In February 2018, three Dallas, Texas, homes on the same block exploded one day after another, killing one person and injuring several others. The NTSB’s investigation found that the energy company’s leak detection methods and response policies and procedures for natural gas explosions and fires were insufficient. We recommended (P-21-11) that the energy company, Atmos Energy, address those weaknesses. The company made the following changes:
Getting Ahead of the Weather and Potential Catastrophic Derailments
Weather-related railroad accidents account for a small percentage of all reported rail incidents, yet their consequences can be severe. Over the past 40 years, the NTSB has investigated several derailments where unforeseen adverse weather conditions impacted railroad infrastructure and created unsafe operating environments.
One notable incident occurred in 2020 when a high-hazard train transporting denatured ethanol derailed in Kentucky, between a hillside and a river. This derailment resulted in the release of 38,400 gallons of denatured ethanol, which ignited when it mixed with the locomotive's diesel fuel. Fortunately, the train crew evacuated with only minor injuries, despite the destruction of the locomotives.
The
NTSB's investigation into this derailment revealed that two weeks before the incident, the area experienced more than three times its average rainfall, leading to a mudslide that covered the tracks just before the derailment.
In response to this catastrophe, we recommended (R-22-8) that Class I Railroads and Amtrak improve their weather alert criteria by incorporating location-specific current, persistent, and past weather conditions that could lead to hazardous operating conditions. Additionally, we recommended (R-22-9) that the railroads train their employees on updates to their alert criteria and protocols in response to different alerts.
In November, our board members evaluated the response of Class I Railroads and Amtrak to our recommendations (R-22-8 and
R-22-9) and found that their weather alert criteria now include dynamic weather conditions that change over short and long periods, with an emphasis on location-specific current, persistent, and historical rainfall.
Rail Association Calls on Members to Hold Employee Safety Briefings on Lessons Identified from Tragic Collision
The NTSB issues safety recommendations to those entities that can take action to prevent the recurrence of similar transportation accidents and incidents. A fast and effective method of reaching our affected audiences with a safety message is through their trade associations and professional societies.
In 2021, the NTSB issued a recommendation to the American Short Line and Regional Railroad Association (ASLRRA) asking it to share with its members the circumstances of a 2021 collision that killed a 19-year-old train conductor, who was riding on the rear platform of a train slowly backing down the tracks (also known as shoving).
When the conductor’s rail car entered a highway-railroad grade crossing, an 18-wheeler struck it, pinning the conductor between the train and the truck. The grade crossing had warning signs but no mechanical gates to prevent crossing. Our investigation found that the truck driver did not heed the warning signs and failed to stop when entering the grade crossing.
In response to our recommendation (R-23-021), ASLRRA asked its members in its newsletter to read the details of the
NTSB investigation report, review their procedures related to shoving movements, and communicate them to their employees in an upcoming safety briefing. In the news article, the association also highlighted to its members: “The NTSB recommends that railroads require ground protection at highway-railroad grade crossings equipped only with flashing lights or passive warning devices.”
The NTSB recently closed the ASLRRA recommendation and classified the association's publication of an article in its member newsletter as acceptable.
CSX Railroad Trains Emergency Responders on Hidden Hazards to Reduce Risk
In a 2017 train derailment in Hyndman, Pa., involving several rail cars containing hazardous materials, CSX railroad's emergency responders put their lives at risk by working perilously close to the derailment scene to hasten stabilization.
NTSB's
accident investigation discovered that emergency responders were unaware of a potentially hazardous bulge developing in the tank because the rail car's protective layer, known as a jacket, obscured the surface of the tank car's shell. The jacket is an eighth of an inch thick steel skin that wraps around the tank shell.
In response to NTSB's safety recommendation
(R-20-24), CSX revised its emergency responder training and outreach programs to incorporate lessons learned about jacketed tank cars from NTSB's investigation of the CSX train derailment. By 2025, rail tank cars carrying crude oil and ethanol will be required to be jacketed.
CSX also built a full-size model train called a Responder Incident Training (RIT) train to give emergency first responders hands-on experience with the safety features of jacketed tank cars.
After NTSB staff attended CSX's in-person and virtual training, the NTSB classified CSX's response to our safety recommendation as acceptable. While the in-person training is only available on CSX properties, the virtual
Emergency Response to Rail Incidents (ERRI) training is free to the public on the Transportation Community Awareness Emergency Response's website.
Emergency response is an aspect the NTSB commonly assesses during its accident investigations. Recently, NTSB's investigation of the Feb. 3, 2023, Norfolk Southern train derailment and hazardous materials release in
East Palestine, Ohio, again highlighted the importance of effective emergency response.
