Testimony of Jim Hall, Chairman National Transportation Safety Board
before the Committee on Transportation and Infrastructure, Subcommittee on Aviation
House of Representatives, Regarding Issues Raised by the Crash of ValuJet Flight 592
June 25, 1996

Good morning, Chairman Duncan and Members of the Committee. It has been just over 6 weeks since ValuJet flight 592 crashed into the Everglades following an in-flight fire, killing all 110 persons aboard. Since that time, the Federal Aviation Administration has grounded the airline, and as this morning's hearing shows, many questions have been raised about ValuJet's operations and the FAA's oversight of those operations.

The enormous tragedy of the accident, the intense public and news media scrutiny of the airline and the FAA since then, and perhaps the perception of mixed signals sent by government officials since that accident, have combined to raise doubts in the minds of some Americans about the safety of their airline system.

Before addressing the issues before us today, Mr. Chairman, I'd like to put this concern in some perspective. I think that, as Chairman of the National Transportation Safety Board, I am in a position to do so, because Congress in its wisdom established the Board 29 years ago to be an independent investigative agency, to provide impartial analysis of industry and government alike.

Congress intended the Safety Board to take the longer view, to separate the investigation from the passion of current events, and direct recommendations to those in the position to affect improvements in transportation safety, be they in government or private industry.

In our 29-year history, we have investigated more than 100,000 aviation accidents and issued over 3,600 aviation-related recommendations, most of which were directed to the FAA. To its credit, the FAA has adopted over 80 percent of those recommendations, and over 90 percent of our urgent recommendations.

Over the decades, dedicated government employees at the Safety Board and the FAA have worked closely together to define the latest technologies and the most meaningful regulations to ensure that the American people have the safest transportation system in the world.

I do not mean to imply that we haven't had our differences with the FAA over the years. There are a number of safety improvements that we believe the FAA has not adopted or has taken too long to adopt, and when that happens we make sure you in Congress and the American people know about it. Even though we have our disagreements, the relationship between the FAA and the NTSB has always been a professional one, and we have nothing but the highest regard for the efforts of the 48,000 men and women at the FAA who work every day to fulfill their responsibilities.

That relationship has worked to benefit the American people. In an industry that has seen traffic grow from 106 million passengers in 1967, the year the Safety Board opened its doors, to 545 million passengers last year -- a five-fold increase -- the fatal accident rate has dropped at the same time almost 75 percent. In 1995, for example, there was one fatal Part 121 airline accident for every 4.l million flights.

This remarkable safety record did not happen by chance, but by the dedicated efforts of thousands of inspectors, air traffic controllers, investigators, pilots, mechanics and manufacturing personnel, and through the oversight and policy and budgetary support provided by you and your colleagues in Congress.

I congratulate you, Mr. Chairman, for holding these timely hearings to allow the American people to hear what their government is doing to ensure their safety in the skies.

Eighteen months ago, after a series of fatal accidents, Secretary Peña convened an airline safety summit here in Washington, providing a forum for government agencies and the airline industry to establish heightened safety goals. Several hundred senior government and airline officials attended the two-day meeting. While I applauded the decision to hold the summit, I noted in my remarks that absent from the agenda were certain issues the Safety Board had addressed over the years, issues like airline management, FAA oversight, and corporate culture. Without addressing these issues, I felt, we could never approach the summit's goal of "zero accidents."

Although the aviation industry had taken many of the necessary steps over the years to prevent most accidents through the systematic elimination of hazards and the use of technology to overcome human failures, I questioned the rate of progress in eliminating management causes.

Mr. Chairman, that is a question we must continue to address. How far have we come to eliminate a management mindset that allows unsafe practices to flourish at airlines, or go undetected at the FAA?

I am sorry to say, Mr. Chairman, that while we have not yet determined what exactly happened aboard flight 592 that fateful day, I would not be surprised if at the conclusion of this investigation we find that this accident is the result of previous lessons learned and forgotten.

This hearing has been convened to examine issues raised by the ValuJet crash, and no issues more directly concern the circumstances of this accident than the carriage of hazardous materials on aircraft and fire protection on airliners.

