"Today's Investigators, Tomorrow's Trends and Technology"
Chairman Jim Hall
National Transportation Safety Board
before the
International Society of Air Safety Investigators International Seminar
Seattle Washington
September 25, 1995

Good morning. I just want to tell you what a marvelous opportunity this is to speak to the best experts in aircraft accident investigation in the world -- bar none.

I must say a very warm Happy Birthday to one of your most prominent members -- Mr. Jerome Lederer, who is celebrating his 93rd birthday today. I really look forward to meeting Jerry later this week. All of the members of ISASI must be very proud to have a colleague like Jerry, whose life spans the entire history of powered flight. His pioneering work in the field of aviation safety has helped mature an industry that has shrunk the size of our planet and brought us all closer together.

As an indication of Jerry Lederer's decades-long influence on all of us involved in aviation safety, I'd like to point out that the Safety Board quoted from a 1939 statement of his regarding airframe icing in our final report on the 1992 USAir accident at LaGuardia.

While I have not spent my entire career in the field of aviation safety, like you I have dedicated my life to helping people.

I am fortunate to have the unique perspective of being the Chairman of the National Transportation Board, which has on its staff many of the world's best accident investigators -- and not just in aviation. I take very seriously my responsibility to the people of the United States to ensure that we conduct thorough and independent accident investigations.

During my tenure at the NTSB, I have visited NTSB counterparts in Canada, Britain, France, Russia, and the Bureau of Aviation Investigation in Australia. As a result of these trips and our recent investigations, I feel like I know many of you already, and I look forward to sharing this conference with all of you these next three days.

Let's discuss a few matters which I am sure we share in common.

First, the importance of air safety investigators in the overall aviation safety equation;

Second, the need for timely and complete communications among air safety investigators;

Third, the need for extensive and continuing training for air safety investigators to maintain the

high level of competence in both state-of-the-art technology and in the basics of accident investigation;

And finally, as I mentioned our shrinking planet, I can't emphasize enough the importance of international cooperation in today's fast moving air safety concerns.

Today's air safety investigators have one of the most difficult and important jobs in the air safety system. Generally, you are on-call 24 hours a day, 365 days a year, weekends, holidays and, of course, your child's birthday party.

Usually the call comes just as you are sitting down to eat with the family or your beeper goes off in the middle of a movie. Stress on the family is an accepted, though unwanted, reality.

In addition, investigators need to always be fit and ready to go. Investigators can quickly find themselves in such localities as the side of a steep Japanese mountain in heavy rain, or the hot Middle Eastern deserts or swamps in South Florida.

I know everyone of you have your own remarkable stories. In fact, I heard some of them last night. But not very far from our emotional insulation is the reality of the tragic circumstances of the accident, including the deaths and suffering of the victims. We may not share this with outsiders, but I know all of us feel the pain of every transportation death. And for many of us, it spurs us on to get the answers to solve the accident.

Add to that the political sensitivities. Accident investigators have to deal with the severe impact on the key parties to the investigations, such as the airlines, the unions, and the airframe and engine manufacturers.And what investigation would be complete without the media? Of course, most of them are only trying to write a quick story for their editors. It's unfortunate that we live in a society that hears of an accident in the morning, and wants the answer by the eleven o'clock news.

Investigators also have to deal with the intensity of lawyers representing families, organizations affected by the accidents, members of the public and politicians.

In order to accomplish their mission, air safety investigators have to remain focused, objective, and at the same time, develop accident prevention measures to prevent similar accidents.

As all of us know, you will never be able to measure the thousands of lives that have been saved. No one counts accidents that did not happen. The news media does not cite the number of successful takeoffs and landings that are the direct result of the efforts of air safety investigators.

For example, in the 27 months ending in July 1994, the U.S. major airlines carried almost a billion passengers without a fatality, but you didn't read any headlines about that, did you? However, we got more than our share of media attention when our Nation suffered a series of devastating airline accidents in the latter half of last year.

This is not surprising. The industrial nations have developed such a safe air transportation system that the public is shocked when something goes wrong. While no one year makes a trend, 1994 was not a good year.

Unfortunately, some things went wrong. While there was growing pressure on the commuter industry with the December '93 Hibbing, Minnesota accident, and the January '94 Columbus, Ohio accident, the first "major" accident in some time occurred with the crash of USAir flight 1016 in Charlotte, North Carolina on July 2, 1994.

