Honorable Carol J. Carmody
National Transportation Safety Board
Remarks for the International Aviation Women's Association's
November 11, 2002
Good morning. I am pleased to have been invited back to speak to such an auspicious gathering of aviation professionals. I have had the pleasure of addressing this group twice before - the first in the fall of 1994 just after I started my new job as the U.S. Representative to the International Civil Aviation Organization - the second in the fall of 2000 just after I started my new job as a Member of the National Transportation Safety Board (NTSB). I am as impressed now as I was on those occasions by the diversity and strength of the women I have met here. And, I appreciate being given this opportunity to discuss aviation transportation safety issues with you.
I was especially pleased to see that the Federal Aviation Administration (FAA) Administrator -- the second woman in the job - spoke at your luncheon yesterday. During the past year, I worked closely with Marion when she served as the Chairman of the Safety Board. It was the first time in the Board's history that women were appointed to serve as Chairman and Vice Chairman at the same time. Marion and I have both been cross-fertilized: she went from NTSB to FAA; I went from the FAA (after several intervening years) to the NTSB. I believe both organizations benefit from exposure to the other's work, mindset and personnel. And, I am looking forward to an even stronger partnership with the FAA, under her leadership, to promote our common goal -- safety.
The Safety Board has approximately 440 employees and I'm proud to say that women make up about 40% of our workforce. Many of those women occupy senior-level and key investigative positions. They provide the Board expertise in areas such as aircraft performance, systems, structures, maintenance and airworthiness; flight crew performance, survival factors, and airport operations and air traffic control. Women are assuming greater and more visible roles throughout the aviation community and conferences such as this offer a wonderful opportunity to meet and network with some truly extraordinary people who share the common goal of promoting aviation and advancing women in the industry.
I am here today to talk about aviation safety, which occupies a great deal of the resources of the National Transportation Safety Board (NTSB). Of course we are charged with investigation accidents in all modes of transportation, but aviation is our biggest area of concentration. Our mandate is to investigate, determine the probable cause, and then make recommendations to prevent recurrence, and to promote transportation safety.
I will talk about a couple of the ongoing investigations, then some safety concerns that we hold. Fresh in everyone's mind is the accident which killed Senator Paul Wellstone and seven others in Minnesota last month. I was the Board Member accompanying the Go-Team, just as I had been the Member on the Carnahan accident two years ago. The flights had been a normal one in all respects; air traffic transmissions normal, the aircraft lined up headed west on the runway when it began to turn south and lose altitude. It crashed minutes later headed due south. An intense post crash fire destroyed most of the aircraft. The accident aircraft was a King Air 100 which was not required to be equipped and was not equipped with a CVR or an FDR. Our investigators will have difficulty determining exactly what happened due to the fragmentation of the wreckage. A few pieces of instruments have been recovered but it is unclear what they tell us at this point. Engines and propellers are being torn down to see what can be learned there.
When the Safety Board investigates 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. You may have seen our hearing last week on AA 587 at which all the parties were present.
The American 587 Airbus accident was the second worse 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. For the past year, we have been looking at a number of issues, many focusing on the vertical stabilizer and rudder and the aircraft's performance. Our investigators believe, based on the information currently developed, that the tail fin separated because it was subjected to aerodynamic loads that exceeded its design limitations. The examinations to date indicate that the vertical stabilizer was actually stronger than its certification requirements. Aerodynamic calculations indicate that the loads on the vertical stabilizer were extremely high. It appears that the rudder movements prior to the fin separation were the source of the large aerodynamic loads. Out job now is to determine why these rudder movements occurred.
Unlike metal failures, 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. Following the accident, Flight 587's fin components were subjected to a series of non-destructive examinations to define the areas of damaged and undamaged structure.
The Safety Board asked NASA to produce a model of the wake vortices that flight 587 encountered to further study their possible role in the accident sequence. We provided NASA with the flight data recorder information from flight 587 and the Boeing 747 aircraft that preceded it on takeoff, including temperature, wind speed and direction, and acceleration data to develop the model.
The information we obtained from the 21 government and industry witnesses will be added to the data we've already gathered and we'll decide what more needs to be done. So, although we completed a great deal of work, we still have a lot more to do before we'll be able to determine a probable cause and issue a final report.
Most of the activity the past year has centered around security issues. I am glad to say that security is not part of the NTSB's responsibility. I am relieved we are not involved with the TSA, which I think has had many challenges. Nevertheless, there are new security precautions which have been put into place and we will evaluate those measures to see how they may affect system safety. For instance, the airlines have taken actions to reinforce the cockpit door. There are a few issues that need to be considered.
But, that does raise 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 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 highlights 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.
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 just two of the aviation safety issues the Board is concerned about: runway incursions and fatigue.
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 October of this year, 280 runway incursions have been reported. Runway incursions can be deadly. When two loaded aircraft are involved the loss of life is high. You may recall the collision between two aircraft at the airport in Milan last year, which killed more than one hundred people or the accident in Singapore in 2000, in which an aircraft hit an obstruction on the runway, killing 83 people. Although the aviation community has been working to reduce this safety hazard, the number of incursions is still too high.
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.
One of the most touted technology improvements to deal with runway incursions is the implementation of AMASS - Airport Movement Area Safety System. AMASS.generates an audible and visual alert to controllers when an aircraft or vehicle is occupying a runway and when arriving or departing aircraft cross a certain threshold or attain a certain speed. AMASS has been in development for ten years, although the FAA says that AMASS will be operational at 32 of the nations' busiest airports by 2003. Although it is a promising technology for some situations associated with runway incursions, AMASS parameters may not provide controllers and flight crews sufficient time to intervene and react to maintain safe separation in all circumstances. We believe that the system is missing a key element - a direct warning to flight crews or vehicle operators. This warning is crucial because it would give both controllers and those operating the aircraft time to react.
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. We have recommended to the FAA that since the technology isn't complete, some operational measures be considered to minimize the possibilities of runway incursions, such as:
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 an
accident like Milan accident on US soil.
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:
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.
Clearly, this is an issue that must be addressed.
Aviation continues to be the safest mode of transportation available to the world's travelers. The Board's job - and all of yours -- 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.