As you know, Mr. Chairman, we recently concluded the recovery efforts in the Everglades, after an unprecedented month-long search for wreckage and, on the part of the medical examiner, for the remains of victims. While our investigation is continuing, some important facts have emerged.

It appears that about 5 minutes after takeoff, the crew of flight 592 decided to return to Miami after hearing a noise and reporting smoke in the cabin to air traffic controllers. Wreckage examination indicates an extremely intense fire in the aircraft, hot enough to melt seat railings and floor beams.

We know the forward cargo compartment carried oxygen generators -- perhaps more than 100 -- packed in cardboard, and at least 3 airplane tires. It appears that at least some of the generators were not empty, as indicated on the shipping documents, and none were equipped with safety caps.

What actually caused the plane to plunge into the Everglades -- for example, was the crew incapacitated or was the aircraft rendered uncontrollable? -- is unknown at this time.

But these facts raise the very real possibility that warnings the airline industry and its regulators received through close calls in past years went tragically unheeded.

I'd like to recount for you an accident that occurred some 8 years ago that may have foreshadowed the accident that has brought us here today.

On February 3, 1988, American Airlines flight 132, a DC-9, departed Dallas/ Fort Worth International Airport for Nashville with a midcargo compartment loaded with, among other things, a 104-pound fiber drum of textile treatment chemicals. Undeclared and improperly packaged hazardous materials inside the fiber drum included 5 gallons of hydrogen peroxide solution and 25 pounds of a sodium orthosilicate-based mixture.

During the flight, a flight attendant and a "deadheading" first officer notified the pilots of smoke in the passenger cabin. The passenger cabin floor above the cargo compartment was hot and soft, and the flight attendants had to move passengers from the affected area. Fortunately, the aircraft landed and a successful evacuation was conducted.

The airworthiness of the airplane was threatened by the fire. Excessive temperatures reached critical flight and engine control cables, floor beams and the passenger cabin floor. We believe that the cargo compartment did not meet the intent of the regulations designed to contain such a fire.

How did we get so close to tragedy? Let me suggest some reasons:

o Because the cargo compartment was not equipped with fire or smoke detection systems, the cockpit crew had no way of detecting the threat until smoke and fumes reached the cabin.

o While smoke was detected in the passenger cabin, the cockpit crew had no means of identifying the location of the fire.

o Further, because the cargo compartment was not equipped with a fire extinguishing system, so even if they knew there was a fire, the cockpit crew had no means available to extinguish or suppress the fire in the cargo compartment.

o Without fire detection or suppression systems, the cockpit crew could only rely on the adequacy of cargo compartment designs and construction to control a fire in the cargo compartment.

Mr. Chairman, the passengers and crew of this particular aircraft were fortunate that day. While no one was seriously injured, the potential for a catastrophic accident was present. And even this incident wasn't the first of its kind. Less than 2 years earlier, an undeclared shipment of 35 percent hydrogen peroxide solution was shipped in drums with no outside markings to warn about the presence of hazardous materials. The shipment had travelled from Florida to Seattle on its way to the Philippines when cargo handlers found several packages had leaked. This was one of more than 2,000 hazardous materials incident reports involving air transportation filed with the DOT in the 17 years leading up to the American Airlines accident in 1988.

It should be noted that the Department of Transportation has the overall regulatory responsibility over the transportation of hazardous materials, through its Research and Special Programs Administration, including the inspection of shippers for compliance with hazardous materials safety requirements.

But Mr. Chairman, despite Safety Board recommendations to the FAA to require fire detection systems, and fire extinguishing systems, and better fire blocking materials in cargo compartments, the sad fact is that the crew of ValuJet flight 592 had no more equipment available to warn them of a fire or to fight it than did the crew of that American Airlines flight 8 years earlier.

Would this have made a difference for the ValuJet flight? We don't know at this point of our investigation, but we're going to try to find out. We intend to conduct tests at the FAA's Technical Center in Atlantic City to determine if the fire started before takeoff, on takeoff, or later. We might be able to determine if a detection system would have alerted the crew early enough to have prevented the tragedy, even without an extinguishing system.

A major issue raised by our investigation involves the precipitating event on the American Airlines plane and maybe on the ValuJet plane -- the carriage of hazardous materials on airliners. NTSB has addressed the issue of undeclared hazardous materials being transported by air in the past. Thousands of companies and individuals ship products by air, usually in small quantities.