As our Charlotte investigation unfolded, we realized that we were looking at a causal factor for an airline accident that we hadn't seen in the United States in almost a decade -- windshear. Not since August of 1985 had an airliner been brought down by this weather phenomenon, a record attributable to windshear detection equipment like LLWAS, and to improved pilot training. Unfortunately, the more sophisticated weather detection equipment -- Terminal Doppler Radar -- had fallen years behind schedule due to procurement and design problems. Sadly, that delay caught up with the industry in Charlotte.

Then the Halloween night accident in Roselawn, Indiana, brought icing to the forefront again. But, thanks to a state-of-the art flight recorder, we were able to learn within days that the French-built ATR's upset was initiated by a rapid deflection of the right aileron. We deduced that this was because the wings had accumulated a substantial amount of ice during the 30 minutes the plane was in a holding pattern.Within a week of the accident, we issued urgent safety recommendations to the FAA to restrict the operation of ATRs in icing conditions until a fix could be developed to counteract the phenomenon the accident aircraft encountered. Within a month, following test flights in the United States and France, the FAA effectively grounded the aircraft in icing conditions. A redesign of the wing anti-icing boots was developed, and the modified airplanes have been returned to the skies. We are closely monitoring the operation of these aircraft as another winter approaches.

The Nation suffered its last fatal airline accident of the year on December 13 when an American Eagle British-built Jetstream 3200 crashed on approach to Raleigh, North Carolina. We will issue our final report on this accident this Fall. Two of the issues we're pursuing in this investigation are pilot training and an airline's ability to learn from other airlines the work record of pilot applicants.

While 1995 was off to a good start, in August of this year, after 8 months without a major fatal airline accident in this country, an Atlantic Southeast Airlines Brazilian-built Embraer-120 commuter plane crashed in Carrollton, Georgia, killing seven passengers and the pilot. Twenty-one people survived. Again, like in Roselawn, the Safety Board was able to issue an urgent safety recommendation within a week of the accident.

Our metallurgists discovered a fatigue crack in a U.S.-made propeller blade that had separated from one of the Canadian-built engines in flight. Our recommendation called for ultrasonic inspections of certain Hamilton Standard blades to determine if the condition is present in other blades, and a reevaluation of the regular inspection cycle. After the FAA issued the required airworthiness directive, all the targeted blades were inspected and those that had a possible defect were moved from service.

These investigations are progressing like most, some a little quicker than others, depending on what we find and what tools we have available to us, like the quality of the on-board recorders. But there's one accident investigation that is not progressing like the others, and that is the crash of USAir flight 427 near Pittsburgh last September.

This has been one of the most complex and extensive aircraft accident investigations ever conducted by the Safety Board. So far, the investigating team, including the Safety Board and party specialists, have expended more than 40,000 investigative staff-hours in direct support of the investigation. The team has consisted of nearly 100 investigators from the Board and other domestic and foreign organizations.

I won't describe the exhaustive nature of this investigation; I'm sure it's well-known to you. Today, at the FAA Technical Center at Atlantic City, New Jersey, we're conducting flight tests to gather data on the possible effects a Boeing 727's wake vortices could have on a 737. I don't expect a draft final report on this investigation before Spring.

All of these investigations have led or will lead to improvements in aviation safety. And all of them have displayed remarkable international cooperation. You might have noticed the global nature of our airline industry just in my descriptions of the investigations.

In addition, the Safety Board has addressed a broad array of other aviation safety issues in the last year. They include:

 Commuter airline safety, including improvements in pilot training, maintenance, and required safety equipment;

 The regulation of sightseeing or air tour operations;

 Inspections of a significant number of turbofan engines to detect cracks caused by manufacturing process defects.

None of these accomplishments could have been achieved without the total dedication and commitment of the air safety investigators representing many governments and industries. They required immediate communications and objective and forthright sharing of the facts related to the safety deficiencies uncovered by the investigators.

This leads me to one of the hallmarks of my Chairmanship at the NTSB -- communications. I have been working to improve communications within my agency, communications among our own government agencies, and communications within our industry on a worldwide basis. This seminar is an excellent means to fulfill that need to improve aviation safety.

The explosive expansion of the airline industry has brought us closer together; however, it has also produced problems that require improved communications.

As you know, most aircraft are manufactured from components that are designed, manufactured, and assembled in many countries. The aircraft are operated in many countries under differing regulatory regimes.

The diversity and expansion of our global aviation system requires timely and accurate communications within the entire industry. Manufacturers of aircraft, engines, and components must ensure communications of safety-related information as part of their in-service monitoring to prevent an accident from occurring. Likewise, airlines must communicate safety-related information to other airlines, manufacturers, and regulators to prevent other accidents occurring from previously identified deficiencies. Of course, regulators and air safety investigators must ensure prompt and precise communications to prevent accidents.

