Honorable Carol J. Carmody
Vice-Chairman, National Transportation Safety Board
Executive Women in Government Luncheon
National Press Club
May 16, 2002
Thank you for inviting me to be here today. Coming from an agency that has many women in executive and senior-level positions, I am impressed by the diversity and strengths of the women in your organization. I appreciate being given this opportunity to discuss aviation transportation safety issues with you.
The National Transportation Safety Board (NTSB) is an independent agency created by the Congress in 1967 to investigate transportation accidents in all modes - aviation, highway, rail, marine, pipeline, and hazardous materials; to determine the probable cause and make recommendations to prevent similar accidents from occurring. Being a completely independent agency means, among other things, that we submit our budget directly to Congress without the necessity of going through the Office of Management and Budget, even though we send a copy of our budget to them. We are a creation of the Congress and I believe it treats us very well.
The NTSB has five board members with a bipartisan flavor -- by statute, three are from the President's party and two from the other party. And, our small staff of about less than 450 has earned a well-deserved reputation as experts in the field around the world.
Our Congressional statute requires us to investigate all aviation accidents and we do about 2,000 a year. Currently, along with our other on-going investigations, such as the Alaska Airlines flight 261 accident, we are investigating the November 2001 American Airlines flight 587 accident in New York. Despite media reports to the contrary, we have not found any evidence to suggest that the accident was anything but an accident. As our investigation progresses, we are looking at a number of issues:
· Vertical stabilizer and rudder. Testing has begun on small composite samples from the accident aircraft's vertical stabilizer and rudder -- which separated from the aircraft during the accident -- at the NASA facility in Hampton, Virginia. The non-destructive testing is essentially complete and destructive testing has begun and will take at least four to five months to complete. We are working closely with the manufacturer in France, where some work has been done on the rudder units. The NTSB also acquired another vertical stabilizer from an identical plane, which had experienced an incident involving reversing rudder movements. The idea is to test it to see if there was damage undetected by inspections after the incident.
· Aircraft Performance. The Safety Board has also asked NASA to produce a model of the wake vortices that flight 587 encountered to further study their possible role in the accident sequence.
So, although a lot of work has been done, we have a lot more to do before we're finished.
The Safety Board always has the lead in aviation investigations unless there is credible evidence of criminal activity; then the Chairman and the Attorney General are supposed to confer and decide that the Federal Bureau of Investigation (FBI) would take the lead. Such was the case following the September 11th terrorist attacks in New York, Virginia, and Pennsylvania. When the first plane hit the trade center, we started to assemble a go-team; when the second plane hit it was clear that these were NOT aviation accidents. At the time, I was the Acting Chairman, so I spent that morning at the FBI, and pledged the Board's support to the Director. That afternoon, we sent staff to all three sites -- New York City, the Pentagon, and Shanksville, PA, to identify aircraft parts, to look for the cockpit voice recorders (CVRs) and the flight data recorders (FDRs). We also sent our family assistance personnel to work with the airlines to providing assistance to the victims' families. We were successful in locating the recorders at the Pentagon and in Pennsylvania and they provided useful information to the investigation. We have never recovered the recorders at the Trade Center.
Not long after the attacks, I visited Ground Zero. TV pictures had not prepared me for the sight, or the atmosphere. It reminded me of pictures I have seen of London during the blitz. I was impressed by the courage and determination of members of New York's police and fire departments and the other government agencies who began work minutes after the attack, and continued to work 24 hours a day. Seeing the destruction, the buildings gone, the buildings damaged but still standing - left me with the same feeling I always get from horrible accidents - realization at the randomness of death, and admiration for the resilience of people in the face of the most appalling events.
NTSB staff was looking for the recorders by sifting through wreckage and by manning a high-powered camera focused on the rubble six floors below. I saw part of an engine that had sheared off when the jet hit the south tower, and landed on a building more than a block away. When we went out to the landfill where all the material was being sifted, I asked to see the aircraft parts that had been retrieved thus far. It was in a pile about the size of a small conference table - all that remained of two massive planes. We are still working with investigators -- providing technical expertise as needed.
