Address by Jim Hall, Chairman
National Transportation Safety Board
13th Annual Aircraft Cabin Safety Symposium
Southern California Safety Institute
February 2, 1996, San Diego, California

Good morning ladies and gentlemen. This is the second year that I have been privileged to give the closing remarks to your group. Once again, I am impressed by the number of participants and the subjects selected for your agenda. It reassures me that we are all striving together to reach our common goal of improving cabin safety.

When I spoke to you last year, the United States had just witnessed a 6-month period in which major and commuter airline accidents had killed more than 200 passengers. Since then, the Department of Transportation has issued new rules governing commuter airlines and proposed rules dealing with hours of service, all of which address safety recommendations the National Transportation Safety Board has issued in recent years. More about those rules a little later.

In December, as I was first contemplating my remarks here, I thought we would be able to note a relatively accident-free year. That was before the tragic loss of American Airlines flight 965 near Cali, Colombia on December 20, which took the lives of 160 persons. My agency has been assisting the Colombian authorities in this investigation and I can tell you that Colombia is running a very professional inquiry into this accident. Much has already been learned and shared with the public.

The important thing is that, just as we all know that the sky isn't falling after a series of accidents, we also know that all is not necessarily well after an accident-free period. It takes the constant oversight by regulatory agencies like the FAA, and the constant vigilance of the NTSB, and the constant effective management by the airlines themselves, to keep our system as safe as it is.

As you heard in detail yesterday, five years ago a National Transportation Safety Board Go-Team arrived up the road a bit at LAX after an overnight trip from Washington to begin its investigation of a runway collision between a Boeing 737 and a Swearingen Metroliner, that killed all 12 persons aboard the commuter. Of the 89 persons aboard the 737, 22 of them died, but only 1 from impact injuries. The other 21 survived the impact but died of smoke inhalation while trying to escape the burning aircraft. One of those was a flight attendant.

The accident, while raising major survival factors issues that the Safety Board is still pursuing today, reminded us again that thousands of times a day, cabin crew members perform vital safety responsibilities and, on occasion, put their lives on the line to save passengers who have been entrusted to their care.

And their role is becoming more vital every year, because the passenger airline industry is enjoying immense growth. U.S. airlines carried about 550 million passengers worldwide last year. The FAA projects that number will increase to over 900 million annual passengers in the next 10 years. Regional airlines, which already carry almost 60 million passengers a year in the U.S., are projected to carry 115 million passengers 10 years from now.

This industry's marvelous safety record must continue to improve, or, as has been calculated by Boeing Aircraft Company, we could see a major transport category aircraft accident somewhere in the world every week by the year 2015. Again, it will take the concerted efforts of all of our organizations, and of all sectors of the airline workforce, those on the ground and in the air.

My organization, the National Transportation Safety Board, is an independent federal agency, independent of the Department of Transportation and the FAA. We are accountable only to the American people through their elected representatives. We have two major tasks: to determine the probable causes of major transportation accidents and to issue safety recommendations aimed at preventing accidents and injuries that result from them. We fulfill this mandate by investigating accidents and the injuries that result from them, by conducting special investigations and safety studies; and occasionally by convening symposia ourselves.

We did this last November, when the NTSB and NASA-Ames Research Center sponsored a Fatigue Symposium. Over 500 attendees, from at least 16 countries, attended the symposium. The conference highlighted the latest fatigue research, and perhaps most importantly, fatigue countermeasures that can be applied to prevent accidents in all modes of transportation.

Many of you are probably familiar with Dr. Mark Rosekind, of NASA-Ames Research Center, who developed the Fatigue Countermeasures Program. He spoke at this symposium two years ago. The Safety Board will be publishing the proceedings of the fatigue conference soon and I urge you to obtain a copy.

NASA Ames' pioneering work in fatigue countermeasures and Crew Resource Management are examples of government-funded work that can be used by many groups within the transportation industry. Certainly, fatigue countermeasures and crew resource management are of vital importance to flight attendants.

The Safety Board has been concerned about flight attendant duty time since 1985. In comments on a petition to the FAA for rulemaking, we supported the principle of flight and duty time limitations for flight attendants for the modest purpose "that they have adequate rest." The FAA denied the petition in 1989. Congressional legislation was introduced that year to establish flight attendant duty time limitations. In 1993, the FAA issued a notice of proposed rulemaking (NPRM) that would set duty time limitations and rest requirements for flight attendants engaged in air transportation and air commerce.

