Tag NTSB

A National Disaster Safety Board

Tim Riecker, The Contrarian Emergency Manager 4 Comments

You’ve heard of the National Transportation Safety Board (NTSB), right? If not, the nitty gritty of it is that they are an independent federal accident investigation agency. They determine probable cause of the full range of major transportation incidents, typically putting forward safety recommendations. They are granted some specific authorities related to these investigations, such as being the lead federal agency to investigate them (absent criminal aspects) and they maintain a schedule of deployment-ready teams for this purpose.  They can conduct investigative hearings (ever see the film Sully?) and publish public reports on these matters. Overall, I’ve had positive interactions with NTSB representatives and have found their work to be highly effective.

While certainly related to emergency management, the main purpose for my quick review of the NTSB in this post is to provide a starting point of understanding for Congressional legislation urging the formation of a National Disaster Safety Board (NDSB). The draft bill for discussion can be found here. This bill has been put forth with bi-partisan sponsors in both the US Senate and the House of Representatives.

The purpose of the NDSB, per this bill, is:

  1. To reduce future losses by learning from incidents, including underlying factors.
  2. Provide lessons learned on a national scale.
  3. Review, analyze, and recommend without placing blame.
  4. Identify and make recommendations to address systemic causes of incidents and loss from incidents.
  5. Prioritize efforts that focus on life safety and injury prevention, especially in regard to disproportionately impacted communities.

To execute this mission, the bill provides that the NDSB will have the authority to review incidents with 10 or more fatalities; may self-determine the need for board review of an incident; and shall have the full ability to investigate, review, and report on incidents.

The bill directs the NDSB to coordinate with all levels of government to identify and adopt standard methods of measuring impacts of disasters to provide for consistent trend analysis and comparisons, and to ensure that these standards are uniformly applied. The bill requires the NDSB to coordinate with all levels of government in their investigations during incident responses, and to participate in the incident command system for coordination of efforts as well as investigative purposes. Affected authorities shall have an opportunity to review the NDSB report 30 days prior to publication.

The NDSB will be comprised of seven board members, selected by the President from a slate of candidates provided by both houses of Congress, with no more than four board members having affiliation with the same political party, and with all members having technical and/or professional qualifications in emergency management, fire management, EMS, public health, engineering, or social and behavioral sciences.

There is a lot of other legalese and detail in the bill, but I’m happy to find that the language supports coordination among and with federal agencies, including FEMA, NIST, NTSB, and others; and also has an emphasis on investigating impacts to disproportionately impacted communities. The bill also charges the NDSB with conducting special studies as they see fit and providing technical support for the implementation of recommendations.

I’m thrilled with this effort and I’m hopeful the bill progresses to law. We have had a history of outstanding research from academic institutions and after action reports from government entities, which should all still continue, but it’s incredibly substantial that the NDSB will establish standards and consistency in how we examine disasters over time. We’ve seen how impactful the NTSB has been since its inception in 1967, and I feel the NDSB could have an even greater impact examining a broader spectrum of disasters. This is an effort which has been long encouraged by various emergency management related groups. The NDSB, I suspect, will also support a stronger and more defined FEMA, as well as strengthening all aspects of emergency management at all levels.

What thoughts do you have on the NDSB? What do you hope will come of it?

© 2020 Timothy Riecker, CEDP

Emergency Preparedness Solutions, LLC

Taking Another Look at Mass Casualty Incidents

Tim Riecker, The Contrarian Emergency Manager 2 Comments

In case you missed it, the NTSB issued their findings and recommendations relative to the derailment of Amtrak 188 in the City of Philadelphia last May, which resulted in the loss of eight lives and injuries to over 200 other passengers.

The NTSB surmised that the engineer was distracted by reports over Amtrak’s radio of a nearby train having rocks thrown at it, which is apparently a common occurrence on a certain stretch of tracks through Philadelphia.  His distraction resulted in him speeding up the train, rather than slowing it prior to heading into a curve.  Taking the curve at high speed led directly to derailment of the train.  It has been pointed out that the presence of an automatic Positive Train Control system, not installed on many trains, would have slowed the train and likely prevented the derailment.  A rail industry union consortium indicated that the presence of two engineers on the train may have also mitigated this incident.

What I found most interesting in the report was that after listing findings and recommendations related to the derailment itself, the NTSB report identified issues beyond the crash.  The report states that

“…as a result of victims being transported to hospitals without coordination, some hospitals were over utilized while others were significantly underutilized during the response to the derailment.  The NTSB further found that that current Philadelphia Police Department, Philadelphia Fire Department, and Philadelphia Office of Emergency Management policies and procedures regarding transportation of patients in a mass casualty incident need to be better coordinated.”

Why is the NTSB providing recommendations on how mass casualty incidents are handled?  These recommendations are, in fact, fully within the scope of their mission statement as they address, ultimately, how victims are cared for.  The NTSB has also brought us best practices that extend beyond crashes, such as Family Assistance Centers.

The recommendations the NTSB provides in this report are spot on.  Mass casualty incidents MUST be coordinated.  Triage, treatment, and transport.  We’ve all heard of these three key activities.  Yes, it’s excruciatingly difficult to not ‘Scoop and Run’ when we encounter an injured victim, but let’s consider a few reasons why we shouldn’t:

  1. Patients with certain injuries, such as those to the cervical spine, are not being stabilized, and could have their injury worsened.
  2. A patient could ‘crash’ from a multitude of causes, which require the resources of an ambulance and paramedic to address, absent being in a hospital.
  3. Scoop and Run violates the concept of triage, which is intended to provide care and transport for the most critically injured first.
  4. The emergency personnel and vehicles involved in Scoop and Run may be otherwise needed at the scene.
  5. Depending on the incident, victims may be contaminated. Scoop and Run can endanger personnel who are not aware of this.
  6. Scoop and Run circumvents patient tracking and accountability, which is important for on-scene operations, liability and insurance, post-incident medical monitoring, and investigation.
  7. Scoop and Run, as the NTSB report pointed out directly, doesn’t account for spreading patients among receiving hospitals, meaning that some patients can end up at hospitals unequipped for their type of injury as well as overcrowding of hospitals.

While the City of Philadelphia did a great job overall, this gave them cause to take another look at their mass casualty plans and procedures; resulting in Philadelphia Office of Emergency Management asking for better coordination of the multiple entities involved in a mass casualty incident.  While this incident provided some great lessons learned for the City of Philadelphia, it also provides lessons learned for all of us.  It’s a good opportunity to convene your mass casualty planning group and give a review of your plan.  Any jurisdiction can be susceptible to a mass casualty incident.

In need of a structured plan review, planning, training, or exercises involving mass casualty incidents?  Emergency Preparedness Solutions can help!  Contact us now!

© 2016 – Timothy Riecker, CEDP

Emergency Preparedness Solutions, LLC – Your Partner in Preparedness!