STATEMENT OF JIM HALL
CHAIRMAN, NATIONAL TRANSPORTATION SAFETY BOARD
AVIATION SAFETY CONFERENCE
JANUARY 9, 1995, WASHINGTON, D.C.
Secretary Pena, Administrator Hinson, Deputy Administrator
Daschle, Congressman Oberstar, Mr. Broderick, and members of the aviation
industry, I am certainly pleased to be invited to speak before you this
I feel that you all know us at the National Transportation
Safety Board. It is our job to investigate all civil aviation accidents
in this country -- and participate in many abroad -- to determine the causes
and to issue safety recommendations to prevent future accidents.
Like policemen who tend to encounter people when
they're in distress, we often encounter the U.S. airline industry when
it is going through its worst and try to help maintain it as the very best
in the world. By worst, I mean that in the course of our investigations
we'll probably find some deficiency in pilot training or performance, aircraft
design, air traffic control, FAA surveillance, or other areas. But unlike
some policemen, we don't develop a jaundiced view of our job, and we never
lose our appreciation for the remarkable professionalism of the people
in the airline industry, and the precision of its hardware.
There might now be a perception of crisis in the
industry. Since July 2 of last year, there have been four catastrophic
airline accidents that have killed 252 persons. The public has been shocked
by these occurrences.
We don't know what this series of accidents portends
for the industry, but looking at the cold numbers themselves, we can take
comfort in knowing that we've been through spells like this before, and
the industry has reacted and rebounded.
For example, in 1985, more than 500 people died in
passenger airline accidents in the United States or on U.S. airliners overseas.
The previous year, 48 people had died, all on commuters, and the following
year -- 1986 -- no one died on U.S. airlines as a result of accidents,
although there was a major midair collision involving a Mexican carrier
in California. Was the industry so much safer in 1984 and in 1986 than
it was in 1985? I think this demonstrates that statistics alone are not
a reliable barometer of the relative safety of the air transportation system.
The fact is that airline accidents are extremely
rare events; this is why they make such big news. I've been tot eh scene
of every one of the four accidents that occurred in recent months. The
human tragedy they represent is overwhelming. But if I'm going to look
at the cold statistics of the accidents of 1994, I must also look at the
fact that until the Charlotte accident on July 2, the major U.S. scheduled
airlines operating under Part 121 had not recorded a passenger fatality
in 27 months. That represented a string of nearly 1 billion passengers
carried safely. This is not the result of happenstance; it is the result
of the extraordinarily complex series of safety checks and balances that
has been developed over the decades to make our airline industry the safest
in the world.
Such accomplishments establish public confidence
in the safety of the airline industry. There was very little publicity
during that remarkable 27-month period, partly I suppose because no one
wanted to evoke the devil, but also because the public takes such an accident-free
string for granted. But as we have learned in recent months, public confidence
is a fragile commodity.
Our record in aviation safety has been built on industry
and government constantly seeking to improve safety, constantly coming
up with improvements in technology and in integrating the human equation
into that new technology. Building and maintaining public confidence is
the responsibility of all of us. It is the responsibility of the FAA to
exercise the proper regulatory control of the industry. It is the responsibility
of the airlines to ensure the safety of their own operations. And it is
the responsibility of the NTSB to exercise vigilant oversight of both the
FAA and the airlines, to assure the American public we are independently
and thoroughly assessing how they are doing their jobs.
Much has been made lately about so-called "tombstone
technology," whereby safety improvements allegedly are not mandated
until a sufficient number of people have died to justify the new rules.
I can speak for the Safety Board that we do not wait for accidents to happen
to assess potential safety improvements. WE try to address problems before
Recently, we completed an 8-month study on the safety
of the commuter airline industry, which was begun before the recent increase
in public concern. We did not launch this study because we thought commuters
were not safe, although they do record a consistently higher accident rate
than the major carriers. On the contrary, we believe that all scheduled
air service is safe, be it the major airlines or the commuters. However,
we had noted the phenomenal growth of commuters since deregulation, that
commuters now carry 50 million passengers a year and operate three times
as many aircraft as they did just 10 years ago. The 17 recommendations
we issued to make commuters safer basically called for the elimination
of the regulatory differences between the commuters and the major airlines.
We were gratified when we immediately received significant
commitments from the FAA and the industry to adopt those recommendations,
but again today we call on them to implement those changes within the 6-month
and one-year deadlines we specified.
I'm sure many of you are familiar with the National
Transportation Safety Board's Most Wanted list. This is a list of our recommendations
that, if implemented, would in our opinion bring about the greatest safety
improvements. Unfortunately, while most of the recommendations on the list
are classified "Open -- Acceptable Action," it is a list that
sometimes outlines our frustration about the Department of Transportation's
implementation of much-needed change.
Among other concerns on our Most Wanted list, we
note that the FAA has been slow to complete action on some very important
safety problems, even after agreeing that action is required. For example,
the FAA has agreed to implement a series of recommendations we made to
correct the runway incursion problem. Two of the main solutions involve
installation of improved ground radar (ASDE III) and a runway conflict
alert system (AMASS). This equipment will have a major positive impact
on reducing runway incursions.