NYC Mass Transit Creates a System of Continuous Safety Improvement
Following the NTSB’s investigation of a series of accidents on New York City’s commuter and inner-city mass transit system, we issued several recommendations (R-14-66 thru -68) to the Metropolitan Transportation Authority (MTA) to identify and mitigate hazards across the city’s entire transit system. In response, the MTA created a safety council comprised of safety officers from each of the MTA’s railroads that meet each week to review safety data, trends, hazards, and mitigations. The council shares that information monthly with the MTA railroad presidents and board members. The forum enables the MTA to systematically evaluate deficiencies identified on one MTA property and apply the hazard mitigations to the others. We recently classified our recommendations to the MTA as Closed-Acceptable Action.
WMATA Improves Operator Emergency Shutdown Training, Implements Recurring Ventilation System Testing
Our 2015 investigation of a WMATA Yellow line train that encountered heavy smoke while leaving the L’Enfant Plaza station heading toward the Potomac River Bridge identified issues with the train operator not correctly shutting the railcar ventilation system down to minimize smoke being pulled into an occupied WMATA car. We recommended WMATA train operators on emergency shutdown procedures and regularly test railcar ventilation systems. WMATA revised its operator training to ensure that operators can take needed emergency actions and implemented recurring testing of its railcar ventilation systems. (Safety Recommendations R-16-19 and
R-16-20.)
Strengthening Shoreside Firefighting Readiness
NTSB investigations into dockside vessel fires have repeatedly shown that land-based fire departments can face unfamiliar and dangerous conditions when called to fight fires aboard ships. In response to NTSB safety recommendations, local fire departments, port authorities, and national port partners have made substantial safety improvements that extend those lessons across fire departments, ports, and accidents.
Those improvements include better training, pre-fire planning, vessel familiarization, equipment, and coordination among fire departments, vessel operators, and port partners.
A fire aboard a vessel in port can look, at first, like a typical fire structure. But for land-based firefighters, it is one of the most complex and dangerous environments they may face.
That challenge was underscored most recently by the NTSB’s investigation of the July 5, 2023, fire aboard the roll-on roll-off container vessel
Grande Costa D’Avorio while it was docked at Port Newark, New Jersey. Two Newark firefighters died, other emergency responders were injured, and the vessel sustained extensive damage.
The investigation identified several safety issues and highlighted the need for better pre-fire planning, ship familiarization, communication, and coordination among vessel operators, port partners, and local fire departments. 
The Grande Costa D’Avorio was not the only accident we investigated that showed how difficult vessel fires can be for shoreside responders.
After the 2020 fire aboard the vehicle carrier
Höegh Xiamen in Jacksonville, Florida, the NTSB found that firefighters were seriously injured after opening a garage deck vent, which allowed fresh air into a hot, smoke-filled space and triggered a dangerous pressure blast. After the 2022 fire aboard the passenger vessel
Spirit of Norfolk, the NTSB identified similar concerns about responders’ understanding of shipboard fire boundaries and the risks of opening doors to spaces where a fire is contained.
Together, these investigations showed that fire departments called to fight fires aboard ships need training, plans, equipment, and coordination in place before the call comes in.
The NTSB’s recommendations following the Grande Costa D’Avorio investigation are turning that lesson into action.
Since the accident, the Newark Fire Division has reported significant changes to strengthen its readiness for marine firefighting (Closed Acceptable Action M-25-4). Those actions include:
- Overhauling its marine suppression curriculum
- Conducting roll-on/roll-off vessel tours
- Providing incident command system training
- Updating radio procedures and alarm response
- Acquiring International Shore Connection adapters for vessel water supply operations
- Developing a shipboard firefighting general order for land-based units
- Conducting live vessel boarding exercises with the Department of Homeland Security and the Port Authority of New York and New Jersey
Those efforts are designed to help firefighters better understand vessel layouts, shipboard hazards, fire control plans, suppression systems, and the operational limits they may face during a maritime emergency.
The Port Authority of New York and New Jersey has also taken steps to improve preparedness at its marine terminals. The Port Authority created vessel familiarization seminars and tours for fire departments likely to respond to its New York and New Jersey Marine Terminal facilities, with about 280 area firefighters participating.
It has also hosted seminars, drills, and exercises on communications, hostile vehicles, autonomous surface vessel attacks, and mass casualty incidents on cruise vessels. In addition, the Port Authority is coordinating with the New Jersey Fireboat Task Force, a multiagency response force that includes fire departments, the U.S. Coast Guard, and other partners.
The Board classified the Port Authority’s response to Safety Recommendation M-25-5 as Open—Acceptable Response, pending further developments from the New Jersey Fireboat Task Force.
