Remarks of Ellen G. Engleman
Chairman, National Transportation Safety Board
2003 Technical Seminar of the
International Society of Air Safety Investigators
August 26, 2003
It is a privilege to serve as the 10th chairman of the National Transportation Safety Board. I follow in the footsteps of dedicated and gifted professionals and enjoy the unique opportunity to work with an amazing team of fellow Board Members and staff. On behalf of Vice Chairman Rosenker, Members Goglia, Healing and Carmody, as well as the 429 family members of the NTSB team, it is an honor to talk with you this morning.
Thanks to Frank Del Gandio, Ron Schleede, Nora Marshall, and Vicky Anderson and the ISASI membership for inviting me to join you this morning.
Much is to be celebrated with the centennial year of flight. As we look back in amazement at the last 100 years, from a wobbly flight of 12 seconds that went 120 feet at a height of about 10 feet to the development of an international airline industry which had over 3 trillion miles of passenger flight in the year 2000. Human spirit and accomplishment are unlimited.
As the Wright Brothers worked toward their goal of human flight, they were meticulous in their experiments and adhered to the best scientific principles. As a result of analyzing their own glider experiments they began to question some of the commonly accepted scientific data. They approached each problem methodically, keeping meticulous notes on the variations and results of each test. They would allow no guesswork, no hunt and peck -- an approach to problem solving that was standard to the world of the 19th century.
The qualities that made the Wright Brothers a success are still enormously important in aviation today. International sharing of information, the use of scientific testing to support hypotheses, questioning commonly held beliefs and a desire to cut costs are all principles that we adhere to today when we conduct accident investigations.
The first official investigation of an aviation accident occurred five years after the Wright brother's historic flight and was due to the death of Lt. Thomas Selridge at Fort Meyer, Virginia in 1908. Unfortunately other accidents would follow and with each investigation changes were made to both improve aviation safety and the accident investigation process. The independent NTSB is one of the results of this.
We may not label the Wright Brothers and other early pioneers as accident investigators, but clearly their approach to aviation is no different than our modern approach to accident investigation. The early pioneers had many more mishaps and accidents to learn from than we do today, but all of their improvements were a result of meticulous investigation into the problems of flight and a willingness to question commonly-accepted theories and practices.
As you all know the NTSB does not have regulatory authority. Our power lies solely in our credibility. I have stated and will continue to say that the NTSB's credibility is based on our use of fact, science and data, NOT supposition, guess or desire -- in making our determinations of probable cause as well as issuing our safety recommendations. It is this strict discipline that gives the NTSB it's worldwide credibility for unbiased, fact based assessments and allows us to go forth and issue the significant safety recommendations that we send to industry, to the 50 states and to other federal agencies and the DOT, including the FAA.
Constant review of data from accidents and normal operations, a curiosity to explain what happened when something goes wrong and a willingness to question accepted theories and practices will yield new safety knowledge from fuel tank inerting and rudder re-design.
As we review the past and look to the next hundred years of flight, one constant remains the same, however, and must remain the same -- the issue of safety.
I do not believe that there is or can be a question of choice between safety OR security. In a post 9/11 world, we must find a way to accomplish both tasks without jeopardizing or negatively impacting the other. It must be safety AND security. There is a balance that will be achieved and must be achieved in order for peace and prosperity to continue. Let us remember that economic strength is one of the greatest weapons against terrorism. The direct impact of the airline industry on Gross Domestic Product in the US is $306 billion. Internationally, the revenues of the top 150 airlines groups is estimated $300 billion and we haven't even included the impact of related industries such as the travel and hospitality industries. Therefore it is critical that all partners in this industry, manufacturers, management, maintenance, the pilots, the flight attendants, the airports - internationally and nationally, -- work together to get this industry back in the sky. Our ultimate mission is to ensure public confidence in the national and international transportation system.
As you know the role of the NTSB is unique -- I have had more than one person tell me that while they were delighted to meet me the first time, they hoped to never have to meet me again. I understand.
It's sometimes hard to determine how to frame one's words and thoughts when everything you say is based on the fact that an accident occurred and that lives were lost. But it is in tribute to them, that the work of the NTSB is focused -- that out of tragedy may come the promise of a safer future. May we learn in order to protect.
The NTSB is responsible, consistent with the US Department of State requirements, to fulfill the obligations of t he United Sates presented in Annex 13 to the Chicago Convention on International Civil Aviation.
This means that for an accident or incident in a foreign state involving civil aircraft of a US operator or of US registry, manufacture or design, while the state of occurrence is responsible for the investigation, the US Government participates in these investigations through an NTSB appointed accredited representative and a team of technical advisors named by the NTSB. The U.S. is also responsible to transmit information to maintain continued airworthiness and the safe operation of aircraft. Thus our role is to appropriately participate in foreign investigations and maintain the health of the US manufactured fleet.
As you know, the NTSB is a fiercely independent agency that must remain so in order to accomplish our mission of determining the probable cause irrespective of fault. Once that probable cause is determined we issue our recommendations -- we have issued over 12,000 with 80+ percent acceptance rate .... and while that is good on its face, when I came to this office in March we had 1,025 open recommendations.
Open recommendations mean that the safety loop is not closed..... open recommendations mean that our job is not done.... the risks that have been identified still remain -- and action is yet to be completed.
