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 morning.

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 they occur.

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 recorders.

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.

Jim Hall's Speeches