The impact is reaching beyond the Port of New York and New Jersey.
The American Association of Port Authorities shared the NTSB’s findings and recommendations through the National Port Partner Emergency Response Summit, its Security Committee, and its September 2025 “AAPA Advocacy Now” update. By sharing the lessons with ports across the country, AAPA helped move the recommendations beyond a single accident and into the broader port and emergency-response community.
The fire service community also helped extend those lessons nationally. In response to Safety Recommendation M-25-9, the International Association of Fire Fighters and the International Association of Fire Chiefs advised their members of the circumstances of the Grande Costa D’Avorio fire and encouraged fire departments that may respond to marine vessel fires to identify gaps in their training and become familiar with available resources, including National Fire Protection Association firefighting standards. The International Association of Fire Fighters also developed a Shipboard Firefighting introductory course for shore-based firefighters.
The Board classified AAPA’s response to Safety Recommendations M-25-7 and M-25-8 as Closed—Acceptable Action. It classified the International Association of Fire Chiefs’ response to Safety Recommendation M-25-9 as Closed—Acceptable Action, and classified International Association of Fire Fighters’ response to Safety Recommendation M-25-9 as Closed—Exceeds Recommended Action.
Newark, the Port Authority, AAPA, the national fire service organizations, and their response partners did more than address the findings of one investigation. Their actions are helping create a model for other ports, fire departments, vessel operators, and maritime communities that may one day face the same challenge.
From Tragedy to Reform: Safety Gains Since the Conception Dive Boat Fire
On
September 2, 2019, a devastating fire swept through the Conception dive boat off the California coast, killing 33 passengers and one crew member in one of the deadliest maritime disasters in recent U.S. history. Trapped in a below-deck bunkroom, they had no warning and no way out.
Six years later, we honor the lives lost and recognize the progress made. Many overdue safety reforms have been implemented, fulfilling several key NTSB recommendations. These improvements represent a significant step forward in safeguarding passengers and crew aboard small passenger vessels.
What Went Wrong
NTSB’s investigation of the Conception fire revealed critical safety failures:
- No interconnected smoke alarms—crew never heard a warning.
- No roving patrol (crewmember watch) and means to verify that roving patrols are being conducted—no one awake to ensure safety or detect and respond to the fire.
- Inadequate escape routes—both exits from the bunkroom led to the same compartment, which was blocked by a large fire.
- Unsafe battery charging practices—lithium-ion batteries used to charge phones and other devices likely ignited the blaze.
- Inconsistent enforcement of safety rules—key safety requirements were not being followed.
In October 2020, the NTSB concluded the probable cause was a lack of effective oversight by the operator and insufficient Coast Guard regulations to ensure safe overnight operations.
What’s Been Done to Make Vessels Safer
Congressional Action
Following the tragedy, Congress passed the Small Passenger Vessel Safety Act, which was later included in the Coast Guard Authorization Act of 2020 and the 2021 National Defense Authorization Act. The law directed the Coast Guard to upgrade fire safety requirements and implement NTSB recommendations aimed at enhancing the protection of passengers and crew.
Coast Guard Regulations
As mandated by the law, the Coast Guard issued new rules effective March 2022 to improve fire safety on overnight passenger vessels carrying more than six people. Requirements include:
- Smoke detection systems in all accommodation spaces (M-20-14,
M-20-15,
-20-M--20-16)
- A monitored, mandatory night roving patrol (M-20-17) to stay alert while passengers sleep
- A secondary escape route that leads to a different space than the primary exit, reducing the risk that a single fire blocks both ways out. (M-20-18,
M-20-19,
M-20-20)
- Crew fire training and drills
- Logbooks to record fire system checks, night roving patrols, and emergency drills
To enforce these rules, the Coast Guard also launched nationwide inspections to ensure that these requirements are being met.
Still Needed: Safety Management Systems (SMS)
While we are encouraged that many NTSB recommendations have been implemented, one critical recommendation remains unfinished: requiring operators of U.S.-flag passenger vessels to implement safety management systems. Until that gap is closed, passengers and crews remain at unnecessary risk.
The NTSB has urged action on SMS for more than 20 years. We reiterated this recommendation after the Island Lady fire in 2018, before the Conception tragedy. Had SMS been in place, Truth Aquatics, the operator of Conception, could have identified unsafe practices, corrected fire risks, and prevented loss of life.
Although the Coast Guard issued an advance notice of proposed rulemaking in 2021, final SMS regulations are still pending. Until they are in place, this remains the NTSB’s oldest open marine safety recommendation. Visit our SMS for Passenger Vessels page to learn more.
