complete with
no further action planned. The FAA still does not intend to require dispatch
resource management training, as recommended.
Prior to the accident, guidance was available
urging that dispatchers and pilots train together,
yet at UPS, they did not, and UPS did not require
its pilots and dispatchers to communicate directly
or have a verbal dispatch briefing before every
flight. Because the FAA does not intend to require
this training, Safety Recommendation A-14-73 is
classified CLOSED—UNACCEPTABLE ACTION.
A-14-81 FAA Advise operators of aircraft
equipped with terrain awareness
and warning systems (TAWS) of
the circumstances of this accident,
including that, in certain situations,
an escalating series of TAWS
warnings may not occur before
impact with terrain or obstacles.
Encourage operators to review
their procedures for responding to
alerts on final approach to ensure
that these procedures are sufficient
to enable pilots to avoid impact
with terrain or obstacles in such
situations.The safety issue identified in these safety recommendations
occurred a decade ago. It is not prevalent in the current
system and predates current air carrier awareness of TAWS
operational performance guidance. The FAA maintains that these
recommendations are best addressed through reinforcement
of flightpath and energy management, the previously discussed
changes to the required checklist used by flightcrews and division
of PF and PM duties, in combination with FAA surveillance and
oversight of training activities and enroute procedures, and the
use of the FAA’s Safety Assurance System data collection tools.
The FAA has effectively addressed Safety Recommendations
A-14-73, -81, -83, and -84 and considers its actions complete with
no further action planned. Our recommendation asks the FAA to advise
operators of the circumstances of this accident,
including that, in certain situations, an escalating
series of TAWS warnings may not occur before
impact; and encourage operators to ensure that
their procedures for responding to alerts on final
approach enable pilots to avoid impact with terrain
or obstacles in such situations. The FAA addresses
neither of these concerns. As the FAA’s actions
are not responsive and it has not reported plans
for additional actions, Safety Recommendation
A-14-81 is classified CLOSED—UNACCEPTABLE
ACTION.
APPENDIX A: Report of 2024 Recommendations Closed in an Unacceptable Status to the US DOT and the US Coast Guard67
2024 Annual Report to Congress National Transportation Safety BoardRecommendation Recipient Recommendation Text Recipient Response NTSB Response
A-17-39 FAA Establish minimum initial and
recurrent training requirements for
personnel authorized to exercise
operational control, including, but
not limited to, approved subject
knowledge areas, training hours,
subject hours, and qualification
modules.The FAA still believes its actions to date address these safety
recommendations. It does not plan a rulemaking to establish new
minimum or initial training for personnel authorized to exercise
operational control. It updated existing guidance to include
requirements and policies related to operational control that apply
to 14 CFR Parts 121 and 135 air carriers. The FAA’s actions on
Safety Recommendations A-17-39 and -41 are complete and it will
take no further action. The FAA considers its existing guidance and
policy adequate and, therefore, it does not
intend to establish the recommended initial and
recurrent training requirements for personnel
authorized to exercise operational control.
Although the FAA requires operators to provide
training on operational control, it does not include
any information about what, specifically, must
be included in that training. The FAA directs
inspectors to encourage operators to establish a
qualification module, but also says that one is not
required. The FAA has stated that it does not intend
to act. Consequently, Safety Recommendations
A-17-39 and -41 are classified CLOSED—
UNACCEPTABLE ACTION.
A-17-41 FAA Revise Federal Aviation
Administration Order 8900.1 to
include guidance for inspector
oversight of operational control
training program subject areas,
including, but not limited to, the
criteria for a qualification module.The FAA still believes its actions to date address these safety
recommendations. It does not plan a rulemaking to establish new
minimum or initial training for personnel authorized to exercise
operational control. It updated existing guidance to include
requirements and policies related to operational control that apply
to 14 CFR Parts 121 and 135 air carriers. The FAA’s actions on
Safety Recommendations A-17-39 and -41 are complete and it will
take no further action.The FAA considers its existing guidance and
policy adequate and, therefore, it does not
intend to establish the recommended initial and
recurrent training requirements for personnel
authorized to exercise operational control.
Although the FAA requires operators to provide
training on operational control, it does not include
any information about what, specifically, must
be included in that training. The FAA directs
inspectors to encourage operators to establish a
qualification module, but also says that one is not
required. The FAA has stated that it does not intend
to act. Consequently, Safety Recommendations
A-17-39 and -41 are classified CLOSED—
UNACCEPTABLE ACTION.
A-20-36 FAA Establish a confidential voluntary
data clearinghouse of deidentified
pilot selection data that can be
used to conduct studies useful for
identifying effective, scientifically
based pilot selection strategies.
This program should be modeled
after programs like Aviation Safety
Information and Analysis Sharing
and Flight Operations Quality
Assurance.The FAA disagrees, characterizing the recommendation as
adding (or withholding) a second-level FAA endorsement of an
FAA-certificated pilot. The FAA mistakenly postulates a new
database, which would best be implemented by a separate
federal department, such as the US Department of Labor’s Bureau
of Labor Statistics. The FAA adds information about the Pilot
Records Database and states that it considers actions on Safety
Recommendation A-20-36 complete, with no further actions
planned. This safety recommendation does not ask for an
FAA database. Rather, it asks the FAA to establish
a program, like ASIAS (Aviation Safety Information
Analysis and Sharing), that includes airline pilot
selection data instead of safety data. Establishing
a program like ASIAS for collecting and analyzing
deidentified airline pilot selection data would
provide air carriers important aviation safety
information for use in their hiring decisions and the
FAA has the expertise to establish such a program.
Because the FAA has not taken any action, Safety
Recommendation A-20-36 is classified CLOSED—
UNACCEPTABLE ACTION.
APPENDIX A: Report of 2024 Recommendations Closed in an Unacceptable Status to the US DOT and the US Coast Guard68
2024 Annual Report to Congress National Transportation Safety BoardRecommendation Recipient Recommendation Text Recipient Response NTSB Response
M-09-4 USCG Require mariners to report to the
Coast Guard, in a timely manner,
any substantive changes in their
medical status or medication
use that occur between required
medical evaluations. (Supersedes
M-05-5).The Coast Guard concurs with the intent of this recommendation,
but requiring all mariners to report changes in their medical
condition would require a regulatory change, which sections
of the maritime industry would resist. The Coast Guard tried to
introduce such a requirement in a final rule in 1978, but OMB
removed it, citing lack of supporting data. Since then, the Coast
Guard has worked with the maritime community to encourage
such disclosure. In addition, in 2007, the Coast Guard revised the
Medical and Physical Evaluation Guidelines for Merchant Mariner
Credentials in response to the Cosco Busan casualty. The Coast
Guard strives to create a culture where mariners are less fearful
of sharing medical information with the Coast Guard. This may
also encourage mariners to actively manage their health issues,
reducing the risk of medically related casualties. It hopes these
positive strides meet the intent of the original recommendation.We are aware that the Merchant Mariner Medical
Manual reflects the substantial revisions that the
Coast Guard has made to its medical guidance
since the 2007 Cosco Busan accident. Although
the Coast Guard has significantly improved its
oversight of merchant mariner medical fitness, it
has not required mariners to report any substantive
changes in their medical status or medication use
that occur between required medical evaluations.
Accordingly, Safety Recommendation M-09-4 is
classified CLOSED—UNACCEPTABLE ACTION.
M-17-17 USCG In collaboration with the NWS,
provide timely broadcasts of
the Tropical Cyclone Forecast/
Advisories, Intermediate Public
Advisories, and Tropical Cyclone
Updates to mariners in all regions
via medium-frequency navigational
TELEX (NAVTEX), high-frequency
voice broadcasts (HF VOBRA),
and high-frequency simplex
teletype over radio (HF SITOR), or
appropriate radio alternatives (and
appropriate future technology). In March 2020, the NWS and the Coast Guard renewed a
memorandum of agreement (MOA) for the dissemination of marine
weather information. This information includes Tropical Cyclone
Forecast/Advisories, Intermediate Public Advisories, and Tropical
Cyclone Updates to mariners via medium-frequency Navigational
TELEX (NAVTEX), high-frequency voice broadcasts (HF VOBRA),
and high-frequency simplex teletype over radio (HF SITOR). The
NWS and Coast Guard’s joint Impact-Based Decision Support
Services (IDSS) includes forecast advice and interpretative
services to aid decision-making, or in response to a weather
event. The Coast Guard considers action on this recommendation
complete and requests that it be closed. The Coast Guard and the NWS were working
under the MOA at the time we issued this
recommendation. Although we commend the
Coast Guard’s continuing MOA with the NWS, and
its efforts to develop decision support services,
it has not acted to address this recommendation
specifically. Because it intends to take no
further action and requests that we close this
recommendation, Safety Recommendation M-17-17
is classified CLOSED—UNACCEPTABLE ACTION.
M-17-36 USCG Require that vessels in ocean
service (500 gross tons or over) be
equipped with properly operating
meteorological instruments,
including functioning barometers,
barographs, and anemometers.The Coast Guard remains of the opinion that it is unnecessary
to mandate carriage of meteorological instruments beyond that
which is already recommended in SOLAS V-5.2. The El Faro had an
anemometer, but it did not function. The Coast Guard considers its
action on this recommendation complete and requests that it be
closed.The Coast Guard notified us that it does not intend
to take our recommended action and requests
that this recommendation be closed. Accordingly,
Safety Recommendation M-17-36 is classified
CLOSED—UNACCEPTABLE ACTION.
APPENDIX A: Report of 2024 Recommendations Closed in an Unacceptable Status to the US DOT and the US Coast Guard69
2024 Annual Report to Congress National Transportation Safety BoardRecommendation Recipient Recommendation Text Recipient Response NTSB Response
M-17-47 USCG Propose to the International
Maritime Organization (IMO) to
amend resolution MSC.333(90) to
specify that “normal operations” are
defined as when a ship is under way
using its main propulsion unit and to
assess voyage data recorder (VDR)
problems, including not capturing
both sides of internal phone calls
on the bridge electric telephone and
unrecorded very-high-frequency
communications, and identify steps
to remedy them.The Coast Guard believes that the phrase “normal operations”
requires no further clarification. It proposed that the IMO require
VDRs to record both sides of internal bridge electric telephone
conversations. It considers the Coast Guard’s action on this
recommendation complete and requests that it be closed.We commend the Coast Guard for proposing
that the IMO standards require VDRs to record
both sides of internal calls on the bridge electric
telephone. However, it did not act to clarify “normal
operations” in the performance standard. Because
the Coast Guard considers its actions on this
recommendation complete and it requests that
it be closed, Safety Recommendation M-17-47 is
classified CLOSED—UNACCEPTABLE ACTION.
