Honorable Carol J. Carmody
Vice-Chairman, National Transportation Safety Board
ICAO Air Navigation Commission (ANC)
June 6, 2002
Good morning, Mr. President, Members of the Air Navigation Commission, Observers,
Ladies and Gentlemen.
I appreciate the opportunity to speak with you this morning. As many of you know, I represented the United States on the ICAO Council from May 1994 to February 1999. I am happy to meet with you now in my capacity as Vice Chairman of the National Transportation Safety Board to thank each of you for your assistance to and support for the Safety Board's accident investigation efforts and for your on-going endeavors to improve aviation safety around the world.
Your work has greatly helped the men and women of the Safety Board as they have conducted domestic aviation accident investigations and participated as Accredited Representatives and Advisors in investigations conducted by other States. In particular, I would like to thank you all for the role you played in convincing the Assembly to add Annex 13 to the Universal Safety Oversight Audit Program.
I want to talk a bit about some of our accident investigations, as well as our recommendations in a moment, but first let me say the purpose of my visit to ICAO this week is to advise you of new development at the NTSB. We are creating an Academy that we expect to open in early 2003. It will house classrooms, laboratory space, and an accident simulation area. The Academy will teach state-of-the-art investigative techniques for transportation accidents and will conduct other related training for investigators and operators. We believe there is great potential for cooperation with ICAO in this area and we have come to Montreal this week to explore it.
The NTSB has been active in aviation lately. The United States responsibilities within ICAO Annex 13 and Annex 8, as the State of the Operator or the State of Manufacture require considerable dedication of NTSB resources. In the past 8 months, the NTSB staff has participated in 16-transport airplane accident investigations conducted by other states.
Most recently an NTSB Accredited Representative team proceeded to Taipei for the China Airlines Boeing 747-200 May 25 accident in the Taiwan Straits with 234 fatalities. Other major Accredited Representative teams were recently dispatched to:
Dalian, China -- MD 82, China Northern Airlines, May 7, crashed in the sea following a cabin fire, 112 fatalities.
Tunis, Tunisia-- B737-500, May 7, Egypt Air possible CFIT accident during approach, 14 fatalities and 48 survivors.
Busan, Korea - B767-200, April 15, Air China possible CFIT accident during a circling approach, 138 fatalities, 28 survivors.
There have been other events that were not so newsworthy where the U.S. as the State of Manufacture and the NTSB responded with appropriate assistance to Canada (B767), El Salvador (DC-10), Indonesia (B737), and Colombia (B727).
The Safety Board also provided a special staff envoy to Nigeria in response to a request from their Minister of Transport following the BAC 1-11 accident in Kano. Even though the airplane was not of US manufacture, the NTSB sent an experienced investigator on a 10-day mission to assist responsible officials in Abuja to organize the overall investigative effort.
Both ICAO and the U.S. recommend or require EGPWS/TAWS for all turbine-powered
airplanes with 6-to-9, or more seats. In addition to the suspected CFIT accidents
at Busan, Korea, and Tunis, there have been two more suspected CFIT accidents
in Colombia; both accidents involved operators and airplanes registered in Ecuador.
If they turn out to be CFIT, these 4 events most probably could have been avoided
if the flight crews had been provided with the benefits of a ground proximity
warning system that had a predicative terrain hazard warning system. I hope
that you, as we and the FAA do, will continue to stress the importance of equipping
aircraft with this important technology.
I understand that many members here are concerned about the confidentiality of certain material collected during accident investigations. I want to assure you that the NTSB shares your concern, particularly for cockpit voice recorders (CVRs). Under U.S. law, CVR recordings are treated differently than the other factual information obtained in an accident investigation. A CVR investigations group usually consisting of representatives of parties to the investigation, i.e., NTSB investigators, FAA, operator of the aircraft, manufacturer of the airplane, manufacturer of the engines, and the pilots union, is formed to listen to the recording. This investigations group creates a written transcript of the tape to be used during the investigation. This transcript contains only pertinent portions of the recording.
Crash-protected cockpit and cabin image recording systems have become possible due to recent technological advances. Accident investigators agree that information from cockpit image recording would have been extremely valuable in the Silk Air, Egypt Air, and Concorde investigations. Since September 11, there is added support from the aviation security community for similar devices. The NTSB continues to emphasize this subject on its safety recommendations "Most Wanted" list. We would appreciate your efforts to eventually introduce the installation of crash protective video recording systems on aircraft.
Finally, I'd like to inform you about the NTSB investigation into the crash of American Airlines Flight 587, an Airbus Industrie A300-600, in New York, on November 12, 2001. This was the second worst domestic airline accident in US history, the first catastrophic loss of an Airbus product in the United States, and the first airliner crash we have investigated that involved an in-flight failure of a major structural component made of composite materials - in this case, the vertical stabilizer and its attached rudder.
After recovery from the Bay, the tail section pieces of flight 587, including the vertical stabilizer and rudder were sent to NASA's Langley Research Center in early December 2001. The NTSB selected NASA because they have been studying composite materials in aviation for decades.
Our investigators believe that there are two reasons the vertical stabilizer may have come off the aircraft: the tail fin separated either because it was subjected to aerodynamic loads that exceeded its design limitations, or because it did not perform up to its design strength. Aerodynamic calculations indicate that the loads were high.
Unlike the failure of metals, which include local fracture surface markings that indicate whether it is the result of fatigue or static overload, the analysis of damage patterns of composites is more complicated.
AA587's fin components were subjected to a series of non-destructive examinations (NDE) to define the areas of damaged and undamaged structure, i.e., an instrumented tap test, a Lamb wave test, and thermography, ultrasound mapping, and x-ray radiography. More intrusive examinations are being conducted now.
We have cut a number of sections - called coupons - from undamaged areas of the stabilizer. These are being tested at NASA Langley to generate basic information on the material used in the manufacture of the fin, and to see if the material was manufactured to desired specifications. As you may know, these composites are a series of layers of carbon fiber fabric or tape, with each layer laid down in a desired orientation. (In this examination, we will go layer by layer to check the number, stacking sequence and orientation of each.)
In the course of the investigation, we are reviewing all design and certification documentation to make sure Airbus met the requirements during the certification process in the 1980s, and that we understand the basis for the design specifications.
We have provided NASA the FDR information from the accident aircraft and the 747 that preceded it, including temperature, wind speed and direction, and acceleration data. NASA will provide a model of the wake vortices produced by the 747 to assist us in determining what role wake turbulence played in the accident sequence.
We plan to duplicate the flight loads experienced in the cockpit through the use of motion-based simulation. We would like to study the effect of those motion-induced loads on the flight crew's ability to control the airplane. We are also trying to determine whether the rudder motion was caused by the flight crew or by a mechanical malfunction.
On Tuesday, June 4, the NTSB announced that two large panels were removed from the vertical stabilizer from flight 587 and sent to the Ford Motor Co. lab in Michigan. This is one of the most advanced laboratories using CT scanning in the world and can accommodate the size of these panels.
Last, the NTSB announced that the Safety Board has voted to convene a public investigative hearing on the crash of flight 587. It will be held in Washington, D.C. in October. The exact dates, as well as the issues that will be discussed at the hearing, will be announced at a later time. Check our website for the latest information. You are welcome to attend.
Thank you for the opportunity to make these remarks today, I hope they provide
some insight into the work we do at NTSB.