Why This Matters
Thanks to changes driven by NTSB recommendations, passenger vessels like Conception are now safer: alarms are interconnected, escape routes are safer, roving patrols are required to be verified, and battery charging risks are better managed. These lifesaving reforms address the very hazards that contributed to the Conception tragedy, representing real progress.
On this solemn sixth anniversary, we remember the 34 lives lost. And we continue to urge the Coast Guard to require SMS on all passenger vessels. Only then will operators be able to move from reacting to hazards toward preventing them altogether.
U.S. Coast Guard Improves Duck Boat Safety for Sightseers
Five years after 17 lives were lost when a DUKW amphibious (duck) boat capsized and sank during a storm on Missouri’s Table Rock Lake, the Coast Guard published a
rule on Sept. 13, 2023, requiring duck boat operators to implement several safety measures we recommended. Duck boat operators had 120 days from the date the interim rule was published (Sept. 11, 2023) to comply with the requirements.
The nine requirements listed in the Coast Guard’s interim rule are aimed at preventing the boats from filling with water and improving passenger survival if they capsize and sink.
The nine requirements are:
- Remove the canopies and any window coverings of such vessels for waterborne operations or install a canopy that does not restrict horizontal or vertical escape by passengers in the event of flooding or sinking;
- If a canopy and window coverings are removed from any such vessel pursuant to paragraph (1), require that all passengers wear a personal flotation device approved by the Coast Guard before the onset of waterborne operations of such vessel;
- Re-engineer such vessels to permanently close all unnecessary access plugs and reduce all through-hull penetrations to the minimum number and size necessary for operation;
- Install independently powered electric bilge pumps that can dewater such vessels at the volume of the largest remaining penetration in order to supplement an operable Higgins pump or a dewatering pump of equivalent or greater capacity;
- Install not fewer than four independently powered bilge alarms;
- Conduct an in-water inspection of any such vessel after each time a through-hull penetration has been removed or uncovered;
- Verify the watertight integrity of any such vessel through an in-water inspection at the outset of each waterborne departure;
- Install underwater light emitting diode (LED) lights that activate automatically in an emergency; and
- Otherwise, comply with any other provisions of relevant Coast Guard guidance or instructions in the inspection, configuration, and operation of such vessels.
The Coast Guard’s rulemaking satisfied our Safety Recommendation M-19-16, recommending that the Coast Guard require DUKW boat operators to remove canopies, side curtains, and their associated framing during waterborne operations to improve emergency egress in the event of sinking.
Coast Guard Improves Vessel Traffic System’s Role in Safely Managing Marine Traffic
In 2016, the NTSB completed a study of the Coast Guard’s Vessel Traffic System (VTS), a marine traffic monitoring system established by harbor or port authorities, similar to air traffic control for aircraft. We issued 17 recommendations to the Coast Guard to address safety issues found in the investigation. The Coast Guard recently reported to us that it has taken several actions in response, including revising its VTS National Standards for Operating Instruction. As a result, we classified 9 of our 17 recommendations Closed-Acceptable Action. (M-16-6)
Enhancing Child Passenger Safety
For decades, the safety of young passengers has been a critical focus for the NTSB. In particular, the proper use of child safety restraint systems, seatbelts, and airbags has been a key factor in reducing child fatalities and injuries in vehicle accidents.
Montana was among the states that had not fully updated its laws to align with national standards for child passenger safety. However, after 30 years of advocacy and sustained efforts by the NTSB, child safety advocates, and state lawmakers, Montana has now passed legislation (HB 586) that revises its child restraint system laws, marking a significant milestone in the state’s commitment to protecting its youngest passengers.
Key Safety Improvements
Following the NTSB's recommendation (H-96-14), which mandates that children up to 8 years old must use child restraint systems and booster seats under the state's child restraint use law, Montana has taken critical steps to enhance its child passenger safety laws. The newly enacted HB 586 revises the state's regulations to require that:
- Children under 2 years old must be in a rear-facing child safety seat.
- Children aged 2-4 must be in a rear-facing seat or a forward-facing seat with an internal harness.
- Children aged 4-8 must use a forward-facing seat or booster seat, depending on their size.
- Children aged 9 and older must be secured with an adult seatbelt once they outgrow booster seat requirements.
These updates ensure that Montana’s laws now fully reflect best practices in child safety, reducing the likelihood of severe injuries and fatalities in crashes.