2024 Annual Report to Congress National Transportation Safety BoardAppendix B:
NTSB Safety Recommendations Identified for
Classification Change
Every 5 years, the NTSB is required to submit to Congress a 5-year retrospective review of open safety recommendations to determine if they
should be updated, closed, or reissued.24 Our justification for updating, closing, or reissuing each recommendation is determined based on
the following required criteria:
24 Title 49 U.S.C. section 1116 (d), as amended by section 1111 of the National Transportation Safety Board Reauthorization Act of 2018 (Division C of Public Law 115-254). »changed circumstances,
»more recently issued recommendations,
»the availability of new technologies, or
»new informa tion making the recommendation ineffective or insufficient for achieving its objective.
Based on these criteria, our 2024 review found that 12 recommendations (1.1 percent) were suitable for additional review and updated classifications.
TABLE 20. NTSB Safety Recommendations Identified for Classification Change
Recommendation RecipientOriginal
ClassificationNew Classification Safety Recommendation Text Justification for Classification
A-16-36 FAA Open—Acceptable
ResponseClosed—Acceptable
ActionRequire all 14 CFR Part 135 operators to establish
SMS programs.The FAA published a final rule in April 2024 requiring
all Part 135 operators to have an SMS and is
responsive to A-16-36.
A-19-28 FAA Open—Acceptable
ResponseClosed—Acceptable
ActionRequire all commercial air tour operators, regardless
of their operating rule, to implement an SMS.The FAA published a final rule in April 2024 that
requires all operators conducting air tours under
14 CFR 91.147 to have an SMS and is responsive to
A-19-28.
A-21-7 Maverick
Helicopters
(formerly
Island
Express
Helicopters,
Inc.)Open—Unacceptable
ResponseClosed—
Unacceptable ActionParticipate in the FAA’s SMS Voluntary Program. The FAA published a final rule in April 2024 requiring
all Part 135 operators to have an SMS. Although
the FAA’s final rule eliminates the need for this
recommendation, the Board voted to classify this
recommendation Closed—Unacceptable Action
because the recipient previously informed us that it
did not intend to act.
APPENDIX B: NTSB Safety Recommendations Identified for Classification Change71
2024 Annual Report to Congress National Transportation Safety BoardRecommendation RecipientOriginal
ClassificationNew Classification Safety Recommendation Text Justification for Classification
A-21-13 FAA Open—Acceptable
ResponseOpen—Unacceptable
ResponseRequire SMSs for the revenue passenger-carrying
operations addressed in Safety Recommendations
A-21-9 and -10.The FAA published a final rule on SMS in April 2024;
however, the rule does not require SMSs for all Part 91
revenue passenger-carrying operations discussed in
this recommendation.
A-21-14 FAA Open—Acceptable
ResponseOpen—Unacceptable
ResponseFor the revenue passenger-carrying operations
addressed in Safety Recommendations A-21-9
and -10, provide ongoing oversight of each operator’s
SMS once established.The FAA published a final rule on SMS in April 2024;
however, the rule does not require SMSs for all Part 91
revenue passenger-carrying operations discussed in
this recommendation.
A-21-48 FAA Open—Acceptable
ResponseOpen—Unacceptable
ResponseRequire organizations that design, manufacture, and
maintain aircraft to establish an SMS.The FAA published a final rule in April 2024 that
requires organizations that design and manufacturer
aircraft (Part 21) to have an SMS; however, it does
not require SMS for those organizations that maintain
aircraft, such as Part 145 repair stations. Therefore,
the final rule does not fully address A-21-48.
A-22-15 FAA Open—Unacceptable
ResponseClosed—Acceptable
ActionDevelop guidance for small operators for scaling
an SMS that includes methods and techniques for
implementation and specific examples applicable to
several operational sectors, including air tours.The FAA’s April 2024 final rule on SMS did not
address our concerns regarding guidance in Advisory
Circular (AC) 120-92. On May 21, 2024, the FAA
published AC 120-92D. The updated AC (particularly
Appendix G) is responsive to Safety Recommendation
A-22-15, which was classified Closed—Acceptable
Action in AIR: Safety and Industry Data Improvements
for Part 135 Operations.
H-12-22 NHTSA Open—Unacceptable
ResponseClosed—No Longer
ApplicableEvaluate the effects of seat spacing and armrests
as factors for potential occupant injury, and if safer
spacing or armrest configurations are identified,
develop and implement appropriate guidelines.NHTSA’s final rule amending the Federal Motor
Vehicle Safety Standard No. 209 for occupant crash
protection to require the installation of lap/shoulder
belts at each passenger seating position in all new
over-the-road buses became effective November 28,
2016. When H-12-22 was issued, lap/shoulder belts
were not required and not typically installed, and
any evaluation of the effects of seat spacing and
armrests as factors for potential occupant injury
started with the assumption that passengers would
be unrestrained. However, with ever-increasing
passenger restraint availability in motorcoaches, as
older coaches are replaced with newer post-2016
models, and with belt use increasing, the trend is
toward having more restrained passengers, reducing
the potential effect of what was intended to be
studied in H-12-22.
APPENDIX B: NTSB Safety Recommendations Identified for Classification Change72
2024 Annual Report to Congress National Transportation Safety BoardRecommendation RecipientOriginal
ClassificationNew Classification Safety Recommendation Text Justification for Classification
H-12-58 NHTSA Open—Unacceptable
ResponseClosed—No Longer
ApplicableDevelop minimum performance standards for
onboard brake stroke monitoring systems for all air-
braked commercial vehicles.Collision mitigation technologies and advanced
braking technologies, such as automatic emergency
braking and disc brakes, make this recommendation
obsolete.
H-12-59 NHTSA Open—Unacceptable
ResponseClosed—No Longer
ApplicableOnce the performance standards in Safety
Recommendation H-12-58 have been developed,
require that all newly manufactured air-braked
commercial vehicles be equipped with onboard brake
stroke monitoring systems.Collision mitigation technologies and advanced
braking technologies, such as automatic emergency
braking and disc brakes, make this recommendation
obsolete.
M-19-16 USCG Open—Acceptable
ResponseClosed—Acceptable
ActionFor DUKW amphibious passenger vessels without
sufficient reserve buoyancy (commonly referred to as
original and/or “stretch” DUKWs), require the removal
of canopies, side curtains, and their associated
framing during waterborne operations to improve
emergency egress in the event of sinking.On September 11, 2023, the Coast Guard published
an interim final rule, DUKW Amphibious Passenger
Vessels (88 Federal Register 62295-62301), which
added congressionally mandated requirements
to 46 CFR Subchapter T in a new section 175.124.
As a result of this new requirement, any DUKW
boat permitted to operate after January 9, 2024, is
prohibited from having canopies and side curtains
that would impede passengers’ emergency egress.
M-20-6 Ripley
Entertainment,
Inc, (dba Ride
the Ducks–
Branson)Open—Acceptable
ResponseClosed—No Longer
ApplicableRe-evaluate emergency procedures regarding
the donning of lifejackets aboard modified DUKW
amphibious passenger vessels when equipped with
fixed canopies.On September 11, 2023, the Coast Guard’s
interim final rule, DUKW Amphibious Passenger
Vessels (88 Federal Register 62295-62301), added
congressionally mandated requirements to 46 CFR
Subchapter T in a new section 175.124. As a result
of this new requirement, any DUKW boat permitted
to operate after January 9, 2024, is prohibited from
having canopies and side curtains that would impede
passengers’ emergency egress.
2024 Annual Report to Congress National Transportation Safety BoardAppendix C:
Outreach
Office of Aviation Safety
The Office of Aviation Safety participated in 45 events in 2024. The most significant of
these events are highlighted below.
Presentations and Briefings
K. Dunks and T. LeBaron. “NTSB Update.” Presentation
to Alaska Air Carriers; Anchorage, Alaska;
February 2024.
A. Sauer and C. Shin. “Bell 407 Tail Boom Separation
Investigation Summary.” Presentation at the 2024
HAI Heli-Expo; Anaheim, California; February 2024.
C. Shin and A. Sauer. “Bell 407 Tail Boom Separation
Investigation Summary.” Presentation at the 2024
HAI Heli-Expo; Anaheim, California; February 2024.
L. Ward. “NTSB Accident Investigations.” Presentation
at FedEx Headquarters; Memphis, Tennessee;
February 2024.
K. Dunks. “General Aviation Accident Investigations.”
Presentation at the Montana Aviation Conference;
Butte, Montana; February 2024.
L. Ward. “NTSB Briefing.” Presentation at an Airlines for
America Meeting; Erlanger, Kentucky; March 2024.
K. Dunks, K. Wilson, C. Strong, and L. Read. “Where
Safety is No Accident!” Presentation at the Women in
Aviation Conference; Orlando, Florida. March 2024.
K. Wilson. “Is Your Cockpit a Distraction-Free Zone?”
Presentation at the Sun ‘n Fun Aerospace Expo;
Lakeland Florida; April 2024.
L. Ward. “NTSB Safety Beyond Compliance Omni Air
International Safety Symposium.” Presentation at the Omni Air International Symposium; Tulsa, Oklahoma;
April 2024.
A. Sauer. “An Introduction to the NTSB.” Presentation at
a Wisconsin US DOT Seminar; Rothschild, Wisconsin;
May 2024.
R. Enders. “About the NTSB.” Presentation at Cambria
County Coroner’s Seminar; Johnstown, Pennsylvania;
May 2024.
D. Sevillian. “NTSB Perspective on Automation Issues
in the Aviation Industry.” Presentation at a Department
of Homeland Security Marine and Aviation Event;
Ashburn, Virginia; May 2024.
B. Banning. “Resilient Skies in the Face of Uncertainty.”
Presentation at the National Air Transportation
Association Air Charter Summit; Oklahoma City,
Oklahoma; June 2024.
K. Dunks. “NTSB Update.” Presentation at the 2024
General Aviation Manufacturers Association General
Aviation Air Safety Investigations; Wichita, Kansas;
September 2024.
Participation on Panels
J. Sedor. Quad Agency Working Group Annual Meeting;
Vanderberg Space Force Base; Santa Barbara,
California; June 2024.C. Johnson. Vertical Aviation International Safety
Working Group Meeting; Philadelphia, Pennsylvania;
June 2024.
J. Sedor. FBI Commercial Space Tabletop;
Cape Canaveral, Florida; July 2024.
V. McKenny. International Bird Strike Committee;
Minneapolis, Minnesota; August 2024.
P. Suffern. FAA Icing Working Group; Boulder, Colorado;
September 2024.
Instruction or Instructional Presentations
E. Gutierrez. “General Aviation Accident Overview.”
Presentation to The Flight Academy; Renton,
Washington; January 2024.
Participation in/Attendance at Meetings
and Conferences
K. Wilson. Participation in the Transportation Research
Board (TRB) Annual Meeting; Washington, DC;
January 2024.
K. Dunks. Attendance at the General Aviation Joint
Safety Committee and Headquarter meetings;
Washington, DC; January 2024.
S. Blum. Attendance at the Airlines for America
Council Meeting with Chairwoman; Honolulu, Hawaii;
January 2024.
