Remarks of Carol J. Carmody
Member, National Transportation Safety Board
before the ABA Aviation Litigation Section
New York, N.Y.
June 5, 2003

 


Thanks for inviting me to address the ABA Aviation Litigation Section. I appreciate being asked to discuss aviation safety issues of concern to your organization and the National Transportation Safety Board (NTSB). In fact, I am always pleased to speak about the NTSB because it is a unique organization.

Our mission is to investigate accidents, determine the probable cause, and make recommendations to prevent a recurrence. Originally aircraft accident investigations were handled by the Department of Commerce. When the Civil Aeronautics Board was established in 1940, the investigation function was incorporated there. It wasn't until 1967 that Congress established the National Transportation Safety Board to investigate accidents in all modes of transportation: aviation, highway, marine, rail, pipeline, and hazardous materials, and to provide oversight to the Department of Transportation modal administrations. In 1974, Congress completely removed us from the Department, and made the NTSB a totally independent agency. My career in government has included stints at the Central Intelligence Agency, the Federal Aviation Administration and the Department of State, and - take it from me - an independent agency is the way to go. Being independent 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. It means we are not an item, which can be shuffled and bartered, in a departmental budget. And, because we are a creation of the Congress, and because of our mission, we have an enormous white hat. All in all it is an enviable position for an agency to be in, and being a Board Member is one of the best jobs in Washington.

We take our independence very seriously. Investigative organizations must be truly independent from any other governmental body. No entity should be expected to investigate or oversee itself -- it can't and doesn't work. I believe the traveling public has benefited from the work of professional air safety investigators and accident investigation agencies throughout the world. Their work has led to direct improvements in the way aircraft are built, maintained and operated. It is for that reason that the Safety Board has long advocated that all countries have an investigative organization separate from other governmental agencies that oversee the regulation and operation of their transportation systems.

In 1994, the European Civil Aviation Conference, which represents nearly 40 European states, adopted a directive that aviation accidents and serious incidents will be investigated by an authority that is independent of the organizations responsible for regulation and safety oversight of the aviation system. Currently, we have 10 such independent boards in place around the world. And, we have formed an organization, International Transportation Safety Association, to share ideas and discuss issues of mutual concern.

The NTSB has five board members with a bipartisan flavor -- by statute, no more than three can be from the same political party. And, our small staff of about less than 450 has earned a well-deserved reputation as experts in the field around the world. When the Board investigates an accident, we don't do it in isolation. We involve the organizations involved 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. As those of you who have been involved in our investigations are aware, we exclude lawyers from direct involvement in the investigative process - especially on scene, and in our progress meetings and at hearings.

The system has worked well and has helped give the American people confidence in their transportation system. Maintaining that confidence requires constant vigilance by everyone within that system -- regulators must properly regulate the industry; owners and operators must ensure the safety of their operations; manufacturers must design and build safe products; and the NTSB must reassure the public that there is an independent review of how well those entities are fulfilling their responsibilities. This interrelationship creates a healthy tension between the participants -- by design -- and it works.

I'd like to talk about a couple of the Board's ongoing investigations and some other areas of interest to the Board.

We're still assisting NASA with its investigation of the space shuttle Columbia tragedy. Soon after the shuttle was destroyed, the Safety Board launched six people to Texas and Louisiana to assist NASA in debris recovery and to help initiate the investigation. We sent two seasoned investigators-in-charge who have extensive experience with in-flight break-ups, a forensic pathologist, and structure, systems and aircraft performance experts. In Washington, our staff began working on the radar data and working with meteorologists to help locate wreckage. In the weeks that followed, six investigators were assigned to the Kennedy Space Center in Florida helping NASA engineers reassemble portions of the shuttle. We also assigned several radar interpretation experts to assist their NASA counterparts at the Johnson Space Center in Houston. In addition, several NTSB supervisory personnel assisted members of the independent Columbia Accident Investigation Board, also operating out of the Johnson Space Center.

We are also working on the recent accident involving an Air Midwest Beech 1900 that crashed shortly after takeoff from Charlotte, North Carolina on January 8, 2003, killing all 21 persons on board. On May 20 and 21st a public hearing was held at the Safety Board' headquarters to collect additional factual information. Two areas of focus in this investigation are the weight and balance of the aircraft, and recent maintenance on the elevator system. Average passenger and baggage weights were used by the airline, and our investigators have calculated that the actual weight and balance of the airplane at the time of takeoff was loaded to beyond its maximum gross weight and approved aft center of gravity.

Several days before the accident, the airplane had undergone routine maintenance, including re-tensioning of the elevator control cables, in Huntington, West Virginia. The flight data recorder indicates that following maintenance there is a 10-degree forward shift in the pitch control position parameter. Examination of the wreckage found that elevator control cable turnbuckles were not adjusted to the same length. Typically, these turnbuckles are adjusted evenly. Bear in mind that the airplane made nine revenue flights after maintenance with no pilot reports of any flight control difficulties. The FAA has already taken action both with respect to the maintenance and the weight issue, but clearly, we are still in early stages of this investigation.