Why This Matters
According to National Highway Traffic Safety Administration’s (NHTSA) 1994 Fatal Accident Reporting System (FARS) data, over 5,900 children were involved in fatal vehicle accidents each year, many of whom were unrestrained or improperly restrained. However, in 2022, NHTSA reported 1,129 traffic fatalities among children aged 14 and younger in the United States. This decline highlights the progress made in child passenger safety, but it also emphasizes the continued need for proper child restraint use and safety measures to further reduce fatalities and injuries.
NTSB’s 1996 safety study highlighted that unrestrained children are twice as likely to be killed in an accident compared to those who are properly secured.
A Step Forward, but Work Remains
We celebrate Montana for closing this recommendation after three decades of advocacy. However, several states:
Alabama, Arkansas, Florida, Iowa, Nevada, and South Dakota, still have not fully implemented child restraint system laws that align with national standards and still have open NTSB recommendations. The NTSB urges these states to take similar actions to protect their young passengers and reduce the risk of preventable fatalities.
The progress made in Montana demonstrates the impact of safety recommendations and the continued need for proactive measures across the country.
NHTSA Takes Important Step Toward Standardizing Impaired-Driver Toxicology Testing Nationwide
On New Year’s Day 2021, a 28-year-old drug-impaired driver swerved his sport utility vehicle (SUV) into oncoming traffic on a two-way road near Avenal, Calif., and collided head-on with a pick-up truck carrying an adult driver and seven children. The SUV driver and all eight pickup truck occupants died.
In this
highway investigation, the NTSB found that the driver’s blood alcohol concentration was more than double California's legal limit. Unfortunately, the NTSB could not determine if other drugs contributed to the driver's impairment because the Fresno County medical examiner's postmortem toxicology testing of the driver's blood did not screen for other common drugs. The NTSB later detected cannabis in the driver's blood when conducting its post-crash toxicology tests.
For alcohol impairment, years of experience and a robust data-gathering process have reliably established detectable levels of blood alcohol associated with impairment. However, for other widely available drugs, both legal and illicit, the data available are insufficient to develop enforceable impairment markers and effective countermeasures.
We could improve the information on the prevalence of impairing drug use by drivers if testing protocols were standardized. Like many other states, California had no uniform standard for drug toxicology testing at the time of the 2021 Avenal crash.
Following our investigation, the NTSB issued a safety recommendation
(H-22-33) to the National Highway Traffic Safety Administration (NHTSA) to disseminate a nationally recognized drug toxicology testing standard to state officials.
The NTSB recently closed its recommendation to NHTSA as an acceptable action when NHTSA distributed the National Safety Council's "Recommendations for Toxicological Investigations of Drug-Impaired Driving and Motor Vehicle Fatalities through the Regional Toxicology Liaison Program" to all state officials.
NTSB’s School Bus Stop-Arm Camera Recommendation Takes Hold in the States
NTSB’s call for states to permit school bus stop-arm cameras is steadily taking hold across the country, with 25 states enacting laws to prevent illegal school bus passings that have reached an epidemic level, putting student safety at risk.
Florida, Michigan, and Delaware are the most recent states to adopt NTSB’s stop-arm camera safety recommendation, which the agency issued in 2020 to 28 states and the District of Columbia. The agency made the recommendation (H-20-12) following its investigation of a 2018 Rochester, Indiana crash, where three children were struck and killed and another severely injured when crossing a two-lane highway to board their school bus.
The National Association of State Directors of Pupil Transportation Services estimates that over 41 million vehicles illegally passed school buses in a 180-day school year. Stop-arm cameras record the license plates of vehicles illegally passing school buses, enabling police to issue citations to violators, an effective deterrent to dangerous driver behavior.
Read NTSB’s testimony in support of stop-arm camera legislation before Oregon’s House Judiciary Committee.
Texas Adopts NTSB’s Recommendation to Use Variable Speed Limits to Prevent Highway Crashes
Following the NTSB’s recommendation that Texas use variable speed limit signs to reduce crashes occurring on its highways during inclement weather, the state recently authorized the Texas Transportation Commission to use them on its roads.
Variable speed limit signs, unlike static ones, can be adjusted when changing road conditions require safer speed limits to reduce the risk of highway crashes.
The NTSB first asked Texas (H-05-20) to install variable speed limit signs following the agency’s investigation of a 2003 crash near Hewitt, Texas, where a motorcoach bus skidded during braking, crossed over a grassy median, entered the southbound lane, and collided with an SUV. The crash occurred during inclement weather with reduced visibility due to fog, haze, and heavy rain. Seven people died, and several other people were injured in the crash.
In 2023, the NTSB asked Texas again (H-23-3) to use variable speed limit signs following the agency’s investigation of a 2021 Fort Worth crash where six people died in a multivehicle pileup on an icy highway with a posted speed of 75 miles per hour.
Updated June 23, 2026