On August 19, 1994, the FAA published a final rule requiring air carriers, air taxis, and commercial operators to provide duty period limitations and rest requirements for flight attendants. The final rule became effective a month later, with a compliance date of March 1, 1995. Following a court challenge by a commuter airline, the U.S. Court of Appeals stayed the compliance date. That stay was lifted on August 25, 1995, and in October, the FAA notified the public of its intention to enforce flight attendant duty limitations and rest requirement rules on February 1, 1996. I am pleased to say that, since yesterday, flight attendants are finally covered by the same kind of rules that govern other safety-sensitive airline employees. It is long overdue!

Last year I spoke to you about a comprehensive Safety Board study on flight attendant training and performance during emergency situations in which we issued more than a dozen recommendations to the FAA. I am pleased to report that the FAA has responded positively to some of those recommendations. For example, the FAA issued Air Carrier Operations Bulletin 1-94-30, "Crewmember Cabin Safety Training," which discusses the reduction of hours of recurrent training, especially for flight attendants qualified on more than one type of aircraft. The FAA has revised Advisory Circular 120- 51B "Crew Resource Management (CRM) Training," to provide guidance regarding flight attendant CRM training. The Safety Board also notes that the FAA has mandated CRM training for flight attendants. Three other ACOBs were also issued along these lines.

Unfortunately, the Safety Board was forced to classify one of the recommendations from our study as "Closed-Unacceptable". We had recommended that the FAA assign separate cabin safety specialists to each of their regions. While the FAA agreed with us on the need for proper oversight and surveillance of cabin safety topics, it did not assign a cabin safety specialist to each region.

A recent accident investigation of an air carrier in one of the regions without a cabin safety specialist reaffirmed the Board's wisdom in issuing that recommendation. On June 8, 1995, a DC-9 taking off from Atlanta's Hartsfield International Airport experienced an uncontained engine failure. Although all the occupants successfully evacuated the aircraft, the plane was destroyed by fire. You might recall from Nora Marshall's presentation yesterday that one of the flight attendants suffered shrapnel-like wounds and second degree burns to her leg.

In our investigation, we noted significant problems with the air carrier's flight attendant manual and training program. We were very disturbed to learn that flight attendants had not had any hands-on experience with the tailcone release handle, and that the flight attendant training program had not been reviewed by an FAA cabin safety specialist.

Last year I described several examples of poor ergonomics in the cabin and I spoke of the FAA's reluctance to address a recommendation about ergonomic design requirements for cabin safety equipment. The Safety Board closed the recommendation "Unacceptable Action" on January 12, 1995. Unfortunately last year we saw another example of a "problem" design. On July 9, 1995, the passenger entry door of an ATR-72 separated shortly after takeoff from Chicago's O'Hare International Airport. The Board has not yet determined what caused the door's separation. However, our investigators learned that within that company's ATR-72 fleet, some of the entry door handles were reversed to accommodate a modification of the stairs.

Thus, flight attendants were operating passenger entry doors during several short flight segments on a mixed fleet of ATR-72s in which the door handles on different airplanes moved in completely opposite directions. A flight attendant might open an ATR-72 passenger entry door on the first flight by moving the handle upwards, and change to another airplane for the second leg in which the handle moved downward to open the door. Is this wise design strategy for the intense moments of an emergency? Although all of the flight attendants were trained on the differences, the Safety Board believes that flight attendant training should not have to overcome poorly designed equipment.

In addition to the design factors, we learned in that investigation that the flight attendant who was seated adjacent to the door had been awake for more than 16 hours and on duty for 14 and a half hours when the door separated shortly after takeoff. She had 5 hours sleep the night before. This was another case that emphasizes the shortsightedness of policies that don't recognize the vital safety functions performed by flight attendants.