When the Safety Board is responsible for investigating an accident, we don't do it in isolation. We involve all of the organizations with an interest in a particular accident - in the case of an aircraft accident, that's the regulators, the airlines, the airports, the manufacturers, and the various professional associations and unions -- through what is known as the party system.
This system has worked well and has helped give the American people confidence
in their transportation system -- confidence that was severely shaken by recent
events. Regaining and maintaining that confidence will require the constant
vigilance of everyone in the aviation community. Although the NTSB's charter
does not involve us directly in security issues, we are closely following the
new security precautions being put in to place, and evaluating their effects
on the system's safety.
For instance, the airlines are taking actions to reinforce the cockpit door. However, there are a number of safety issues that need to be considered as they under take that effort.
· Ease of communication. During some of our investigations, we have
found that communication problems between the cockpit and the cabin crews, caused
by damaged interphone systems, cockpit workload issues, or human error, could
be resolved by face-to-face discussions between the crews. As security improvements
are implemented, we must be sure that crew communications during emergency situations
are not compromised.
· Emergency Access. Access to the cockpit can also be very important in an emergency. For example, in the DC-10 accident at Sioux City, Iowa in 1989, an off-duty DC-10 check airman seated in the cabin was taken to the cockpit by a flight attendant so that he could provide much needed assistance to the flight crew as they tried to land the plane.
· Emergency Escape and Rescue. We must consider how changes to the cockpit door would affect the crew's ability to escape or be rescued following an accident. Rescue personnel have had to use the cockpit door to free the trapped pilots, and crew and passengers have used the cockpit windows to escape when other exits were inoperable or blocked.
In the wake of the September 11th terrorist attacks, a debate has also emerged within the pilot community, the airline industry and governmental agencies as to whether pilots should be allowed to carry and use firearms for defense against future terrorist attacks. A vocal majority of pilots and pilot associations are calling for the option to carry and use firearms. The associations have also petitioned the Transportation Safety Agency (TSA) for rulemaking on the issue. Currently, the airlines have not approved of arming pilots and plan to study the issue more carefully.
The NTSB is often asked whether pilots should be allowed to carry and use firearms in defense of the cockpit but it really is a question that goes beyond the ordinary scope of the Board's capabilities and expertise. The extraordinary means of defense that pilots could have available to them when confronted with a criminal or terrorist act is clearly a matter of security rather than one of safety under normal aircraft operating conditions. And, I believe that the issue of security and pilot defense tactics more appropriately resides with those who have the expertise and capability to assess in-flight threats and potential responses.
But, that does bring me to another issue that has generated a great deal of controversy over the past few months - cameras in the cockpit. Recording images of the cockpit is both technically and economically feasible, and would make it possible for investigators to see what is happening in the cockpit so that questions regarding crew actions can be readily resolved. For example, a cockpit video recorder could tell us which pilot was at the controls, what controls were being manipulated, pilot inputs to instruments such as switches or circuit breakers, or what information was on the video displays such as the display screens and weather radar. The Board believes that the equipment would help us determine more quickly the probable cause of accidents -- and, therefore, prevent future accidents. September 11th has shown us that they may have even more uses. Imagine how much information such cameras could have provided investigators following the attacks.
In April 2000, the Safety Board recommended that the Federal Aviation Administration (FAA) require commercial aircraft currently equipped with a CVR and a FDR to also be equipped with a crash-protected cockpit image recording system. We made this recommendation because we didn't have adequate information about the cockpit environment in several recent major investigations, such as the ValuJet flight 592 and EgyptAir flight 990 investigations. In each of these investigations, crucial information about the circumstances and physical conditions in the cockpit was simply not available to investigators, despite the availability of good data from the FDRs and CVRs. The Egyptair accident is the poster child for the need for a video recording of the cockpit environment. The Safety Board's staff believes that it would answer the questions surrounding the flight crew's actions in the cockpit, which resulted in the changes in the aircraft's controls, as well as the circumstances that prompted those actions.