A problem we noted with the FAA's cargo compartment fire protection research and testing is that the FAA did not consider the effects of hazardous materials involvement on the capability of a cargo compartment to contain an in-flight fire. In certificating Class D compartments like those found on the American and ValuJet aircraft, the FAA assumes that a fire will be snuffed out when the available oxygen is consumed. This is negated, however, when you have an oxidizer in the compartment, as we did on the American Airlines flight, and as it appears we did on ValuJet.

That is why on May 31, 1996 the Safety Board issued urgent safety recommendations to the FAA to evaluate airline practices, including training, for accepting passenger baggage and freight shipments and for identifying undeclared or unauthorized shipments of hazardous materials, and require air carriers to revise their procedures as necessary. Because of the presence of oxidizing materials in some previous accidents, as well as this one, the Board urged the RSPA and the FAA to prohibit the transportation of oxidizers and oxidizing materials in cargo compartments that do not have fire or smoke detection systems.

We know of at least two other incidents in recent years that involved fires associated with chemical oxygen generators that were shipped by air. So far, it appears that neither shipment of oxygen generators was declared to be a hazardous material.

Certainly, there are several actions we have recommended that can be accomplished quite easily:

o Public education is necessary to address the potential for unintentionally offering hazardous materials.

o Carrier personnel must be trained to recognize potential hazardous materials shipments when they see them or to ask the right questions.

o And airlines can improve the appearance, content and location of notices that are posted to warn passengers and shippers about hazardous materials restrictions and special shipping requirements. Notices that are not read are not effective.

The DOT's program to regulate the transportation of hazardous materials by air, and its regulations to protect aircraft and occupants from the effects of fires on airliners will be major focus areas in our ValuJet investigation.

A relevant focus of today's hearing, Mr. Chairman, is whether there are systemic problems with the oversight of airline operations and maintenance, particularly in those segments that are outsourcing to contractors. I'd like to briefly review some recommendations on this subject that the NTSB has made in the past.

The Safety Board first addressed the issue of FAA oversight of contract maintenance operations 20 years ago. In 1976, a DC-6 operated by Mercer Airlines crashed in Van Nuys, California following the failure of a propeller blade that had been improperly repaired by a contracted repair station. The Board learned that neither the airline nor the FAA District Office responsible for surveillance of the repair station was aware that overhauls were not being accomplished according to the current manual.

As a result, the Board recommended that the FAA remind airlines of their responsibility for ensuring the adequacy of the maintenance of their aircraft and components, even if the maintenance is contracted to outside repair stations. We also recommended that the FAA review its surveillance procedures for certificated repair stations to make sure they maintain and use complete and correct maintenance manuals.

We addressed the issue of contract maintenance again in 1982, following the Air Florida Boeing 737 accident during a snow storm here in Washington. Air Florida's maintenance at National Airport was performed by another carrier. The Board's examination of the deicing procedures used for the flight disclosed that there had been little communication between the carriers regarding these procedures and that contractor maintenance personnel had only limited familiarity with the 737 aircraft. We concluded that there should have been more complete discussions between Air Florida and the contractor regarding procedures to be applied during B-737 maintenance so that respective responsibilities were understood.

Let me quote from our recommendation letter of 14 years ago: "The Safety Board believes that the FAA should be more attentive to contract maintenance agreements between air carriers or with other contractors to assure that all personnel are adequately trained for the aircraft involved and fully aware of their individual responsibilities in the conduct of maintenance."

At least two major accidents prompted Safety Board recommendations on maintenance practices by the airlines and on the FAA's so-called "white gloves" inspections conducted under its National Aviation Safety Improvement Program, or NASIP.

On April 28, 1988, a flight attendant was killed and 8 others received serious injuries when an Aloha Airlines Boeing 737 experienced an explosive decompression at 24,000 feet and 18 feet of fuselage skin and structure ripped off during an inter-island flight in Hawaii.