C. Johnson. Attendance at the 2024 HAI Heli-Expo;
Anaheim, California; February 2024.
L. Read. Attendance at the Women in Aviation
Conference; Orlando, Florida; March 2024.
C. Strong. Attendance at the Women in Aviation
Conference; Orlando, Florida; March 2024.
APPENDIX C: Outreach74
2024 Annual Report to Congress National Transportation Safety BoardK. Wilson. Attendance at the Women in Aviation
Conference; Orlando, Florida; March 2024.
K. Dunks and L. Schiada. Attendance at the General
Aviation Manufacturers Association and Gulfstream;
Washington, DC; April 2024.
J. Demko. Attendance at the General Aviation Joint
Safety Committee Safety Analysis Team Meeting;
Washington, DC; April 2024.
D. Eick. Attendance at the Friends and Partners in
Aviation Weather; Dallas, Texas; May 2024.
A. Sauer. Attendance at the Experimental Aircraft
Association AirVenture Annual Safety Meeting;
Oshkosh, Wisconsin; May 2024.L. Ward. Attendance at the Regional Airline Association
Safety Meeting; Daytona Beach, Florida; June 2024.
B. Banning. Attendance at the Q3 Airlines for America
Meeting; Seattle, Washington; July 2024.
S. Woods. Attendance at the Human Factors
Ergonomics Society Annual Meeting; Phoenix, Arizona;
September 2024.
L. Ward and D. Bower. Attendance at the United
Airlines Outreach/Training Exercise; Chicago, Illinois;
September 2024.
B. Bramble. Attendance at the International Society
of Air Safety Investigators; Lisbon, Portugal;
September 2024.
Office of Highway Safety
The Office of Highway Safety participated in 35 events in 2024. The most significant of
these events are highlighted below.
Testimony Before State Legislators
K. Poland. Testimony before the Maryland Senate
regarding School Bus Seat Belt Bill 724; Annapolis,
Maryland; February 2024.
K. Poland. Testimony before the Maryland House of
Representatives regarding School Bus Seat Belt Bill
196; Annapolis, Maryland; February 2024.
K. Poland. Testimony before the Illinois Senate
regarding School Bus Seat Belt Bill 2696; March 2024.
E. Lee. “Vehicles: Safety Equipment.” Testimony
before the California Senate regarding Senate Bill 961;
Sacramento, California; April 2024.
E. Lee. Testimony before Transportation and the
Environment Committee, Council of the District
of Columbia regarding the Strengthening Traffic
Enforcement, Education, and Responsibility
Amendment Act, B25-0425; Washington, DC; April 2024.Presentations and Briefings
T. Barth. “An Update of Emergency Response
Recommendations and Current Investigations.”
Presentation at the TRB Annual Meeting; Washington,
DC; January 2024.
E. Lee. “Multivehicle Crash Involving Excessive Speed,
Impairment and Speeding Recidivism.” Presentation
at the TRB Annual Meeting; Washington, DC; January
K. Poland. “True or False? 94 Percent of Traffic
Crashes Are Due to Human Error—and Why it
Matters.” Presentation at the SAE Government and
Industry Meeting Annual Meeting; Washington, DC;
January 2024.
R. Molloy. “NTSB Crash Investigation Update to the
NSA Traffic Safety Committee.” Presentation at
the National Sheriffs Association Annual Meeting;
Washington, DC; February 2024.R. Molloy. “NTSB Investigation into the Collapse of the
Fern Hollow Bridge.” Presentation at the Transportation
and Highway Engineers Conference; Chicago, Illinois;
February 2024.
M. Fox. “NTSB Crash Update and Lessons Learned.”
Virtual presentation to the Summer Safety Meeting;
June 2024.
D. Walsh. “NTSB Investigation of the Fern Hollow
Bridge Collapse.” Presentation at the AASHTO
Committee on Bridges and Structures Annual Meeting;
Indianapolis, Indiana; June 2024.
R. Molloy. “When the Safety Oversight Disappears: The
Tragedy of the FIU Pedestrian Bridge.” Presentation
at the National Association of State Highway and
Transportation Unions 24th Annual Conference;
Washington, DC; June 2024
M. LaPonte. “Update on Current NTSB Investigations.”
Presentation at the American Bus Association Summer
Bus Industry Safety Council Meeting; Orlando, Florida;
July 2024.
K. Poland. “Automated Vehicle Rule of the Road
Compliance: Theory, Practice, and Policy.” Presentation
at the ARTS24 Automated Road Transportation
Symposium; San Diego, California; July 2024.
T. Barth. “Overview of the ARTS24 Session: First
Responders First.” Presentation at the Automated
Vehicle Research Group; Automation Projects;
July 2024.
K. Poland. “School Bus Occupant Protection.”
Presentation at the Maryland Fall 2024 Pupil
Transportation Directors Summit; Ocean City,
Maryland; October 2024.
K. Poland. “School Bus Safety.” Keynote speech for
the National Association for State Directors of Pupil
Transportation Services 2024 Annual Conference;
Arlington, Virginia; November 2024.
M. Sweeney. “School Bus Safety and NTSB
Investigations.” Presentation at the National
Association for State Directors of Pupil Transportation
APPENDIX C: Outreach75
2024 Annual Report to Congress National Transportation Safety BoardServices 2024 Annual Conference; Arlington, Virginia;
November 2024.
Participation on Panels
K. Poland; panel co-chair. “NTSB Investigations.”
Participation in the TRB Annual Meeting; Washington,
DC; January 2024.
T. Barth; panel moderator. “First Responders First.”
Participation in the ARTS24 Automated Road Transportation Symposium; San Diego, California;
July 2024.
Participation in/Attendance at Meetings
and Conferences
S. Currie. Attendance, and presentation of a case study
of the investigation process, at the Amazon Safety
Team Meeting; Nashville, Tennessee; September 2024.
Office of Marine Safety
The Office of Marine Safety participated in 18 events in 2024. The most significant of these
events are highlighted below.
Presentations and Briefings
A. Ehlers. “Capsizing of Liftboat SEACOR Power :
Stability of Vessels with Unusual Configurations.”
Presentation at the TRB Annual Meeting; Washington
DC; January 2024.
M. Karr. “NTSB Overview and Marine Case Study.”
Presentation at the Marine Compliance Alliance
Western Rivers; Washington, DC; March 2024.
D. Johnston. “Crane Wire Failure on Cargo Ship Thorco
Basilisk .” Presentation at the National Aeronautics and
Space Administration Headquarters; Washington, DC;
April 2024.
M. Karr. “ Spirit of Norfolk Case Study.” Presentation at
the Oil Pollution Act of 1990 Forum; Washington, DC;
May 2024.
L. Larue. “ Dali Investigation Overview.” Presentation
at the Science for Disaster Reduction Interagency
Working Group; July 2024.
E. Stolzenberg. “Grounding of Passenger Ferry
Commodore .” Presentation at the MAIIF Americas 13;
Valparaiso, Chile; August 2024.E. Stolzenberg. “Briefing on Investigation of
Containership Dali Contact with Francis Scott Key
Bridge.” Presentation at the US Committee on the
Marine Transportation System Coordinating Meeting;
Washington, DC; September 2024.
A. Ehlers and A. Tucker. “NTSB Investigation:
Passenger Vessel Conception Fire.” Presentation at the
Society of Accredited Marine Surveyors International
Meeting and Education Conference; New Orleans,
Louisiana; September 2024.
L. Wisniewski. “NTSB Marine Safety 101: Overview,
Authority, Investigations.” Presentation at the National
Maritime Safety Association Technical Committee
Meeting; Baltimore, Maryland; September 2024.Participation on Panels
L. Larue, panelist. “Responding to an Accident
Scenario.” Participation at the Greater New Orleans
Barge Fleeting Association; New Orleans, Louisiana,
April 2024.
L. Larue, panelist. “ Dali Investigation Overview.”
Participation at the American Waterway Operators
Summer Safety Meeting; Chicago, Illinois; August 2024.
L. Larue, panelist. “The Limitations of Technology.”
Participation at the Navtech Conference; Seattle,
Washington; December 2024.
Instructional Presentations
A. Ehlers and B. Barnum. “Casualty Analysis and
Watchkeeping.” Presentation to the Maine Maritime
Academy; Castine, Maine; March 2024.
R. Jones. “Introduction to NTSB Investigations.”
Presentation to the US Coast Guard Senior
Investigating Officer Training and Conference;
Washington, DC; September 2024.
Participation in/Attendance at Meetings
and Conferences
M. Turrell. Attendance at Passenger Vessel Association
Annual Meeting; Portland, Oregon; January 2024.
D. Johnston. Participation in the IMO Subcommittee
on Human Element, Training, and Watchkeeping;
February 2024.
A. Ehlers. Participation on the IMO Subcommittee
on Ship Systems and Equipment; London,
United Kingdom; March 2024.
M. Muise. Participation on the IMO Subcommittee on
Navigation, Communications and Search and Rescue;
London, United Kingdom; June 2024.
APPENDIX C: Outreach76
2024 Annual Report to Congress National Transportation Safety BoardOffice of Railroad, Pipeline and Hazardous Materials Investigations
The Office of Railroad, Pipeline and Hazardous Materials Investigations participated in
62 events in 2024. The most significant of these events are highlighted below.
Presentations and Briefings
S. Lyons. Presentation on open and recently
closed pipeline investigations at the American Gas
Association Operations Executive Committee Meeting;
January 2024.
A. Horton (with Chairwoman Homendy). “The NTSB
Pipeline Investigative Process and Update on the
NTSB Investigation of the Jackson, Mississippi Natural
Gas-fueled Home Explosion and Fires.” Presentation
at a community meeting hosted by US Representative
Bennie Thompson; Jackson, Mississippi; April 2024.
M. Hiller and S. Lynum. Briefing on recent
pipeline investigations, NTSB advance notice of
proposed rulemaking, and high-priority pipeline
recommendations to the American Gas Association
Managing Committee; Seattle, Washington; May 2024.
S. Lynum. “NTSB Investigation Protocols.” Presentation
to the Texas Railroad Commission Pipeline Conference;
Austin, Texas; July 2024.
P. Stancil. “The NTSB Investigation of the East
Palestine, Ohio, Rail Disaster.” Presentation to the TRB
AT040 Hazmat Committee Meeting; Washington, DC;
August 2024.
B. Clatterbuck. “The Emerging Risks of Lithium
Batteries.” Presentation to the National Volunteer Fire
Council; Kansas City, Missouri; September 2024.
P. Warren and T. Lloyd. “The NTSB Investigation of
the East Palestine, Ohio, Rail Disaster.” Presentation
to AASHTO Council on Rail Transportation Annual
Meeting; Norfolk, Virginia; September 2024.
P. Warren and S. Lyons. “NTSB Pipeline Investigations
and Safety Priorities.” Presentation at PHMSA All
Hands Conference; Tucson, Arizona; September 2024.Participation on Panels
A. Garcia; lectern session co-chair. “The State of
Transportation Policy in Indian Country.” Applied
Experimental Human Factors Conference; Nice,
France; July 2024.
