The U.S. National Transportation Safety Board and the
Independent Investigation of Transportation Accidents
Keynote Address by
The Honorable Jim Hall
Chairman, National Transportation Safety Board
Washington, D.C.
before the World Congress on Safety of Life at Sea
Genoa, Italy
April 24, 1996

Bon giorno. That's about all the Italian you're going to get out of a country boy from Tennessee. You should know that the pace of my speech has not been tailored to accommodate the needs of the translators. We really do talk this slowly in the southern part of the United States.

I would first like to thank the gracious conference host, the National Rescue Society of Italy and its President, Mr. Giuseppe Marino, for inviting me to speak to you here assembled in Genoa today. Its great to address an international audience involved in so many timely and important marine safety issues.

But what I'm going to talk to you about today is not limited to marine transportation, but affects all modes of transportation -- the value of an independent accident investigation agency.

I am the Chairman of the National Transportation Safety Board, an independent agency within the United States government established in 1967 to investigate major transportation accidents to determine cause, and, more importantly, to formulate safety recommendations for government or industry aimed at preventing accidents in the future. During the course of our investigations, we often must examine what role other government agencies might have played in the accidents, and that is why it is imperative that we are independent of those agencies. We cannot appear to be investigating ourselves.

The benefits of an independent agency are made plain every time we issue our findings or recommend changes to improve transportation safety. And, as transportation becomes more and more an international industry, independent, objective and professional investigations will become more important, not just for us in the United States, but for all of you, as well.

In the U.S., 11 percent of our nation's Gross Domestic Product is generated by transportation, $688 billion in 1993. Our aviation manufacturing companies alone account for billions of dollars of exports a year. When accidents happen to U.S. transportation vehicles, companies that purchase those vehicles and people that use them must be assured that the findings of any investigation are not tainted by outside pressures.

This independence lends credibility to the investigation in the eyes of the public and the policymakers who must act to correct deficiencies revealed by the investigation. Without support from the public, including the news media, the changes necessary to improve safety are often difficult if not impossible to achieve.

The agency's independence must be unequivocal. For the first 7 years of the NTSB's existence, although it was considered independent, it relied on the Department of Transportation for administrative support -- payroll, supplies and facilities. This eventually proved to be unworkable, and in 1974 Congress passed a law that removed any administrative connection between the Safety Board and DOT.

Other countries have realized the benefits of our system and have established their versions of NTSB-like agencies. Canada and the Netherlands are just two countries that have set up such organizations, and Mexico is contemplating a similar move.

 

Some of you may be aware of our investigations into major aviation accidents, but the Safety Board also investigates major highway, railroad, pipeline, hazardous materials, and marine accidents, and even accidents related to space transportation, such as the Challenger disaster. And as you will learn later this morning when Bill Gossard of my staff speaks, we also investigate some recreational boating accidents.

We often open our doors to investigators from other countries. In a highly celebrated case, the cockpit voice recorder from the DC-9 that crashed into the Tyrrhenean Sea in the early 1980s -- the so-called Ustica accident -- was brought by Italian investigators to our laboratory after being recovered from the water 7 years later. More recently, investigators from this country came to our headquarters to work on evidence removed from an MD-80 that had suffered a fire on the ground in Turin.

We are neither a law enforcement nor a regulatory agency. The Safety Board does not establish legal fault or liability, nor do we levy fines. Our investigative reports are not admissible as evidence in judicial proceedings and we do not get involved in matters of litigation.

Since its inception in the late '60s, the Safety Board has investigated more than 100,000 aviation accidents, and thousands of surface transportation accidents as the world's premier transportation accident investigation agency. Many of the Board's staff of 350 employees are on-call 24-hours a day, 365 days a year. Safety Board investigators travel throughout the U.S. and the world to investigate significant accidents.

For example, the world was startled in 1988 when a cargo door ripped off of a Boeing 747 in flight, taking 9 passengers with it. The good news out of that tragedy was that the resulting rapid decompression did not destroy the airplane because "blow out" panels on the floor that we had recommended just a few years earlier did their job. The plane landed safely and more than 200 lives were saved.

In the marine mode, Safety Board recommendations led to new regulations that for the first time required commercial fishing vessels to carry specific life-saving devices. These improvements are having a dramatic impact on the safety of this industry. In Alaska, there was a 53 percent decline in lives lost in just one year.

We also are called in from time to time to assist our military. Early this month we sent a team of investigators to Croatia to assist the United States Air Force in its investigation of the crash of a military version of the Boeing 737 that killed 33 Americans, including a cabinet secretary.

In its 29-year history, the Safety Board has issued more than 10,000 safety recommendations in all transportation modes to more than 1,250 recipients, including government agencies and transportation companies.