Several recent accidents have revealed again the important role that flight attendants have in mitigating the dangers of an emergency. On August 21, 1995, an Embraer EMB-120RT crashed about 25 minutes after departing Atlanta's Hartsfield International Airport. The scheduled flight carried 26 passengers and a crew of three. While climbing through 18,000 feet, the flightcrew declared an emergency and initially attempted to return to Atlanta. The pilots advised that they were unable to maintain altitude and were vectored toward the regional airport in Carrollton, Georgia, for an emergency landing. The airplane didn't make it; it landed in a field and was destroyed by impact forces and post-crash fire. The captain and seven passengers sustained fatal injuries.

Many passengers praised the lone flight attendant on the plane for the calm she displayed during preparation for the emergency landing. The passengers stated that the flight attendant's professionalism gave them confidence. Although she was injured seriously, she was able to lead many passengers away from the wreckage.

A passenger, describing the flight attendant as "spectacular," stated that she informed them they were returning to Atlanta for an emergency landing and instructed them to review their safety information cards. She demonstrated the brace position to each passenger, ensured that each passenger was in the proper position, and repeatedly instructed them to "Stay Down." Another passenger said, "She made the best out of a bad situation." Following the impact, another passenger saw the flight attendant help extinguish fires on some of the survivors, and direct people to stay away from the airplane. She deservedly received national attention for her heroism.

And, just last month, on January 17, an Airbus A-300 operating between Miami, Florida, and San Juan, Puerto Rico, encountered severe turbulence 40 to 45 minutes after takeoff, injuring 25 passengers, one seriously. None of the crew was injured.

The seat belt sign was illuminated at the time of the occurrence and the Purser had made several announcements in both English and Spanish to remind passengers to keep their belts fastened. The flight attendants decided to delay their food service because of the bumpiness that they had experienced since takeoff. I'm happy to report that the flight attendants used common sense and opted to restrain themselves when they perceived that turbulence was intensifying, rather than wait for the order from the cockpit. While we haven't yet had an opportunity to analyze their performance, I am sure that their decision to keep the carts out of the aisle prevented additional injuries.

One of the flight attendants warned a woman that she should keep her seat belt fastened, but she got out of her seat to use the lavatory anyway. She was injured during the incident.

The Safety Board is continuing its investigation of this accident.

In 1994, the Safety Board addressed the issue of why commuter operations had a separate level of regulation, and determined that to the extent possible, commuter airlines should operate under the same safety regulations as scheduled airlines operating larger planes. In a major safety accomplishment, the FAA has adopted rules that will bring all commuter airline flights in aircraft having 10 or more passenger seats under the Part 121 rules. This should be completed by early 1997. This issue is on the Board's Most Wanted list of safety improvements. At the same time, DOT proposed rules that would decrease the allowable number of hours pilots can operate these aircraft, addressing another issue on our Most Wanted list, operator fatigue.

I'm happy to say that appreciation for the importance of cabin safety issues is spreading beyond our borders. Safety Board staff attended a conference last November that was jointly hosted by the FAA, Transport Canada, and the European Joint Airworthiness Authorities (JAA). The purpose of the conference was to establish a joint international research plan for cabin safety. The stated goal of the Cabin Safety Research Program is to coordinate activities among the various authorities and to conduct cooperative, joint and complementary programs to benefit the three authorities.

I support this cooperative research - it makes good sense to me to avoid the costs of duplication of work. Many subjects of this research have been identified during accident investigation by the Safety Board or other investigative organizations. A review of these subjects reveals that many of them have been the subject of Safety Board recommendations involving seats and seat restraints, cabin furnishings, human performance, emergency equipment evaluation, water survival, and fire safety.

During our conference here in San Diego, Mr. Haile Belai discussed another example of international standards in his presentation on "ICAO Standards for Flight Attendants." The International Civil Aviation Organization (ICAO), which includes about 183 countries, produces training manuals and guidance materials. The Safety Board recognizes the value of developing international standards for cabin crew safety training.

I urge you to take information that you learn at this symposium and use it to implement improvements. Each of you here today has a contribution to make. When you see the benefits of your improvements, share it with your colleagues, with your government, with your company or organization. We must work together to ensure that our limited resources are used in the most efficient manner in our search for improvements.

To those of you in the audience who are flight attendants, thank you. We in the transportation safety community know the invaluable service you provide. I ask government regulators and airlines to give flight attendants the tools they need to do their number one job -- ensuring the safety of their passengers.

 

Jim Hall's Speeches