B. Clatterbuck. Participation on rail panel at the
National Volunteer Fire Council Meeting; Kansas City,
Missouri; September 2024.
Participation in/Attendance at Meetings
and Conferences
D. Rhine, B. Johnson, and T. Kraholik. “About the NTSB
and Railroad Wheel Bearing Failure Modes.” Presented
at the Joint Rail Conference; Columbia, South Carolina;
April 2024.
D. Casaceli. Participation in the FRA’s
Crashworthiness/Survival Factors Course; Pueblo,
Colorado; June 2024.
G. Scott, J. Morris, and A. Rodrigues. Participation
in the Railway Supply Institute Railway Interchange;
Louisville, Kentucky; June 2024.
D. Rhine. Participation on a panel about university
engagement in technology transfer and workforce
development at the University of Texas Rio Grande
Valley – University Transportation Center for Railway
Safety Conference; Brownsville, Texas; June 2024.
D. Spillers. Participated in the Plastic Pipe Data
Collection meeting; Washington, DC; June 2024.
D. Spillers. Participated in the American Petroleum
Institute meeting; Washington, DC; June 2024.
T. Lloyd. Led discussion of the East Palestine, Ohio,
NTSB accident investigation report, findings, and recommendations with the International Association of
Fire Chiefs; August 2024.
J. Gordon and D. Mack. Participated in the American
Railway Engineering and Maintenance-of-Way
Association Conference; Louisville, Kentucky;
September 2024.
E. Bozkho. Attended the International Pipeline
Conference; Calgary, Canada; September 2024.
D. Spillers. Attended the American Society of
Mechanical Engineers B31 and Non-Metallic Standards
Development Committee meeting; Charlotte,
North Carolina; September 2024.
D. Rhine, G. Scott, and M. Thompson. “About the NTSB
and Railroad Wheel Bearing Failure Modes.” Presented
at the University Transportation Center for Railway
Safety; Edinburg, Texas; September 2024.
R. Gunaratnam. Attended UL Standards and
Engagement TRIP Summit; Dallas, Texas; October
B. Clatterbuck. Attended the Battery Safety Council
Forum 14; Washington, DC; October 2024.
J. Morris and B. Johnson. Attended NEXTGEN Train
Control 2024; Baltimore, Maryland; October 2024.
P. Warren, J. Gordon, and D. Mack. Attended Rail Share;
Fort Lauderdale, Florida; November 2024.
R. Gordon and D. Mack. Participated in the FRA’s Rail
Safety Advisory Committee meetings; virtual and one
in Phoenix, Arizona.
APPENDIX C: Outreach77
2024 Annual Report to Congress National Transportation Safety BoardOffice of Research and Engineering
The Office of Research and Engineering participated in 92 events in 2024. The most
significant of these events are highlighted below.
Presentations and Briefings
J. Price and R. Smith. “NTSB Safety Studies Division:
Alcohol, Other Drug, and Multiple Drug Use Among
Drivers.” Presentation at the TRB Annual Meeting;
Washington, DC; January 2024.
R. Smith. “Emerging Research in Impaired Driving.”
Presentation at the TRB Annual Meeting; Washington,
DC; January 2024.
R. Smith. “Field Detection of Non-Alcohol Drugs.”
Presentation at the TRB Annual Meeting; Washington,
DC; January 2024.
R. Smith. “Working Together to End Impaired
Driving: NTSB’s Investigations, Research, and
Recommendations.” Presentation at the Texas
Impaired Driving Forum; February 2024.
J. Price. “Fatigue-Related Consequences in Aviation.”
Presentation at the Working Time Society Global
Seminar; March 2024.
R. Smith. “Amplifying Victims Voices: A Researcher
Perspective.” Presentation at the Safe Mobility
Conference American Automobile Association
Foundation; Chapel Hill, North Carolina; March 2024.
R. Smith. “Leveraging Data to Improve Crash
Investigations and Traffic Safety.” Presentation
at the 2024 Auto Insurance Report Conference;
Monarch Beach, California; April 2024.
J. Price and R. Smith. “NTSB Safety Research: Drug
Prevalence in Aviation and Highway.” Presentation
at the US DOT Human Factors Coordination Working
Group; Washington, DC; April 2024.R. Smith. “The Oral Fluids Factor: Roadside and
Evidential Testing to Reduce Impaired Driving.”
Presentation at the 2024 Lifesavers National
Conference on Roadway Safety; Denver, Colorado; April
R. Smith. “Brave New World in Cannabis Detection.”
Presentation at the 2024 Lifesavers National
Conference on Roadway Safety; Denver, Colorado;
April 2024.
R. Smith. “Closing Plenary Speech for the 2024 Annual
Lifesaver’s Conference.” Presentation at the Lifesavers
National Conference on Roadway Safety; Denver,
Colorado; April 2024.
A. Lamm. “Helicopter Spindle Separation in Erie,
Colorado.” Presentation at the American Society
of Mechanical Engineers Aerospace Structures,
Structural Dynamics, and Materials Conference;
Renton, Washington; April 2024.
F. Zakar. “Natural Gas Pipeline Rupture in Coolidge,
Arizona.” American Society for Metals International
Phoenix Chapter, Arizona State University; Phoenix,
Arizona; April 2024.
E. Mueller. “Aviation Accident Investigations Involving
Drones and Birds.” Presentation at the Accident
Investigations–Materials International meeting;
Washington, DC; May 2024.
M. Budinski. “NTSB Agency Update.” Presentation at
the Accident Investigations–Materials International
meeting; Washington, DC; May 2024.
D. Kramer. “Failure Analysis of Two Kaman K-MAX
Twin-Rotor Helicopter Servo Flap Failures.”
Presentation at the Accident Investigations–Materials
International meeting; Washington, DC; May 2024.M. Fox. “Accident Investigation Data Management and
Analysis at the NTSB.” Presentation at the Accident
Investigations–Materials International meeting;
Washington, DC; May 2024.
M. Budinski. “NTSB Efforts to Prepare for Emerging
Transportation Technology.” Presentation at the
Accident Investigations–Materials International
meeting; Washington, DC; May 2024.
T. A. Kayagil. “Postmortem Carbon Monoxide
Production in a Fatally Injured Helicopter Pilot.”
Presentation at the Aerospace Medical Association
2024 Annual Scientific Meeting; Chicago, Illinois;
May 2024.
M. Moler. “Determining Airplane Trajectories for
Runway Incursion.” Presentation at the Accident
Investigators-Performance International meeting;
Canberra, Australia; June 2024.
K. Renze. “Cessna Citation Landing Overrun.”
Presentation at the Accident Investigators-
Performance International meeting; Canberra,
Australia; June 2024.
J. O’Callaghan. “Computing Load Factors at Points
Removed from the Center of Gravity During Upsets.”
Presentation at the Radio Technical Commission
for Aeronautics Turbulence Study Group Meeting;
June 2024.
M. Fox. “Fan Blade Fatigue Fractures in CFM56-7B
Engines.” Presentation at the International Conference
on Engineering Failure Analysis; Athens, Greece;
July 2024.
J. O’Callaghan. “Wet Runway Overruns: Still a Slippery
Problem.” Presentation at the Engineering Sciences
Data Unit Meeting; London, United Kingdom; July 2024.
E. Mueller and Z. Keliher. “Review of NTSB
Investigations of Cessna 210 Hydraulic Actuator
Fractures from Fatigue.” Presentation at International
Materials, Applications and Technologies 2024;
Cleveland, Ohio; September 2024.
APPENDIX C: Outreach78
2024 Annual Report to Congress National Transportation Safety BoardM. Budinski, E. Mueller, and J. Panagiotou. “NTSB
Materials Failure Analysis of Lithium-Ion Battery
Incidents from the Boeing 787.” Presentation at the
International Materials, Applications and Technologies
2024; Cleveland, Ohio; September 2024.
T. A. Kayagil, B. Tuttle, and D. Morgan. “Going the
Extra Mile in Transportation Accident Investigations.”
Presentation at the National Association of Medical
Examiners Annual Meeting; Denver, Colorado;
September 2024.
C. Babcock. “2024 Vehicle Recorder Lab Update.”
Presentation at the General Aviation-Air Safety
Investigators Annual Seminar; Wichita, Kansas;
September 2024.
A. Lamm. “Engine Failures Related to Powder Metal
Alloy Processing.” Presentation at the International
Society of Air Safety Investigators; Lisbon, Portugal;
September 2024.
R. Smith. “Impaired Driving Data Needs: Why This
is So Important.” Presentation at the 2024 National
Alliance to Stop Impaired Driving; November 2024.
M. Portman. “AIR 2024 - NTSB Lab Update and
Automatic Speech Recognition Progress.” Presentation
at the Accident Investigators – Recorders International
Meeting; Iceland Safety Investigation Authority;
Reykjavik, Iceland; November 2024.
J. O’Callaghan. “Aircraft Performance Calculations
Using the Data Analysis Numerical Toolbox and Editor
(DANTE).” Presentation at the Accident Investigators–
Performance International Meeting; November 2024.Instruction or Instructional Presentations
E. Mueller. “Failure Analysis: How to Organize and
Run a Failure Investigation.” Guest lecture for Failure
Analysis of Materials class, The Ohio State University;
Columbus, Ohio; January 2024.
S. Payne. “NTSB Overview – Recorders Lab RE-40.”
Guest lecture for Oklahoma State Aerospace class,
Oklahoma State University; February 2024.
J. Price. “Federal Perspective on Driver Impairment
Detection.” Guest lecture for Graduate Seminar on
Driver Impairment, Center for Injury Research and
Policy, Johns Hopkins University; March 2024.
M. Portman. “Inside the Black Box: How the NTSB’s
Vehicle Recorder Lab Supports Human Performance
Investigations.” Guest lecture for Introduction to
Cognitive Engineering class, Department of Integrated
Systems Engineering, College of Engineering, The Ohio
State University; April 2024.
J. Price. “Time of Day, Performance, and Safety.” Guest
lecture for Human Factors class, University of Iowa;
April 2024.
T. Burtch. “One in a Million? - NTSB Case Study.” Guest
lecture for General Aviation Accident Investigation,
Transportation Safety Institute, US Department of
Transportation; Oklahoma City, Oklahoma; June 2024.
S. Payne. “Electronic Devices in Accident
Investigation.” Guest lecture for General Aviation
Accident Investigation, Transportation Safety Institute,
US Department of Transportation; Oklahoma City,
Oklahoma; June 2024.
J. O’Callaghan. “Aircraft Performance at the NTSB.”
Guest lecture for the Aerodynamics and Performance
Class, Embry-Riddle Aeronautical University;
Daytona Beach, Florida; November 2024.Participation in/Attendance at Meetings
and Conferences
C. Babcock, C. Cates, O. Fowler, S. Payne, and
S. Smith. Participation in European Organization for
Civil Aviation Equipment WG-118 Update to Technical
Standards for Flight Recorders Working Group; weekly
meetings throughout 2024.