The accident was a wake-up call for both the industry and the government, prompting an intensive evaluation of maintenance programs for so-called "aging aircraft." The FAA had conducted a NASIP inspection on Aloha Airlines the previous December. Let me again read a portion of our report, which resonates today in light of recent events:

"Technically, as stated by the FAA, if an airline complies with the regulations, it is 'safe.' However, many regulations are subjective in nature and are subject to interpretation. Consequently, even with several significant negative findings by a NASIP team, as was the case with Aloha Airlines, the airline was allowed to continue operations without making immediate changes and without having to set deadlines for completion on recommended actions."

On September 11, 1991, Continental Express flight 2574, an Embraer 120, broke up in flight and crashed near Eagle Lake, Texas, killing all 14 persons aboard. Our investigation revealed that bolts had been removed from the horizontal stabilizer during maintenance the night before the accident and, following a shift change, the bolts were not replaced. The plane crashed on its second flight of the day.

In our probable cause finding, we cited the failure of airline maintenance and inspection personnel to adhere to proper maintenance and quality assurance procedures. The failure of FAA surveillance to detect and verify compliance with approved procedures was cited as a contributing factor.

Following the accident, the FAA conducted a NASIP of Continental Express' maintenance program. It found very few safety deficiencies, and complimented the airline on its internal evaluation system. In our report, we expressed our concern that the NASIP did not find deficiencies in shift turnover procedures and other matters relevant to the accident, and recommended that the agency improve its NASIP procedures.

Some months after Eagle Lake, the same airline had a similar incident when a plane was forced to return to the airport after bolts had been removed from a wing panel. Incredibly, even a fatal accident and an FAA NASIP inspection weren't enough to overcome what appears to have been corporate culture.

The ValuJet tragedy has shone a spotlight on an evolution that has occurred in segments of the airline industry. The Board has traditionally been expressing its concerns about airlines carrying out their own maintenance programs properly. Now, we are looking at what some have dubbed a "virtual airline" -- one that provides transportation but conducts none of its own maintenance or training. As part of our investigation of this tragic accident, we will analyze how carriers that outsource these services are ensuring the safety of their operations. We also will analyze the effectiveness of the FAA and its NASIP program to ensure compliance with safe practices.

And this brings me to an important observation. Last week, the FAA announced that it would now require airlines to demonstrate the regulatory compliance of each of their major contract maintenance programs and facilities. The implication is that airlines have not had to do that until now. If this is true, Mr. Chairman, then we don't just have a ValuJet problem here, we may possibly have an FAA problem.

Our investigation of the ValuJet accident and the announcements made by the FAA last week have raised many questions that the Safety Board is sure to pursue in the coming months:

o Was ValuJet properly ensuring that their contractors were complying with their operating specifications, and was the FAA assuring itself that ValuJet was doing this?

o Is the FAA appropriately structured and staffed to verify that the airline was fulfilling its responsibilities?

o How did ValuJet's manuals, which have been found by the FAA to have deficiencies get to be approved or accepted.

o What is it that the FAA really does when approving programs of start-up airlines in the beginning? And how do they try to handle an airline's rapidly expanding fleet?

o Was the FAA prepared for the large-scale outsourcing that ValuJet presented? I think some of the FAA's actions last week show that they now believe they were not.

In conclusion, Mr. Chairman, the ValuJet accident has brought to the forefront the on-going issue of the need for stronger rules protecting airline passengers from fire dangers aboard airliners, including rules governing the acceptance and carriage of hazardous materials.

We will be examining in our investigation the adequacy of federal standards and requirements for procedures and training of air carrier personnel and shippers in the identification, packaging and handling of hazardous materials; the adequacy of federal surveillance of those procedures and training; and the adequacy of federal standards for airliner fire-worthiness, with particular emphasis on cargo compartments and other unoccupied areas not protected by smoke/fire detection and extinguishing systems.

This investigation also raises serious concerns about the FAA's ability to assure that airlines comply with Federal safety regulations, particularly those that outsource much of their training and maintenance. We will look at the adequacy of the FAA's initial certification of new entrant carriers, and the adequacy of surveillance and oversight of those carriers during start-up and during periods of rapid growth. Did the FAA devote the resources necessary to oversee such an operation, and did ValuJet have the management structure to ensure that its contractors complied with its operating specifications?

This will be an exhaustive investigation, Mr. Chairman, because these are complex issues that must be resolved.