We have not yet concluded our work on the accident that killed Senator Paul Wellstone and seven others in Minnesota in October. I was the Board Member on scene with the go team. The flight 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 -- which will make it difficult for our investigators to determine exactly what happened due to the fragmentation of the wreckage. The engines and propellers have been torn down and there are no indications of pre-impact failures. We have examined radar data from flights that landed before the accident flight and from the FAA facilities inspection airplane that flew the approach after the accident. We have also examined the pilot records to determine his training and experience. Safety Board staff is now analyzing all of the data in preparation of drafting a report to be presented to the Safety Board. While icing was present in the area at the time, indications are that it was not a factor in the accident.

Last October, I chaired a hearing on the American Airlines flight 587 accident which had occurred in November 2001. The accident was the second worse in US history, the first catastrophic loss of an Airbus product in the United States, and the first we have investigated that involved an in-flight separation of a major structural component made of composite materials-in this case, the vertical stabilizer and its attached rudder. This has been a very broad and intense investigation covering a number of issues. We are focusing on the vertical stabilizer, rudder and the aircraft's performance. Our investigators believe, that the tail fin separated because it was subjected to aerodynamic loads that exceeded its design limitations. The examinations indicate that the vertical stabilizer was actually stronger than its certification requirements. Aerodynamic calculations show that the loads on the vertical stabilizer were extremely high -- almost twice limit load. It appears that the rudder movements prior to the fin separation were the source of the large aerodynamic loads.

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.

We've asked NASA to produce a model of the wake vortices that flight 587 encountered to understand the 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. We evaluated that information and found nothing abnormal with respect to the vortices.

A few months after the accident we made recommendations to alert pilots to the possibility of damage to the vertical stabilizer by rudder manipulation. We have examined the design of the A-300 rudder control system and examined the rudder components recovered from the wreckage. Most of the components were severely damaged by impact and fire. These components were inspected, x-rayed and operationally tested when possible. The Safety Board investigators have conducted pilot-in-the-loop simulations rudder system response as well as iron-bird and computer simulations of various rudder system failures. We hope to wrap up this investigation before the end of the year.

Last December, the Safety Board adopted its report on the January 31, 2000 Alaska Airlines flight 261 accident. This was an MD-83 which departed Puerto Vallarta, Mexico enroute to Seattle; nearly four hours into the flight, and after several attempts to control the aircraft and perform an emergency landing at Los Angeles International Airport, the aircraft crashed into the Pacific Ocean, and killed all 88 aboard. The Board determined that the probable cause of the accident was the loss of airplane pitch control resulting from in-flight failure of the acme nut thread in the horizontal stabilizer trim system jackscrew assembly. The component failed because of excessive wear resulting from Alaska Airlines' insufficient lubrication of the jackscrew assembly.

Contributing to the accident were Alaska Airlines' extended lubrication interval and the FAA's approval of that extension. This increased the likelihood that unperformed or inadequate lubrication would result in excessive wear of the acme nut threads. Also contributing was Alaska Airlines' extended endplay check interval and the FAA's approval of that extension. This allowed the excessive wear of the acme nut threads to progress to failure without the opportunity for detection. In addition, the Board believed that the absence of a fail-safe mechanism on the MD-80 to prevent the catastrophic effects of total acme nut thread loss also contributed to the accident.

The Safety Board issued 16 recommendations to the FAA. One called for a review of all existing maintenance intervals for tasks that could affect critical aircraft components. Another recommended that the FAA conduct a systematic engineering review of all transport category airplanes to identify means to eliminate the catastrophic effects of a system or structural failure in the horizontal stabilizer trim jackscrew assembly. We also recommended that the FAA ask air carriers to instruct pilots that in the event of an inoperative or malfunctioning flight control system, the pilot should complete only a checklist and then proceed to land if procedures were not effective.

Most of the aviation activity over the past year has centered on security issues. I am relieved to say that security is not part of the NTSB's responsibility. I have said many times since September 11 that with all the emphasis on security, we must be sure not to give safety short shrift. With all the efforts to make things more secure, we cannot make them less safe. For instance, the reinforcement of the cockpit doors, which was done to improve security, does raise some concerns.

  • Ease of communication. Through 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.

The Board is advocating another change, which has generated a great deal of controversy -- 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, or what information was on the video displays. September 11th showed us that they might have even more uses. Imagine how much information such cameras could have given FBI 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, including ValuJet flight 592 and EgyptAir flight 990. In each of these, 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 highlighted the need for a video recording of the cockpit environment. Such information could have ended the debate over the flight crew's actions in the cockpit, and saved considerable time and expense in the investigation. However, 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 asked and Congress approved applying the same protections that exist for CVRs to the use of image recorders in all modes of transportation. Under these provisions, the Board cannot publicly release these recordings.