T. Kayagil and B. Tuttle. Participation in Quad Agency
Working Group Medical Operations Readiness
Review meetings for human spaceflight with National
Aeronautics and Space Administration, US Air Force,
FAA, private spaceflight companies, and international
agencies; multiple meetings in 2024.
T. Kayagil. Attendance at Substance Abuse and Mental
Health Services Administration Drug Testing Advisory
Board meetings; quarterly meetings in 2024.
B. Rawlinson. Participation in TRB’s BTSCRP BTS-31:
Quantifying the Safety Impacts of Reduced Traffic
Enforcement; Washington, DC; monthly meetings
throughout 2024.
B. Rawlinson. Participation in the TRB’s Incorporating
a Safe System Approach into the NCHRP (National
Cooperative Highway Research Program) 500 (NCHRP
17-113) Working Group; Washington, DC; monthly
meetings throughout 2024.
C. Schultheisz. Session Organizer. “NTSB
Investigations.” TRB Annual Meeting; Washington, DC;
January 2024.
T. A. Kayagil and K. Renze. Attendance at the TRB
Annual Meeting; Washington, DC; January 2024.
K. Renze. Attendance at the SAE–Government/
Industry Meeting; Washington, DC; January 2024.
C. Cates. Participation in Commercial Aviation Safety
Team/ICAO Common Taxonomy Team Flight Data
Monitoring Definitions Working Group; Madrid, Spain;
February 2024.
APPENDIX C: Outreach79
2024 Annual Report to Congress National Transportation Safety BoardC. Schultheisz, T. Burtch, and J. O’Callaghan.
Attendance at the Accident Investigators–Performance
International meeting; June 2024.
T. Burtch, D. Horak, M. Moler, K. Renze, and
C. Schultheisz. Attendance at the Accident
Investigators–Performance International Meeting;
November 2024.Office of Administrative Law Judges
Presentations and Briefings
C. Mayerand, J. DeLisi. “Role of Administrative Law
Judges.” Presentation at the Antonin Scalia Law
School of George Mason University, Fairfax, Virginia,
April 2024.
V. Couch, D. Fun, C. Mayer, K. Primosch, and J. DeLisi.
“Office of Administrative Law Judges and NTSB
Appeals Process Overview.” Presentation to the Legal
Advisory Committee; EAA Airventure 2024; Oshkosh,
Wisconsin, July 2024.
2024 Annual Report to Congress National Transportation Safety BoardAppendix D:
Accident Investigations Not Completed25
25 Title 49 U.S.C. section 1116(c)(5) requires that the agency provide annually “a list of accidents, during the prior calendar year, that the Board was required to investigate under 49 U.S.C. section 1131 but did not investigate
and an explanation of why they were not investigated.”Aviation: None to Report.
Highway: None to Report.
Marine: None to Report.
Railroad, Pipeline and Hazardous Materials: Fatal and Nonfatal Accidents.
The following two sections—Pipeline and Railroad—list those accidents that the NTSB, under 49 U.S.C. section 1131, is required to
investigate but that the agency was unable to investigate because of the reason specified. Section 1210 of the FAA Reauthorization Act
of 2024 amended the NTSB rail investigative authority to provide that accidents occurring at railroad grade crossings, or those that involve
rail trespassers, are not accidents for which NTSB investigation is mandatory unless selected by the Board. Trespassing on railroad property
is the leading cause of rail-related fatalities; however, the NTSB is unable to investigate every trespasser fatality and, in fact, investigates such
accidents extremely rarely because of limited resources and limited safety benefits. Excluding these accidents from the requirement under
49 U.S.C. section 1131(a)(1)(C) allows the NTSB to focus resources on investigating rail accidents for which there are safety benefits.
Pipeline
Staff has reviewed and included all the available information needed to comply with 49 U.S.C. section 1116(c)(5).
Criteria used here are for reporting information only and do not represent NTSB launch criteria for investigating an accident.
TABLE 21. Required Pipeline Accident Investigations Not Completed
Month Day Location Accident Circumstances Reason Not Investigated
1 7 Ingleside, TexasFlint Hills Resources Inc. reported a 2,915-barrel release of crude oil. The spill did not impact water
or leave containment. No injuries, fatalities, or evacuations reported.Limited resources
2 14 East Sparta, Ohio Pipeline failure with release and fire of natural gasoline, no fatalities or injuries. Limited resources
3 25 Atlanta, GeorgiaThird-party hit to natural gas main resulted in an explosion of a closed restaurant, no fatalities or
injuries.Limited resources
APPENDIX D: Accident Investigations Not Completed81
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
4 15 Phoenix, ArizonaRelease of natural gas into the atmosphere from a regulator station after a vehicle strike.
The local fire department on-scene evacuated 300 personnel and a nearby daycare.Limited resources
4 26 Ward County, TexasA 30-inch natural gas transmission steel line ruptured and ignited. No injuries or evacuations
reported. Other pipeline facilities for other gas operators were impacted.Limited resources
5 8 Jackson, LouisianaFlash fire at a natural gas compressor station during preparation for construction work.
One contractor received second- and third-degree burns and was hospitalized.Limited resources
6 3 Reeves County, TexasFlash fire during pigging operation on a natural gas liquids pipeline. Two employees were
hospitalized.Limited resources
7 7 Richardson, TexasAtmos Mid-Tex reported a natural gas release of an unknown amount. One injury was reported.
The contractor crew was retiring a service line when ignition occurred near the service line tee.
The crew was removing the service line tee from the 2-inch steel main as part of the retirement.
Ignition occurred when the crew punched in after removing the cap off the service line tee.Limited resources
7 13 Willston, North DakotaSavage Bakken Connector Inc. reported a crude oil spill from a crude oil storage tank. No
reports of impacts to water. The cause of the spill was indicated to be from an employee
not shutting a valve.Limited resources
7 16 Floresville, TexasContractor bored into natural gas distribution line at residence causing release and explosion;
no injuries or fatalities.Limited resources
7 18 Fairfax, VirginiaThird-party damage to a 12-inch Aldyl A main causing natural gas release and migration;
no injuries or fatalities.Limited resources
9 11 Maysville, OklahomaFlash fire during pigging operation of a natural gas gathering line. Three employees were injured
and hospitalized.Limited resources
9 22 Bronx, New YorkNatural gas main ruptured and leaked gas. Three people were sent to the hospital with gas
related symptoms. Gas company was dispatched, closed the valves, and stopped the leak. Limited resources
9 30 Vicksburg, Mississippi Small leak on half-inch nipple on welding fitting. More than $300K repairs. No injuries or fatalities. Limited resources
10 15 Huffman, TexasThird-party struck a 10-inch energy transfer pipeline. About 1,000 barrels of crude oil were released.
No waterway impacts.Limited resources
11 15 Bartonsville, Texas Plug blew out on 4-inch distribution line while running a steel tap resulting in fatality. Limited resources
APPENDIX D: Accident Investigations Not Completed82
2024 Annual Report to Congress National Transportation Safety BoardRailroad
The NTSB investigated 23 railroad accidents in 2024.26 An additional 483 accidents that met the requirements of 49 U.S.C. section 1131 were identified but
not investigated because of limited investigative resources. An accident with a limited safety benefit is an occurrence for which NTSB investigators were able to
determine quickly that no safety recommendations were likely to be issued or reiterated. Those accidents that were not investigated because of limited NTSB resources
share some similarities with those of limited safety benefits; although the causes of these accidents may not have been immediately identifiable, the low level of severity
of the accidents and other factors were weighed against those of ongoing investigations to make the best use of the resources available.
26 Data provided in this report are received from the FRA and the FTA. Criteria used here are for reporting information only and do not represent our launch criteria for investigating an accident. In addition, some information
reported by the FTA does not provide details regarding agencies or locations. NTSB staff has reviewed and included all the available information needed to comply with 49 U.S.C. section 1116(c)(5).