Overall more than 80 percent of the Board's safety recommendations have been accepted by the recipients and the changes recommended have been implemented. The major recipient, getting almost 9,000 recommendations, is, as you would expect, the U.S. Department of Transportation and its modal administrations: the Federal Aviation Administration, the Federal Railroad Administration, the Federal Highway Administration, the Research and Special Programs Administration and the U.S. Coast Guard.

In the U.S., each transportation industry operates in a different regulatory climate. For example, the aviation industry is heavily regulated at the federal level by the Federal Aviation Administration. Conversely, in the highway mode and in recreational boating, much more control for safety lies individually with the 50 States. Because of these differences, the Safety Board sends its recommendations to different agencies and levels of government in each mode of transportation. In aviation, most of the Safety Board's recommendations are directed to the Federal Aviation Administration, while to improve traffic and recreational boating safety most recommendations are directed to State governments.

A breakout of the recommendations by transportation area would reflect that about 33 percent of the recommendations address aviation safety; 20 percent to marine safety; 17 percent each to highway and railroad safety; and 11 percent pipeline safety.

In the United States, we have found that the most effective and efficient way to accomplish independent accident investigation is to have one agency responsible for investigations in all modes of transportation. This allows for the sharing of safety information, accident investigation techniques, and the more efficient use of technical experts. For example, specialists in certain fields such as human performance, meteorology, survival factors, and the release of hazardous materials can work on investigations in more than one mode. Additionally, the Safety Board has found that safety and special studies into recurring transportation safety problems are effectively addressed because expert resources are available in one agency.

As the Safety Board has gained experience in intermodal operations, the benefits of this arrangement for the independent investigation of transportation accidents fall into three separate categories:

Perhaps, one of the most notable "economy of operation" successes implemented by the Safety Board has been the introduction to the surface modes, such as marine, the concept of the multi-disciplinary Go-Team approach. This approach was developed decades ago as a means of augmenting a very small commercial airline accident investigative staff by compartmentalizing the investigation into as many as 12 specialized technical groups, each headed by a Board specialist and staffed by knowledgeable experts provided by government or industry. This concept has worked well, both in small investigations with but a few investigators, and in the investigations of large catastrophic accidents in which as many as 70 experts assist the Board's investigative staff. This arrangement allows the Board to manage the accident investigation without losing control.

The Safety Board has played a major role in improving safety by the transfer of safety lessons from one mode of transportation to another. For example:

The marriage of all transportation modes into one single agency responsible for independent multi-modal accident investigations also leads to uniform and often improved accident investigative techniques. Many of the techniques that had been developed and used in the aviation mode leant themselves to other modes of transportation such as marine, highway, and railroads. Some of the specific techniques that were developed and applied to other modes of transportation include:

In addition, another major issue, fatigue in transportation, is being appreciated more as a factor in transportation safety. Today's modern society, with its 24-hour transportation system and business practices like just-in-time delivery of supplies, has set the stage for fatigue-related accidents. But getting company management and operators of vehicles to understand the role that fatigue plays and to recognize fatigue when it appears has been a slow process.

I am proud that the National Transportation Safety Board, along with the National Aeronautics and Space Administration, or NASA, sponsored the first ever international forum on Managing Human Fatigue in Transportation. It was held last fall near Washington, D.C. More than 600 persons attended from 16 countries. One of the most important things they learned was that no matter what their specialty, no one is immune; we have identified fatigue in accidents occurring in every mode of transportation.

Since you are mostly interested in marine matters here, I need only mention the name of the EXXON VALDEZ to remind you what fatigue can lead to.

Fatigue is pervasive, and it is insidious. Everyone involved in transportation must be educated about eliminating circumstances that lead to fatigue, and in recognizing its symptoms.

In a related field, the Safety Board has been in the forefront of examining the role of the interface between the human element and modern technology in accident causation. This, along with fatigue, shows the growing importance of human factors studies in all modes of transportation.

For these reasons -- economy of operation, transfer of safety lessons between different modes of transportation, and the advancement of new and innovative investigation techniques -- I suggest that serious consideration be made for a unified independent agency wherever it is feasible. You might want to consider one here in Italy.

In conclusion, based on the Safety Board's 29 years of experience, one of the best and most efficient ways to improve transportation safety is through the lessons learned from independent accident investigations. The organization responsible for these investigations must be completely independent from other governmental and judicial organizations and should be responsible for investigations in all modes of transportation.

I can tell you that I am proud to be the leader of my little agency, little in size but not in accomplishment. We believe that this approach to accident investigation benefits not only our citizens but all of the citizens of the world by making all the modes of transportation a little more safe, whether it is an improvement to a Boeing 737 jetliner or addressing actions needed in recreational boating safety.

And we do this all for the cost of less than 15 cents a year for each American citizen -- that's about 230 lira.

If you are ever in the United States, please come by to visit us in Washington, D.C. Thank you for your hospitality, and I hope we meet again soon.

Jim Hall's Speeches