Before I close, I'd like to briefly discuss two other issues - assistance to the families of aviation accident victims and the NTSB Academy.

After a series of aircraft crashes in the early nineties, a number of family members began sharing their experiences with the Board. They told stories of continuous busy signals from the airline's 800 accident information 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 inevitably followed. In short, when they needed guidance, assistance, and compassion, they felt abandoned and abused. Taking care of the families of victims wasn't in our mandate -- it wasn't any agency's responsibility.

Congress responded to these concerns in 1996 by passing the Aviation Disaster Family Assistance Act, making the Board the lead federal agency for coordinating federal assets at accident scenes and giving us the authority to bring together federal, state, and local government agencies to assist 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. All domestic airlines are required to have a plan in place, and on file with the Department of Transportation (DOT), to efficiently respond to such tragedies. This plan must address how the airlines will provide a reliable toll-free telephone number for families, train the staff to answer all family inquiries, provide timely notification to the family members regarding the accident, and secure a facility to establish a family assistance center. The 1996 act, as amended, prohibits unsolicited communications concerning potential actions for personal injury or wrongful death by attorneys or their representatives, insurance companies, or air carrier litigation representatives to victims or their families for the first 45 days following an aviation accident involving an air carrier providing interstate or foreign air transportation or a foreign air carrier in the United States.

Following a crash in Guam, Congress passed the Foreign Air Carrier Family Support Act of 1997 that required foreign carriers serving the United States to develop family assistance plans and fulfill the same requirements as U.S. domestic airlines. During my last year at ICAO in Montreal, at the triennial Assembly, the NTSB Chairman Hall presented a resolution, which was passed by the Assembly urging all countries to develop a family assistance program. So the NTSB has really led in this area. I have seen the Family Assistance office at work at several crashes and I can tell you I see the tremendous need they fill, and I wonder at how long we existed without their assistance.

Following a 1999 crash at the Little Rock airport, it became apparent that airports also needed to be better prepared to assist survivors and family members. In September 1999, the FAA issued an Airport Emergency Plan Advisory Circular listing areas for airports to consider in order to enhance their ability to assist family members. These areas included issues such as mutual aid agreements among the airlines at the airport; additional coordination with local emergency services; and plans to assist non-tenant airlines involved in a disaster.

In 1996, the Board established the Office of Family Affairs, now called the Office of Transportation Disaster Assistance (TDA), to coordinate and integrate the major resources of the federal government and other organizations, and to work with the local and state government and the airline to meet the needs of aviation disaster victims and their families. The staff helps coordinate family counseling, victim identification and forensic services, communications with foreign governments, and translation services.

In the seven years since the office was created, the staff has been launched to not only major aviation disasters, but also to numerous railroad, highway, marine, and pipeline accidents. I have seen the Family Assistance office at work at several crashes and I can tell you I see the tremendous need they fill, and I wonder at how long we existed without their assistance.

In addition, they have encouraged a collaborative partnership between industry, government and private non-profit organizations to ensure that victims' families receive needed assistance. And, in those seven years we have seen a great deal of improvement in the treatment of family members.

But, we can always do better. We all must continue to work together -- local communities, air carriers, airports, others in the aviation community, and the federal government to ensure that we are prepared for the next disaster.

To that end, the Board is developing a number of training courses at the NTSB Academy on family assistance and other issues. The NTSB Academy is a major Safety Board initiative to improve the training and skills of its own employees, and make its safety expertise more widely available to the global transportation community.

Scheduled to open in this fall and located nearby in Virginia, this state of the art facility will not only provide the training necessary to keep our accident investigators on the cutting edge of investigative technology and performance -- but it will also advance transportation safety worldwide. With our increasingly global transportation systems, we have an obligation to insure that high standards and effective techniques are employed no matter where transportation disasters occur around the world.

The Academy provides an excellent platform for sharing our knowledge, providing training for accident investigators, first responders, law enforcement, firefighters and others worldwide who we need to work with us at an accident site, and for advocating safety improvements on a global scale.

Currently, we are offering courses such as:

  • a two-and-a-half-week course in basic aircraft accident investigation for newly hired investigators from the NTSB, industry, and other government agencies from the U.S. and other nations.
  • a comprehensive family assistance courses for those who assist friends and families of major transportation accident victims.
  • a course of airline industry training to familiarize industry representatives with their duties and responsibilities during NTSB accident investigations.
  • a newly developed course designed for law enforcement officers who initially respond to transportation disasters.

We may be announcing more courses soon. Some of you may have already taken advantage of some of these courses. I hope others of you will -- so that your staffs can be better prepared and will know our procedures better. It will also allow all of us to get to know each other better - before a disaster strikes and we need to call upon one another.

Aviation continues to be the safest mode of transportation available to the world's travelers. Together, we can work to ensure that it remains that way. Thank you for inviting me to be here today.