27 This data set excludes reported trespasser accidents.TABLE 22. Required Railroad Accident Investigations Not Completed
Qualifying Event Limited Resources Limited Safety Benefit
Railroad accident – fatal27 7
Railroad accident – damage over reporting limit, nonfatal (freight) 358
Railroad accident – damage over reporting limit, nonfatal (passenger) 63
Transit accident (passenger train) 55
Subtotal 483
Total of all railroad and transit accidents not investigated 483
FRA Railroad Accidents
TABLE 23. FRA Fatal Railroad Accidents
Month Day Location Accident Circumstances Reason Not Investigated
8 20 Crawford, Arkansas Struck by on-track equipment Limited resources
9 15 Los Angeles, California Struck by on-track equipment Limited resources
10 25 Cook, Illinois Other Limited resources
11 1 Montgomery, Texas Struck by on-track equipment Limited resources
11 17 Tarrant, Texas Struck by on-track equipment Limited resources
11 23 Santa Clara, California Struck by on-track equipment Limited resources
11 24 Bexar, Texas Struck by on-track equipment Limited resources
APPENDIX D: Accident Investigations Not Completed83
2024 Annual Report to Congress National Transportation Safety BoardTABLE 24. FRA Nonfatal Railroad Accidents with Damage Over Reporting Limit (Freight)
Month Day Location Accident Circumstances Reason Not Investigated
1 2 Roanoke, Texas Derailment Limited resources
1 3 Penrose, Colorado Derailment Limited resources
1 5 Milo, Missouri Derailment Limited resources
1 5 Lodi, Ohio Derailment Limited resources
1 6 Sealy, Texas Derailment Limited resources
1 7 Memphis, Tennessee Side collision Limited resources
1 9 Superior, Wisconsin Derailment Limited resources
1 11 Enid, Oklahoma Derailment Limited resources
1 12 Bill, Wyoming Derailment Limited resources
1 14 New Orleans, Louisiana Derailment Limited resources
1 19 Sonora, California Derailment Limited resources
1 19 Dupo, Illinois Derailment Limited resources
1 19 Roanoke, Virginia Other impacts Limited resources
1 21 Arlington, Nebraska Derailment Limited resources
1 22 Belden, California Other Limited resources
1 22 Topeka, Kansas Derailment Limited resources
1 23 Greenville, Ohio Derailment Limited resources
1 24 Roanoke, Virginia Other impacts Limited resources
1 25 Minneapolis, Minnesota Derailment Limited resources
1 28 Fridley, Minnesota Derailment Limited resources
1 30 Catoosa, Oklahoma Derailment Limited resources
1 30 Wright, Wyoming Derailment Limited resources
1 31 Laurel, Montana Derailment Limited resources
2 1 San Jose, California Derailment Limited resources
2 1 Amory, Mississippi Derailment Limited resources
2 3 Fort Worth, Texas Derailment Limited resources
2 5 Cabool, Missouri Derailment Limited resources
2 5 El Paso, Texas Derailment Limited resources
2 6 Reedpoint, Montana Derailment Limited resources
2 7 Valley Falls, New York Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed84
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
2 9 Cairo, Nebraska Derailment Limited resources
2 9 Aurora, North Carolina Derailment Limited resources
2 10 Selkirk, New York Other impacts Limited resources
2 11 Sloat, California Derailment Limited resources
2 12 Hazelton, Kansas Derailment Limited resources
2 12 Paw Paw, West Virginia Derailment Limited resources
2 15 Kansas City, Missouri Derailment Limited resources
2 15 Linden, New Jersey Derailment Limited resources
2 17 Sellers, South Carolina Derailment Limited resources
2 19 Cushman, Montana Derailment Limited resources
2 19 Gordon, Texas Derailment Limited resources
2 21 East St Louis, Illinois Derailment Limited resources
2 25 Kansas City, Kansas Derailment Limited resources
2 25 Trent, Texas Derailment Limited resources
2 27 Salix, Iowa Derailment Limited resources
2 28 Elko, Nevada Derailment Limited resources
2 28 Wenatchee, Washington Derailment Limited resources
3 2 Riverdale, Illinois Rear-end collision Limited resources
3 3 Floriston, California Other Limited resources
3 4 Springfield, Missouri Derailment Limited resources
3 6 Fleming, Colorado Derailment Limited resources
3 7 North Little Rock, Arkansas Other impacts Limited resources
3 8 Kearney, Nebraska Derailment Limited resources
3 8 Oconto Falls, Wisconsin Derailment Limited resources
3 9 Decatur, Indiana Derailment Limited resources
3 9 Yazoo City, Mississippi Fire/violent rupture Limited resources
3 9 Nashville, Tennessee Other Limited resources
3 9 Hearne, Texas Other impacts Limited resources
3 10 Bellevue, Ohio Derailment Limited resources
3 11 West Lafayette, Indiana Derailment Limited resources
3 11 North Platte, Nebraska Derailment Limited resources
3 11 Fort Worth, Texas Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed85
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
3 12 Gallion, Alabama Derailment Limited resources
3 13 Hopedale, Ohio Derailment Limited resources
3 14 Barstow, California Derailment Limited resources
3 15 Rice, Texas Derailment Limited resources
3 19 Hopedale, Ohio Derailment Limited resources
3 20 Springfield, Missouri Derailment Limited resources
3 22 Thedford, Nebraska Derailment Limited resources
3 24 Midland, South Dakota Derailment Limited resources
3 25 Bossier City, Louisiana Other impacts Limited resources
3 25 Socorro, New Mexico Derailment Limited resources
3 28 La Veta, Colorado Derailment Limited resources
3 28 Mulkeytown, Illinois Fire/violent rupture Limited resources
3 28 Pampa, Texas Derailment Limited resources
3 29 Gibsland, Louisiana Derailment Limited resources
3 29 North Platte, Nebraska Other impacts Limited resources
3 30 Alturas, California Derailment Limited resources
3 30 Galesburg, Illinois Derailment Limited resources
3 30 Davenport, Oklahoma Derailment Limited resources
3 31 Roseville, California Derailment Limited resources
4 3 Elkhart, Indiana Derailment Limited resources
4 3 Burns Harbor, Indiana Derailment Limited resources
4 5 Gallup, New Mexico Derailment Limited resources
4 6 Gary, Indiana Derailment Limited resources
4 10 Montpelier, Vermont Derailment Limited resources
4 12 Baker, California Derailment Limited resources
4 13 Cumberland, Maryland Side collision Limited resources
4 13 Wyandotte, Oklahoma Derailment Limited resources
4 14 Chappell, Nebraska Derailment Limited resources
4 16 White Hall, Alabama Derailment Limited resources
4 16 Nebraska City, Nebraska Derailment Limited resources
4 17 Mason City, Iowa Derailment Limited resources
4 17 Middle River, Maryland Obstruction Limited resources
APPENDIX D: Accident Investigations Not Completed86
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
4 18 Belen, New Mexico Derailment Limited resources
4 20 Chambers, Arizona Derailment Limited resources
4 20 Cincinnati, Ohio Derailment Limited resources
4 22 Bennet, Nebraska Derailment Limited resources
4 23 Wright City, Oklahoma Derailment Limited resources
4 23 Merkel, Texas Derailment Limited resources
4 25 Hattiesburg, Mississippi Other Limited resources
4 26 New Orleans, Louisiana Other Limited resources
4 26 Lincoln, Nebraska Derailment Limited resources
4 26 Aberdeen, Washington Derailment Limited resources
4 27 Lincoln, Nebraska Derailment Limited resources
4 28 Unity Village, Missouri Obstruction Limited resources
5 1 Groesbeck, Texas Derailment Limited resources
5 1 Pyote, Texas Derailment Limited resources
5 2 Bremen, Kansas Derailment Limited resources
5 2 Lottie, Louisiana Other impacts Limited resources
5 3 Cumberland, Maryland Side collision Limited resources
5 3 White Lake, South Dakota Derailment Limited resources
5 3 Anna, Texas Derailment Limited resources
5 4 Irondale, Alabama Derailment Limited resources
5 4 Flushing Meadows, New York Obstruction Limited resources
5 5 Alton, Illinois Other impacts Limited resources
5 7 Clifton, Arizona Derailment Limited resources
5 7 Stamford, Connecticut Fire/violent rupture Limited resources
5 7 Valley Mills, Texas Derailment Limited resources
5 9 Irondale, Alabama Other impacts Limited resources
5 9 Ashdown, Arkansas Derailment Limited resources
5 10 Manor, Texas Derailment Limited resources
5 12 Wheatland, Wyoming Derailment Limited resources
5 13 Porter, Indiana Derailment Limited resources
5 14 Dodge City, Kansas Derailment Limited resources
5 14 Fort Worth, Texas Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed87
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
5 15 Long Beach, California Derailment Limited resources
5 18 Livermore, Iowa Derailment Limited resources
5 19 Long Beach, California Derailment Limited resources
5 19 Joliet, Illinois Other impacts Limited resources
5 21 Cherokee, Kansas Derailment Limited resources
5 22 Macon, Georgia Other Limited resources
5 22 North Platte, Nebraska Derailment Limited resources
5 22 Fort Worth, Texas Derailment Limited resources
5 23 Alberta, Minnesota Derailment Limited resources
5 24 Stuttgart, Arkansas Derailment Limited resources
5 24 Lottie, Louisiana Other impacts Limited resources
5 24 Beach City, Texas Other impacts Limited resources
5 25 Emmet, Arkansas Derailment Limited resources
5 25 La Follette, Tennessee Derailment Limited resources
5 28 Gardner, Massachusetts Derailment Limited resources
5 31 Portland, Oregon Derailment Limited resources
6 1 West Mansfield, Ohio Derailment Limited resources
6 4 Custer, Washington Derailment Limited resources
6 5 Delta, Utah Derailment Limited resources
6 6 Dallas, Texas Derailment Limited resources
6 6 Dallas, Texas Other impacts Limited resources
6 7 Bylas, Arizona Derailment Limited resources
6 8 Waycross, Georgia Side collision Limited resources
6 8 Atlanta, Georgia Other impacts Limited resources
6 9 Silsbee, Texas Derailment Limited resources
6 10 Decatur, Illinois Other impacts Limited resources
6 10 Everett, Washington Rear-end collision Limited resources
6 11 Atlanta, Georgia Derailment Limited resources
6 11 Atlanta, Georgia Derailment Limited resources
6 11 Union, Nebraska Derailment Limited resources
6 12 Duluth, Minnesota Derailment Limited resources
6 13 Oakes, North Dakota Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed88
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
6 14 Florence, Minnesota Derailment Limited resources
6 14 Boise City, Oklahoma Derailment Limited resources
6 15 Silsbee, Texas Derailment Limited resources
6 16 Lottie, Louisiana Other impacts Limited resources
6 17 Oakville, Washington Derailment Limited resources
6 18 St Joseph, Missouri Derailment Limited resources
6 20 Mitchell, Nebraska Other impacts Limited resources
6 21 Alvord, Iowa Derailment Limited resources
6 21 Touchet, Washington Derailment Limited resources
6 22 Chicago, Illinois Raking collision Limited resources
6 22 Lafayette, Indiana Derailment Limited resources
6 22 Rugby, North Dakota Derailment Limited resources
6 22 Seattle, Washington Derailment Limited resources
6 24 Venice, Illinois Derailment Limited resources
6 24 Walbridge, Ohio Derailment Limited resources
6 24 Clearmont, Wyoming Derailment Limited resources
6 25 La Puente, California Other impacts Limited resources
6 26 Memphis, Tennessee Derailment Limited resources
6 26 Lindon, Utah Derailment Limited resources
6 27 Matteson, Illinois Derailment Limited resources
6 29 Melrose Park, Illinois Derailment Limited resources
6 29 Montpelier, Iowa Derailment Limited resources
7 1 Melrose Park, Illinois Derailment Limited resources
7 3 Missouri Valley, Iowa Derailment Limited resources
7 5 Linden, Indiana Derailment Limited resources
7 6 Warsaw, North Carolina Obstruction Limited resources
7 7 Gibbon, Nebraska Derailment Limited resources
7 8 Washington, Missouri Obstruction Limited resources
7 8 Auburn, Washington Derailment Limited resources
7 10 Galesburg, Illinois Derailment Limited resources
7 10 Somonauk, Illinois Derailment Limited resources
7 10 Newark, New Jersey Side collision Limited resources
APPENDIX D: Accident Investigations Not Completed89