We are sensitive to the privacy concerns expressed by pilot associations and others with respect to recording images of flight crews. In order to protect crewmembers' privacy, the Safety Board has asked Congress to apply the same protections that exist for CVRs to the use of image recorders in all modes of transportation. Under these provisions, the Board could not publicly release cockpit image recordings.
At least one airline - JetBlue - is putting cameras in the cabins of its planes. It's a good idea. We hope the FAA will act on our recommendation and we will soon see cameras in the cockpit as well.
In its 34-year history, the Board has issued almost 12,000 recommendations to more than 1,250 recipients. Most of our recommendations go to government agencies, but, when appropriate, they are sent to state and local governments and industry organizations and associations.
To date, 80 percent of them have been adopted and they have led to countless safety improvements in all transportation modes -- aircraft collision and ground proximity warning systems; airport wind shear warning systems; passenger vehicle next generation air bags; improved school bus construction standards; pipeline excess flow valves; and better commuter train emergency exit markings - just to mention a few.
I want to focus the remainder of my remarks on a few of the aviation safety issues the Board is concerned about: runway incursions and fatigue.
An incursion is any occurrence on an airport runway involving an aircraft, vehicle, person, or object on the ground that creates a collision hazard. There were 383 runway incursions in the United States last year, almost double the 200 that occurred in 1994. Although that's 43 less incursions than in 2000, we must remember that air traffic was greatly reduced in the last quarter of the year. Through April of this year, 89 runway incursions have been reported. Runway incursions can be deadly. When two loaded aircraft are involved the loss of life is high. Some of you may recall the collision between two aircraft at the airport in Milan last year which killed over a hundred people. Or the accident in Singapore in 2000 in which an aircraft hit an obstruction on the runway and killed 83 people. Although the aviation community has been working to reduce this safety hazard, the number of incursions is still too high. We do not want a Milan or Singapore in our back yard.
Since 1973, the Safety Board has issued more than 100 recommendations regarding runway incursions. The issue has been on our list of Most Wanted Safety Improvements for over ten years. We all know that there isn't any one solution that will eliminate the problem of runway incursions. It will take a combination of approaches including procedural changes, educational efforts, and technology improvements.
So far, technological solutions have been long on promise, but short on performance -- even though the Board has been recommending a collision avoidance system for aircraft ground operations since 1991. The FAA has been implementing a system called the Airport Movement Area Safety System (AMASS), which would give controllers at the busiest airports valuable information on potential collisions. Eleven AMASS systems have So been commissioned, and the remainder are being installed at the rate of two or three a month. However, the system will not prevent runway incursions in all situations because current AMASS parameters may not provide controllers sufficient time to intervene and react to maintain safe separation in all circumstances. Further, AMASS does NOT directly alert flight crews.
Improper or misunderstood clearances continue to place aircraft, vehicles, and their passengers in danger -- despite ongoing safety briefings and seminars, improved signage, painted runway markings, and informational brochures. The reason is simple -- human error. Pilots may misunderstand a clearance or read it back incorrectly and controllers fail to catch the error. Or, they turn at the wrong point. Or, controllers clear an aircraft onto a runway already occupied by a vehicle or another aircraft.
In 2000, the Board held a special meeting on runway incursions, and issued six more safety recommendations. Foremost among these was the recommendation that the FAA require a ground movement safety system that would prevent runway incursions and provide a direct warning to flight crews. We believe this is crucial to allow time to react not only for the controllers, but also for those operating the aircraft. The other five recommendations were of an operational nature, which we believed necessary since the technology was not mature, or in place. For example we recommended specific clearances for each runway crossing; stop allowing departing aircraft to be held on active runways at night; use standard ICAO phraseology to reduce confusion in pilots whose native language is not English.