So a key aspect of my tenure at the board will be to clean up the record of outstanding recommendations -- and we are focused in each mode, with the states and with industry to accomplish this task. I fiercely believe that the NTSB's independence should not be interpreted as adversarial. We must be partners in achieving safety, our goals, our mission and our dedication to protecting lives must be on parallel if not overlapping paths. Here are areas of interest to us as we continue these endeavors:
Runway Incursions. We can't afford to wait for the perfect high tech solution and must find and implement low-tech alternatives or phased in approaches, focusing on the dozen or so of the airports with the highest risk. In the US, the runway status lighting system to be installed at Dallas Fort Worth and the use of 24-hour runway guard lights at Las Vegas will hopefully provide immediate improvements and support a multi-layered approach to safety. But as the tragedy in Taipei, Taiwan on October 31, 2000 and the accident in Milan Italy on October 8th, 2001 illustrated, the issue is not yet resolved.
Center Wing Fuel Tanks. The FAA must complete a rulemaking to prevent operators from flying transport category aircraft with explosive fuel-air mixtures in fuel tanks. The FAA is currently working with Boeing to test a fuel tank inerting system designed to prevent fuel tank explosions, they have not set a deadline to certify the system. Sooner is better than later. We cannot forget the tragedy, which occurred on March 3, 2001 in Bangkok, Thailand with the center fuel tank explosion that occurred at the gate.
Icing. Icing is a continued serious problem. A thorough certification test program, including application of revised standards to airplanes currently certificated for flight in icing conditions, is merited. The NTSB recommends that the FAA ensure manufactures of turbine engine aircraft clarify minimum safe operating speeds in both icing and non-icing conditions, and that carriers publish the information in pilot training and operating manuals.
Human Fatigue. Operating any vehicle or vessel without adequate rest, in any mode of transportation, is dangerous. The laws, rules and regulations governing this aspect of transportation safety are archaic. I hope that all modes will soon respond to this issue as illustrated the new hours of service rules recently completed by the Federal Motor Carrier Safety Administration.
As you know, recommendations that we have made to the FAA often affect the international community through standards and certification issues - and can also have results that return. Last year an NTSB team assisted our colleagues in Germany with the investigations of a fatal midair collision between a Boeing 757 cargo flight and a Tupolev passenger airliner. Our investigations assisted the German authorities with examination of Operational Factors, Air Traffic Control, Traffic Collision Avoidance Systems and aircraft structures. This led to the Board's safety recommendation to the FAA to address potential safety issues in US systems and, I am glad to note that the FAA has recently responded positively to the recommendation and is working to make improvements in the US system.
We believe that safety is job one and will continue to work through the remaining open recommendations with each of the other DOT modes in this SWAT team approach to address all open NTSB recommendations and will continue to dog each and every one of them. Since March 24 we have closed 68 recommendations, and I want an upward slope on that graph.
Uniquely both FAA Administrator Blakey and I have both issued and received recommendations from the NTSB. We have the experience of shared moccasins and I truly believe that under her management and the leadership of Transportation Secretary Mineta that the open NTSB recommendations in all modes will be addressed. Of course, as you know the NTSB is not a regulator --we are a bully pulpit but I am holding daily services.
Performance and funding issues are also internal to the NTSB. We cannot make recommendations if we do not follow our own advice. As "CEO" of the Board, I am leading the staff in focusing on increased performance, fiscal management and quality of product delivery. The Safety Board must improve our ability to deliver an accident investigation report that is soundly developed based on science, data and facts and un-swayed by guesswork, supposition or desire. Our internal procedures are being reviewed to determine if there is a way to increase the timeliness of the reports. Yes, they must be thoroughly developed -- and cannot be hurried for false or artificial deadlines. That being said, I am focused on internal review of processes to see if we can increase our efficiency without affecting the quality. In a perfect world, no major accident report would take longer than 2 years, and general aviation and others would be finished in one year or less. Now that's a perfect world, but it is a goal as well.
And we're seeing results. Since March, the NTSB has conducted 112 accident investigations, including Air Algerie, Boeing 737 which crashed after take-off with 102 fatalities; Sudan Airways, Boeing 737 with 116 fatalities; Kenya, Fairchild Metroliner with 14 fatalities and the NTSB continues to support the investigation of the China Air Boeing 747 which crashed in the straits of Formosa. We have fielded more than 1350 calls from the media or victim's families and our law judges have closed 131 cases and held 40 hearings. We have saved over $250,000 via procurement review and held 8 meetings and public hearings that included the most wanted list, 15 passenger vans, driver distraction, two rail accidents and Emery Worldwide Flight 17. We have also issued 47 new recommendations - so the beat goes on.
A new beginning will be the opening of the NTSB academy. This leased facility is located on the grounds of George Washington University in Ashburn, Virginia and offers new opportunities for safety partnership. It will house the NTSB investigation and safety training programs, offer opportunities for safety symposia, roundtable discussions and forums, formulate safety partnerships for research, development and implementation of new technologies and create a sanctuary for discussion of key safety issues and topics.
The National Transportation Safety Board relies on its partners in safety, and today is no different. We hope that the NTSB Academy will be the forum for international discussion on shared issues and interests. A place where shared knowledge and open debate will help grow the overall body of safety knowledge in industry, government, academia and in personnel. We are working on developing key issues that will be appropriate to this venue and I solicit your comments and support. With your help and the help of other industry and transportation leaders, this timely discussion can and will make a difference in achieving safer skies.