ICAO plays a most important role in the system of communications of safety information. It sets the Standards and Recommended Practices for all members of the international civil aviation community to follow in order to prevent accidents. However, ICAO only establishes the framework for proper communications. The means to effect adequate, timely communications is through the people within government and industry who work in the system on a daily basis.

We at the NTSB are committed to full and open communications on a world-wide basis. I have faith that all of you are clearly committed to this goals. We do not ever want to investigate another tragic accident for which the causes and factors were already known by some and had not been appropriately communicated to others.

Today, you can't have a conversation with one of our investigators without a mention of our new vocabulary -- "put it on the net" (internet), "web site," "e-mail," "f-t-p," "download" -- all now available, worldwide, to every air safety investigator.

I would like to urge all investigators to include in each of their checklists for accident investigation the documentation and assessment of previously known information that, because of a lack of communications, permitted another accident to occur.

Certainly technology is expanding at an exponential rate. This should be a boon to our industry, but it could be a curse if we allow this technology to lead us away from our proven methods. Yes, investigators must maintain a high level of training and familiarization with the state-of-the-art technological improvements in order to maintain their credibility with the industry. But it is equally important, in my opinion, for air safety investigators to maintain their excellence in the basics of aircraft accident investigation, the "gut feelings," the basic "tin kicking" skills.

As you know, two of the most important tools for the air safety investigator are the cockpit voice recorder (CVR) and the flight data recorder (FDR). These recorders provide invaluable evidence in many investigations to determine the causes and to develop accident prevention measures. However, for several reasons, the air safety investigator cannot rely on the CVR and FDR alone.

First, recorders are not installed on all aircraft. Second, many recorders do not survive the crashes, and some are not located after the accidents. Most importantly, many recorders do not contain sufficient amounts of information in themselves to help investigators solve the accidents.

It's unfortunate that a significant number of the world-wide fleet have FDRs installed with insufficient parameters to help solve many accidents. As a result, the Safety Board has urged not only the phasing-in of longer CVRs, but last February the NTSB urged the U.S. Federal Aviation Administration to require more extensive FDR parameters on the U.S. fleet of airliners. We have placed this issue on our "Most Wanted" list. While some significant progress is being made, we must remember that improving the technology of flight recording is not the total answer.Look, let's not kid ourselves. It is vital that government and industry work together to ensure that investigators are trained in the basics of accident investigation. By basics, I refer to being able to document severely fragmented wreckage to determine if pre-crash failures occurred. Investigators must understand complex aviation systems, including both the technical problems and the management problems of the entire aviation system.

This philosophy is useful in many fields. For example, computers are becoming indispensable for many engineering calculations, but it's still nice to be able to use pencil and paper if you have to. That might help prevent the "garbage in, garbage out" problem if one becomes overly dependent on computers.

Investigators must be qualified to interview witnesses, examine records of design, certification, manufacturing, and maintenance. They must also be able to understand pilot, flight attendant, mechanic, inspector, and air traffic controller training programs. Comprehension of the complex organizational factors that most often influence the causes and factors of accidents is paramount.

Obviously, no single investigator could possibly be trained to proficiency in all of these complex areas of expertise that are required to investigate a large aircraft accident. For 28 years, the Safety Board has been successfully implementing a "team effort" involving many investigators under the leadership of a highly trained investigator-in-charge.

The aircraft manufacturers, operators, regulators, and the traveling public cannot afford to have air safety investigators who are not fully capable of performing their important tasks. It is important that all facets of the industry support maintaining the high level of competence of its air safety investigators.

ISASI must stay vigilant on this matter.

I hope that my remarks have emphasized the importance of your job, your training and the need for communications as we move toward the next century of flight.

Perhaps I can close by paraphrasing another thought of Jerry Lederer.

It is impossible to say that safety in air transportation is, has been, or will be, achieved by any one specific detail of equipment, by experience alone, solely by conservative (investigative) policy, by (solid) research, by virtue of good organization, or because of government regulations. All these elements, cemented together by (investigators) imbued with a spirit of apprehension combined with a deep sense of responsibility for the safety of the flying public, have brought about our present laudable (air safety) record and will continue to improve on it.

Jerry Lederer's life and works remind us of your responsibility as air safety investigators. It is a responsibility and a heritage you assume whether you are employed by our government, a manufacturer, a union, or self-employed. It is a responsibility tested by your familiarity with death and human failure.

Yes, Jerry is correct, ISASI members from many different nations and many different backgrounds have made a difference in the past, and I am confident that you will carry that commitment forward and make a difference in the future.

Thank you for inviting me here today, and I look forward to the rest of the conference.

 

Jim Hall's Speeches