To date, the FAA has not implemented any of these recommendations. The FAA's runway incursion program does address awareness and education, and these are certainly important; but in a system as complex as airport traffic control, human mistakes are unavoidable. Our recommendations build in redundancies to compensate for the inevitable lapses in human performance. We believe it is critical to take action to retard the growth in incursions before we have a Milan accident in our backyard.
The Board has also supported other, more cost-effective solutions for lower activity airports, including ground loop technology, runway stop-bars, in-pavement lighting, and airport surface sensors using Global Positioning System technology. However, none of these technologies has been implemented at our nation's airports either.
Recommendations addressing operator fatigue in all modes of transportation have also been on the Safety Board's Most Wanted List since the list's inception in 1990.
Over the years, we have made about 100 recommendations to operators and regulators
asking for additional education and research as well as specific regulatory
changes. In 1989, the Safety Board issued three safety recommendations to the
DOT, calling for an aggressive federal program to address the fatigue problem
in all sectors of the transportation industry. These recommendations asked for:
· a coordinated research effort;
· an extensive educational program; and
· a systematic review and improvement of regulations.
In 1999, the Board reviewed the status of those recommendations. Our report examined the progress, or rather the lack of progress, in each mode. We again asked DOT to require the modal administrations to modify their regulations to establish scientifically based hours-of-service regulations, to provide predictable work and rest schedules, and to consider circadian rhythms and human sleep and rest requirements. We asked that this be done within two years. Here we are three years later - 13 years since our first set of recommendations -- and little progress has been made.
Just last year, the Board found that fatigue played a role in the American Airlines flight 1420 accident in Little Rock, Arkansas, on June 1, 1999. We concluded that the probable causes of the accident were the flight crew's failure to discontinue the approach when severe thunderstorms and their associated hazards to flight operations had moved into the airport area and the crew's failure to ensure that the spoilers had extended after touchdown. Contributing to the accident were the flight crew's impaired performance resulting from fatigue and the situational stress associated with the intent to land under the circumstances.
Before I close, I want to discuss one other issue of special concern to the Board - assisting the families of victims of aviation accidents. Several years ago, during our public hearing on the crash of US Air flight 427, a number of family members shared their experiences with the Board. They told stories of continuous busy signals on the airline's 800 number, the lack of information, untimely notification, misidentified remains, personal effects being mishandled, unidentified remains not handled with dignity, and the use of confidential information in the litigation that followed. In short, when they needed guidance, assistance, and compassion, they felt abandoned and abused. Their feelings were not unique; family members from almost every other accident shared them.
In October 1996, Congress passed the Aviation Disaster Family Assistance Act, making the Board the lead federal agency for coordinating federal assets at accident scenes. And, it gave the Board the authority it needed to bring together federal, state, and local government agencies to serve the victims of transportation accidents and their families. The act also required the U.S. airline industry to take specific steps to mitigate the effects of an airline disaster on the victims' family members, including requiring all domestic airlines to have a plan in place, and on file with the DOT, to efficiently respond to such tragedies. Congress passed the Foreign Air Carrier Family Support Act of 1997 that requires foreign carriers serving the US to develop family assistance plans and fulfill the same requirements as U.S. domestic airlines.
The 1996 and 1997 acts ensure that all victims and their families will be treated fairly and equally regardless of the carrier they use. And, they have required many carriers that may not have previously thought about family assistance issues to actively consider them in their planning. The Safety Board established our Office of Family Affairs to help ensure that the necessary federal resources are made available to assist families, the affected airline and the community in which the disaster occurs. Many airports have been working with the Family Affairs staff to develop plans that incorporate airport and airline emergency plans with local community emergency plans so that they will be able to provide services until airline and federal resources arrive on scene.
It is the right thing to do.
Aviation is the safest mode of transportation available to the world's travelers.
The Board's job is to ensure that it remains that way. The measures that I've
discussed today will help us do that. Thank you for inviting me to be here today.