Nevertheless, the time schedules for the development,
installation and commissioning of these systems continues to slip. The
FAA now advises us that the ASDE III installation schedule will not be
completed until 1996 and that the AMASS system will not be totally in place
until 1999. While we wait for this equipment to come on line, we continue
to see the kinds of accidents that prompted our recommendations in the
first place repeat themselves, like the recent collision at St. Louis.
Before I comment on the agenda of this conference,
I want to discuss a matter of priority for the Safety Board -- and I hope
for anyone in this audience, as well. That is the subject of flight data
The fact of the matter is that too large a segment
of the airline fleet is flying around with inadequate flight data recorders.
On September 8, 1994, a Boeing 737 crashed near Pittsburgh. This is the
second accident in the last four years involving this model aircraft for
which no cause has become readily identified.
As an older design, the 737 has a flight data recorder
that captures only a very limited number of parameters -- airspeed, altitude
and so on. What if they had captured information about the position of
the flight controls, like the rudder? We would have been able to identify
any flight control movements that may have figured in the loss of aircraft
control. Just as important for the public's and the industry's confidence,
we would have been able to quickly rule these factors out, if that
was appropriate. Information we obtain during our accident investigations
from recorders can be used to clear the reputation of aircraft, rather
than allow a cloud to hang over them for an extended period of time.
In stark contrast is our investigation of the ATR-72
accident in Roselawn, Indiana last October 31. This airplane's flight data
recorder captured information on many parameters, even more than required
for a new design like the ATR-72. Reading out the recorder in our laboratories,
we were able to spot the telltale, rapid movement of an aileron control.
This led to our issuance of urgent safety recommendations within a week
of the accident. That's what flight data recorders do -- they help us investigate
accidents and they help the industry prevent accidents.
It is vital that sufficient parameters be captured
by flight data recorders. Newly manufactured aircraft come equipped with
digital electrical data buses that can provide a wealth of information,
and the new solid state flight recorders can capture it all, with little
or no added cost. But we can't just wait for new planes to replace the
old. Further, we must also move faster than the regulatory process permits.
I ask you today, as leaders of this industry, to have the newly manufactured
airplanes delivered to you with recorders capable of accessing all the
information on the data bus, and I encourage you to set a timely deadline
to expand FDR parameters, beyond those currently required by FAA regulations,
for your existing airline fleet.
In this age of high technology, the American public
is puzzled when we can lost a major aircraft like a 737 in Colorado Springs
and not be able to determine what happened to it. We are still in the midst
of the Pittsburgh investigation -- in fact, our public hearing begins two
weeks from today -- and many possibilities ar still being pursued. But
I feel that no one in this room can find it acceptable not to have the
best tools at our disposal to find the causes of these accidents. In summary,
we need better recorders on these aircraft.
While there are other NTSB recommendations I could
discuss, such as aging aircraft, I am pleased that at this gathering, DOT
and the FAA have assembled a very ambitious agenda for the next day and
a half, and I commend them for it. I'm pleased to see the inclusion of
many issues the NTSB has been concerned with for a long time, specifically
crew training, air traffic control and weather, data collection and use,
safe applications of emerging technologies, aircraft maintenance and inspections,
and flight operations procedures. However, notably absent from the agenda
are other issues of great concern to us, such as "airline management"
and "FAA oversight." Also absent is any reference to "safety
management." While I fully appreciate that these factors are implicit
for each of the discussion topics, I would have liked to see them addressed
directly by this meeting. Can we reach the goal of "zero accidents"
without explicitly facing these issues? I think not.
A recent development in our accident investigations
and prevention activities are the so-called "corporate culture"
and other management issues, including safety management. These developments
have followed considerable efforts of the past and present to solve the
human performance factors in aircraft accidents.
It is readily apparent that the civil aviation industry
has taken the necessary steps over the years to prevent most accidents
through systematic elimination of hazards and the use of technology to
overcome human failures. But how far have we come to eliminate management
causes? Will this conference address such issues?
I did not raise this to find disagreement with the
organizers or with many of you here who are managers responsible for aviation
safety programs. The fact that you are here today reflects your dedication
to solve the problems facing the aviation industry. Therefore, I am confident
that you can face the challenge of introspection during this conference
with the view toward developing positive and measurable goals that will
truly impact on the accident rates of our airline industry.
I would like to address one final topic for consideration
by the participants at this conference -- the need for setting realistic
and identifiable time lines for adoption of the goals of this conference.
In order to instill public confidence in the government process that led
to this meeting, I strongly suggest that a specific date for completion
be set and published for each goal. One challenge of this conference should
be to overcome the past rhetoric and bureaucratic processes that have delayed
implementation of obvious safety improvements. I applaud the Secretary
and the Administrator for the vigor they have brought to their jobs. As
I stated earlier, the NTSB has recently revised its language in certain
safety recommendations by identifying a specific date for adoption of actions.
In that manner, the classification of the responsiveness of the actions
can be assessed based on both the timeliness and the content of the actions.
I urge the airline industry to take similar steps.
During my tenure as Chairman of the National Transportation
Safety Board, I intend to continue the close working relationship that
our agency has had with the U.S. aviation industry and the FAA stretching
back over the 27-year lifetime of the NTSB. However, I also intend to maintain
the NTSB's role of total independence in the aviation safety equation by
making the tough calls when necessary.
Thank you for the opportunity to address this distinguished
gathering, and good luck during the next few days. May we have a safe 1995.