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
7 11 Cherryvale, Kansas Derailment Limited resources
7 11 Eastwood, Ohio Derailment Limited resources
7 11 Woodward, Oklahoma Derailment Limited resources
7 12 Suwanee, Georgia Derailment Limited resources
7 12 Pocatello, Idaho Derailment Limited resources
7 12 Wausau, Wisconsin Derailment Limited resources
7 13 Congress, Arizona Derailment Limited resources
7 14 Fort Worth, Texas Obstruction Limited resources
7 14 Abilene, Texas Derailment Limited resources
7 16 North Charleston, South Carolina Raking collision Limited resources
7 17 Barstow, California Derailment Limited resources
7 17 Pocatello, Idaho Derailment Limited resources
7 17 Indianapolis, Indiana Derailment Limited resources
7 18 Fairfield, Connecticut Other Limited resources
7 18 Brewster, New York Other impacts Limited resources
7 20 Venice, Illinois Derailment Limited resources
7 20 Ottawa, Kansas Derailment Limited resources
7 20 Big Lake, Minnesota Derailment Limited resources
7 22 Dodge City, Kansas Derailment Limited resources
7 22 Temple, Texas Derailment Limited resources
7 23 Lincoln, Nebraska Derailment Limited resources
7 24 Atlanta, Georgia Derailment Limited resources
7 24 Ingalls, Kansas Derailment Limited resources
7 24 North Platte, Nebraska Derailment Limited resources
7 25 Hereford, Texas Derailment Limited resources
7 25 Crewe, Virginia Side collision Limited resources
7 26 Westwood, California Derailment Limited resources
7 29 Glidden, Iowa Derailment Limited resources
7 30 Peabody, Kansas Derailment Limited resources
8 1 Brownwood, Texas Derailment Limited resources
8 2 Adrian, Michigan Side collision Limited resources
8 2 Springfield, Ohio Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed90
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
8 2 Houston, Texas Derailment Limited resources
8 3 Temple, Texas Derailment Limited resources
8 4 Marshalltown, Iowa Derailment Limited resources
8 5 Yucca, Arizona Derailment Limited resources
8 7 Nampa, Idaho Derailment Limited resources
8 7 Willmar, Minnesota Derailment Limited resources
8 8 Red Oak, Iowa Derailment Limited resources
8 8 Shreveport, Louisiana Derailment Limited resources
8 10 Glenrock, Wyoming Derailment Limited resources
8 11 Union Mills, Indiana Derailment Limited resources
8 12 Klamath Falls, Oregon Derailment Limited resources
8 14 Lehigh, Kansas Other Limited resources
8 14 Livonia, Louisiana Derailment Limited resources
8 15 Keithville, Louisiana Derailment Limited resources
8 16 Topeka, Kansas Derailment Limited resources
8 18 Slaton, Texas Derailment Limited resources
8 19 Millbury, Ohio Derailment Limited resources
8 20 Vacherie, Louisiana Derailment Limited resources
8 21 Baton Rouge, Louisiana Derailment Limited resources
8 21 Flint, Michigan Raking collision Limited resources
8 22 Boulder, Colorado Derailment Limited resources
8 25 Rocky Mount, North Carolina Derailment Limited resources
8 27 Buna, Texas Derailment Limited resources
8 28 Colton, California Derailment Limited resources
8 28 Ayer, Massachusetts Derailment Limited resources
8 28 Steele, North Dakota Derailment Limited resources
8 29 Belen, New Mexico Derailment Limited resources
8 29 Fort Worth, Texas Derailment Limited resources
8 30 Gallup, New Mexico Derailment Limited resources
8 30 Fort Worth, Texas Derailment Limited resources
8 31 Memphis, Tennessee Derailment Limited resources
8 31 Gladstone, Virginia Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed91
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
9 3 Linden, Alabama Derailment Limited resources
9 4 Roanoke, Virginia Derailment Limited resources
9 6 Beaumont, Texas Other impacts Limited resources
9 7 Hardin, Montana Derailment Limited resources
9 8 Topeka, Kansas Derailment Limited resources
9 11 Kansas City, Kansas Derailment Limited resources
9 15 Gothenburg, Nebraska Derailment Limited resources
9 15 Portland, Oregon Derailment Limited resources
9 16 Bellevue, Ohio Side collision Limited resources
9 18 Wolf Point, Montana Derailment Limited resources
9 18 Tulsa, Oklahoma Derailment Limited resources
9 20 Greenville, Texas Derailment Limited resources
9 22 Caliente, California Derailment Limited resources
9 24 Flat Rock, Michigan Derailment Limited resources
9 24 Columbus, Nebraska Derailment Limited resources
9 25 Kansas City, Kansas Derailment Limited resources
9 25 Cohasset, Minnesota Derailment Limited resources
9 26 Portage, Wisconsin Derailment Limited resources
9 29 Amboy, California Fire/violent rupture Limited resources
9 30 New Salem, Illinois Derailment Limited resources
10 1 Hammond, Indiana Derailment Limited resources
10 4 Black Rock, Arkansas Derailment Limited resources
10 4 Benton, Arkansas Derailment Limited resources
10 4 Kansas City, Kansas Derailment Limited resources
10 4 Woodbridge, New Jersey Derailment Limited resources
10 4 Houston, Texas Side collision Limited resources
10 4 Fort Worth, Texas Derailment Limited resources
10 7 Covington, Virginia Derailment Limited resources
10 8 San Antonio, Texas Derailment Limited resources
10 10 Cedar Rapids, Iowa Derailment Limited resources
10 10 Eunice, Louisiana Fire/violent rupture Limited resources
10 10 Slaton, Texas Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed92
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
10 11 Sahuarita, Arizona Derailment Limited resources
10 11 Onida, South Dakota Derailment Limited resources
10 12 Essex, Montana Derailment Limited resources
10 12 Jamaica, New York Derailment Limited resources
10 13 Waycross, Georgia Derailment Limited resources
10 13 Simsboro, Louisiana Derailment Limited resources
10 15 Des Moines, Iowa Derailment Limited resources
10 15 Walbridge, Ohio Derailment Limited resources
10 17 North Platte, Nebraska Derailment Limited resources
10 18 Donaldsonville, Louisiana Derailment Limited resources
10 18 San Antonio, Texas Other impacts Limited resources
10 19 Bakersfield, California Derailment Limited resources
10 22 Austin, Texas Derailment Limited resources
10 23 Clifton Forge, Virginia Derailment Limited resources
10 27 Nampa, Idaho Derailment Limited resources
10 27 Galesburg, Illinois Derailment Limited resources
10 28 Florence, South Carolina Derailment Limited resources
10 30 L’Anse, Michigan Rear-end collision Limited resources
10 30 Falls City, Nebraska Derailment Limited resources
11 1 Hitchcock, Texas Derailment Limited resources
11 2 Falls City, Nebraska Derailment Limited resources
11 2 La Crosse, Wisconsin Derailment Limited resources
11 3 Sherman, Texas Derailment Limited resources
11 4 Leavenworth, Washington Other impacts Limited resources
11 5 Groesbeck, Texas Derailment Limited resources
11 8 Winterboro, Alabama Derailment Limited resources
11 8 Jacksonville, Florida Side collision Limited resources
11 8 Grants, New Mexico Derailment Limited resources
11 10 Bartow, Florida Derailment Limited resources
11 10 North Platte, Nebraska Other impacts Limited resources
11 12 Stanfield, Oregon Other impacts Limited resources
11 13 North Little Rock, Arkansas Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed93
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
11 16 Cincinnati, Ohio Derailment Limited resources
11 17 North Platte, Nebraska Other impacts Limited resources
11 17 Ambrose, North Dakota Derailment Limited resources
11 18 Pine Bluff, Arkansas Derailment Limited resources
11 18 Jacksonville, Florida Other Limited resources
11 18 Tulsa, Oklahoma Derailment Limited resources
11 18 Denison, Texas Derailment Limited resources
11 20 Frankfort, Indiana Other Limited resources
11 23 Madill, Oklahoma Derailment Limited resources
11 24 Saginaw, Michigan Derailment Limited resources
11 25 Washington, District of Columbia Fire/violent rupture Limited resources
11 26 Greeneville, South Carolina Derailment Limited resources
11 28 Morrill, Nebraska Derailment Limited resources
12 1 Arbor, Nebraska Derailment Limited resources
12 2 Ringgold, Texas Derailment Limited resources
12 3 Estill, South Carolina Derailment Limited resources
12 4 Decatur, Illinois Derailment Limited resources
12 4 Laflin, Pennsylvania Derailment Limited resources
12 4 Austin, Texas Side collision Limited resources
12 6 Highlands, Texas Rear-end collision Limited resources
12 7 St Louis, Missouri Derailment Limited resources
12 7 Fort Worth, Texas Other impacts Limited resources
12 8 Louisville, Kentucky Derailment Limited resources
12 11 Danville, Kentucky Derailment Limited resources
12 12 Tulsa, Oklahoma Derailment Limited resources
12 13 Cameron, Texas Derailment Limited resources
12 16 North Platte, Nebraska Derailment Limited resources
12 18 Cleburne, Texas Derailment Limited resources
12 20 Climax, Michigan Derailment Limited resources
12 22 Gary, Indiana Derailment Limited resources
12 23 Carson, California Side collision Limited resources
12 23 Flat Rock, Michigan Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed94
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
12 24 Potsdam, New York Derailment Limited resources
12 24 Brenham, Texas Derailment Limited resources
12 26 Thompsonville, Illinois Derailment Limited resources
12 27 San Antonio, Texas Derailment Limited resources
12 29 Pocatello, Idaho Derailment Limited resources
12 29 Bellevue, Ohio Derailment Limited resources
12 30 Mojave, California Derailment Limited resources
12 30 Mill Creek, Oklahoma Derailment Limited resources
TABLE 25. FRA Nonfatal Railroad Accidents with Damage Over Reporting Limit (Passenger)
Month Day Location Accident Circumstances Reason Not Investigated
1 3 Bay Head, New Jersey Derailment Limited resources
1 6 Carbondale, Illinois Other Limited resources
1 12 Wilmington, Delaware Other Limited resources
1 13 Windsor, Wisconsin Obstruction Limited resources
2 11 Oakland, California Obstruction Limited resources
2 24 Crystal Lake, Illinois Derailment Limited resources
2 26 South Brunswick, New Jersey Other Limited resources
2 27 Acton, Massachusetts Other Limited resources
3 2 Spokane, Washington Derailment Limited resources
3 8 Pell City, Alabama Obstruction Limited resources
3 15 Leominster, Massachusetts Other Limited resources
3 17 West Palm Beach, Florida Derailment Limited resources
3 24 Brunswick, Maryland Obstruction Limited resources
3 25 Bentonia, Mississippi Obstruction Limited resources
4 6 North Miami Beach, Florida Other Limited resources
4 13 Lakewood, Washington Raking collision Limited resources
4 15 Metuchen, New Jersey Other Limited resources
4 17 Middle River, Maryland Obstruction Limited resources
4 29 Long Island City, New York Obstruction Limited resources
APPENDIX D: Accident Investigations Not Completed95
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
4 29 Ravenna, Ohio Obstruction Limited resources
5 11 Bethune, South Carolina Obstruction Limited resources
5 13 Long Branch, New Jersey Obstruction Limited resources
5 19 Berlin, Connecticut Obstruction Limited resources
5 25 Emporia, Kansas Derailment Limited resources
5 31 Suffolk, Virginia Obstruction Limited resources
6 6 Morrisville, Pennsylvania Other Limited resources
6 8 Dover, New Jersey Derailment Limited resources
6 9 Three Oaks, Michigan Obstruction Limited resources
6 11 Norwalk, Connecticut Other Limited resources
6 20 Nahunta, Georgia Obstruction Limited resources
6 20 Plaistow, New Hampshire Obstruction Limited resources
6 21 New York, New York Other Limited resources
6 25 South Bend, Indiana Obstruction Limited resources
6 26 Windsor, Connecticut Obstruction Limited resources
7 1 Chicago, Illinois Other impacts Limited resources
7 6 Queens Village, New York Derailment Limited resources
7 8 Augusta, Missouri Obstruction Limited resources
7 13 Augusta, Michigan Obstruction Limited resources
7 15 Paterson, New Jersey Fire/violent rupture Limited resources
7 16 Minersville, Pennsylvania Obstruction Limited resources
7 17 Pontiac, Michigan Derailment Limited resources
8 5 North Berwick, Maine Fire/violent rupture Limited resources
8 10 Point Pleasant, New Jersey Fire/violent rupture Limited resources
8 13 Princeton Junction, New Jersey Obstruction Limited resources
8 18 Rensselaer, New York Fire/violent rupture Limited resources
8 19 New York, New York Derailment Limited resources
8 20 Bay Head, New Jersey Derailment Limited resources
8 21 Duluth, Minnesota Derailment Limited resources
8 27 New Buffalo, Michigan Obstruction Limited resources
9 19 Goleta, California Derailment Limited resources
9 30 Dallas, Texas Derailment Limited resources
APPENDIX D: Accident Investigations Not Completed96
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
10 10 Washington, District of Columbia Raking collision Limited resources
10 24 Morton Grove, Illinois Obstruction Limited resources
11 1 Spring Valley, New York Derailment Limited resources
11 13 Raritan, New Jersey Derailment Limited resources
11 15 Pawcatuck, Connecticut Fire/violent rupture Limited resources
11 15 Melbourne, Florida Obstruction Limited resources
12 3 Latta, South Carolina Obstruction Limited resources
12 5 New York, New York Derailment Limited resources
12 13 Hoboken, New Jersey Derailment Limited resources
12 21 Port Jervis, New York Derailment Limited resources
12 21 Peninsula, Ohio Derailment Limited resources
12 24 Port Jefferson, New York Derailment Limited resources
FTA Transit Accidents
TABLE 26. FTA Transit Fatal Accidents (Passenger, Customer, or Employee)
Month Day Location Accident Circumstances Reason Not Investigated
1 1 Washington Metropolitan Area Transit Authority Rail collision with person Limited resources
1 5 Chicago Transit Authority Rail collision with person Limited resources
1 16 MTA New York City Transit Rail collision with person Limited resources
1 29 San Francisco Bay Area Rapid Transit District Rail collision with person Limited resources
3 1 Washington Metropolitan Area Transit Authority Rail collision with person Limited resources
3 19 MTA New York City Transit Rail collision with person Limited resources
4 5 Los Angeles County Metropolitan Transportation Authority Rail collision with person Limited resources
4 21 MTA New York City Transit Rail collision with person Limited resources
5 7 San Diego Metropolitan Transit System Rail collision with person Limited resources
5 13 Port Authority Transit Corporation Rail collision with person Limited resources
5 18 MTA New York City Transit Rail collision with person Limited resources
5 24 MTA New York City Transit Rail collision with person Limited resources
5 24 SEPTA Rail collision with person Limited resources
6 8 MTA New York City Transit Rail collision with person Limited resources
6 28 Massachusetts Bay Transportation Authority Rail collision with person Limited resources
APPENDIX D: Accident Investigations Not Completed97
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
7 2 MTA New York City Transit Rail collision with person Limited resources
7 24 Massachusetts Bay Transportation Authority Rail collision with person Limited resources
8 6 MTA New York City Transit Rail collision with person Limited resources
8 8 MTA New York City Transit Rail collision with person Limited resources
8 8 Metropolitan Transit Authority of Harris County, Texas Rail collision with person Limited resources
9 24 MTA New York City Transit Rail collision with person Limited resources
10 14 New Jersey Transit Corporation Rail collision with fixed object Limited resources
10 17 SEPTA Rail collision with person Limited resources
11 26 MTA New York City Transit Rail collision with person Limited resources
12 26 MTA New York City Transit Rail collision with person Limited resources
28 POV: privately owned vehicleTABLE 27. FTA Transit Fatal Accidents (Not a Passenger, Customer, or Employee)
Month Day Location Accident Circumstances Reason Not Investigated
1 28 Los Angeles County Metropolitan Transportation Authority Rail collision with person Limited resources
2 24 Valley Metro Rail, Inc. Rail collision with non transit motor vehicle (POV28) Limited resources
3 20 Los Angeles County Metropolitan Transportation Authority Rail collision with non transit motor vehicle (POV) Limited resources
4 22 Dallas Area Rapid Transit Rail collision with non transit motor vehicle (POV) Limited resources
5 29 Metro Transit Rail collision with person Limited resources
7 23 Metro Transit Rail collision with person Limited resources
10 23 Santa Clara Valley Transportation Authority Rail collision with person Limited resources
11 12 Tri-County Metropolitan Transportation District of Oregon Rail collision with person Limited resources
TABLE 28. FTA Transit Nonfatal Accidents (Passenger Train)
Month Day Location Accident Circumstances Reason Not Investigated
1 1 San Francisco Bay Area Rapid Transit District Main line derailment Limited resources
1 3 New Orleans Regional Transit Authority Main line derailment Limited resources
1 3 Valley Metro Rail, Inc. Rail collision with non transit motor vehicle (POV) Limited resources
1 4 MTA New York City TransitRail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
1 24 Utah Transit Authority Main line derailment Limited resources
APPENDIX D: Accident Investigations Not Completed98
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
2 21 Metropolitan Atlanta Rapid Transit Authority Yard derailment Limited resources
2 27 Kansas City, City of Missouri Main line derailment Limited resources
2 29 San Diego Metropolitan Transit System Main line derailment Limited resources
3 8 The Greater Cleveland Regional Transit AuthorityRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
3 9 Massachusetts Bay Transportation Authority Main line derailment Limited resources
3 17 SEPTARail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
3 21 Sacramento Regional Transit District Main line derailment Limited resources
3 23 Massachusetts Bay Transportation Authority Main line derailment Limited resources
4 4 Metro Transit Rail collision with fixed object Limited resources
4 10 Massachusetts Bay Transportation Authority Main line derailment Limited resources
4 16 Washington Metropolitan Area Transit Authority Main line derailment Limited resources
4 17 Massachusetts Bay Transportation Authority Rail collision with person Limited resources
4 23 New Jersey Transit Corporation Main line derailment Limited resources
4 30 Los Angeles County Metropolitan Transportation Authority Rail collision with non transit motor vehicle (POV) Limited resources
5 4 City of Milwaukee Main line derailment Limited resources
5 7 Pittsburgh Regional Transit Yard derailment Limited resources
5 10 City of Milwaukee Main line derailment Limited resources
5 12 Utah Transit Authority Main line derailment Limited resources
5 13 Pittsburgh Regional Transit Main line derailment Limited resources
5 16 Massachusetts Bay Transportation AuthorityRail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
5 18 Pittsburgh Regional Transit Main line derailment Limited resources
5 30 San Francisco Bay Area Rapid Transit District Main line derailment Limited resources
5 30 SEPTARail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
6 5 SEPTARail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
6 26 San Francisco Bay Area Rapid Transit DistrictRail collision with rail transit vehicle-rail transit maintenance
or service vehicle on the rail fixed guidewayLimited resources
7 2 Staten Island Rapid Transit Operating AuthorityRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
7 5 Pittsburgh Regional Transit Yard derailment Limited resources
APPENDIX D: Accident Investigations Not Completed99
2024 Annual Report to Congress National Transportation Safety BoardMonth Day Location Accident Circumstances Reason Not Investigated
7 22 New Orleans Regional Transit AuthorityRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
7 27 MTA New York City TransitRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
8 2 New Jersey Transit CorporationRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
8 13 Utah Transit Authority Main line derailment Limited resources
8 23 Massachusetts Bay Transportation AuthorityRail collision with rail transit vehicle-rail transit maintenance
or service vehicle on the rail fixed guidewayLimited resources
8 28 Massachusetts Bay Transportation Authority Rail collision with person Limited resources
9 15 Massachusetts Bay Transportation AuthorityRail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
9 16Bi-State Development Agency of the Missouri-Illinois
Metropolitan DistrictRail collision with rail transit vehicle-rail transit maintenance
or service vehicle on the rail fixed guidewayLimited resources
9 20 SEPTARail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
10 4 New Orleans Regional Transit AuthorityRail collision with rail transit vehicle/rail passenger train -
not in revenue serviceLimited resources
11 1 SEPTARail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
11 3 San Francisco Bay Area Rapid Transit DistrictRail collision with rail transit vehicle-rail transit maintenance
or service vehicle on the rail fixed guidewayLimited resources
11 5 San Diego Metropolitan Transit System Rail collision with non transit motor vehicle (POV) Limited resources
11 6 Dallas Area Rapid TransitRail collision with rail transit vehicle-rail transit maintenance
or service vehicle on the rail fixed guidewayLimited resources
11 11 SEPTARail collision with rail transit vehicle/rail passenger train -
revenue serviceLimited resources
11 18 Tri-County Metropolitan Transportation District of Oregon Rail collision with non transit motor vehicle (POV) Limited resources
11 28 Valley Metro Rail, Inc. Rail collision with non transit motor vehicle (POV) Limited resources
12 3 Valley Metro Rail, Inc. Rail collision with non transit motor vehicle (POV) Limited resources
12 4 Metropolitan Atlanta Rapid Transit Authority Main line derailment Limited resources
2024 Annual Report to Congress National Transportation Safety BoardAppendix E:
Accident Investigations Taking Longer than 12 Months29
29 Title 49 U.S.C. section 1116(c)(6) requires that the agency provide annually “a list of ongoing investigations that have exceeded the expected time allotted for completion by Board order and an explanation for the additional time
required to complete such investigation.” The list above includes investigations not completed within 12 months of initiation and only those which have been submitted to the Board for consideration.TABLE 29. Ongoing Investigations That Have Exceeded the Expected Time Allotted for Completion
Mode Event Date Location Reason Not Completed 2025 Report Date
Aviation (fatal only) None
Highway 5/12/2023 Excelsior Township, Wisconsin Technical complexity 6/4/2025
Highway 6/11/2023 Philadelphia, Pennsylvania Prioritization of resources 3/19/2025
Highway 7/12/2023 Highland, Illinois Technical complexity 5/20/2025
Highway 9/21/2023 Wawayanda, New York Technical complexity
Highway 9/23/2023 Teutopolis, Illinois Technical complexity
Highway 11/14/2023 Etna, Ohio Prioritization of resources
Marine 6/18/2023 Atlantic OceanTechnical complexity ; participation in USCG Marine Board of
Investigation hearings
Marine 7/5/2023 Newark, New JerseyTechnical complexity; participation in USCG Marine Board of
Investigation hearings4/15/2025
Marine 12/27/2023 Dutch Harbor, Alaska Technical complexity
Pipeline 11/15/2023 Gulf of America Delayed determination of jurisdiction 6/13/2025
Pipeline 3/24/2023 West Reading, Pennsylvania Technical complexity 3/18/2025
Railroad 11/29/2023 Manhattan, New York Prioritization of resources
Railroad 8/4/2023 Great Barrington, Massachusetts Technical complexity
Railroad 6/26/2023 Baltimore, Maryland Prioritization of resources
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