Remarks made at the
National Symposium on Dentistry's Role and Responsibility

in Mass Disaster Identification
Chicago, Illinois, June 29, 1996


Good afternoon and thank you for inviting me.

What I'd like to talk to you about today is the vital role you can perform in the aftermath of transportation tragedies. In a sense, when we hear that an accident has occurred, both your organization and mine mobilize to begin doing what we do best. On our part, that means investigating the accident. On your part, that means identifying the victims.

Our work is important because it eventually leads to safety improvements that benefit everyone. Your work for the most part has a more personal outcome. It can help us in determining what happened in the accident, but I believe its more important contribution is in helping to bring closure to the families of the victims. I'll talk more on that later.

As all of you know, transportation is one of the largest and most dynamic industries in our economy. According to the U.S. Department of Transportation, 11 percent of our Gross Domestic Product is generated by transportation. This amounted to $688 billion in 1993.

All of us here utilize our massive transportation infrastructure many times a day:

Unfortunately, when you have so much activity, it is inevitable that accidents occur in our transportation system. And that, often, is when my agency, the National Transportation Safety Board, is called into action. It can also be a time when your expertise is called upon.

Most of you know us because of our high-profile aviation accident work, but the Board also investigates highway, rail, pipeline and marine accidents. The NTSB was established in 1967 by Congress to determine the "probable causes" of transportation accidents and issue recommendations to prevent future accidents. We are independent of the U.S. Department of Transportation, and have no regulatory or enforcement powers.

Since 1967, the Safety Board has investigated more than 100,000 aviation accidents and almost 10,000 surface transportation accidents as the world's premier transportation accident investigation agency.

On call 24 hours a day, 365 days a year, Safety Board investigators travel throughout the country and to every corner of the world to investigate significant accidents, developing a factual record that often leads to safety recommendations aimed at ensuring that such accidents never happen again -- and we do it all at an annual cost of less than 15 cents for each United States citizen.

In its 29-year history, the Board has issued more than 10,000 recommendations in all transportation modes to over 1,300 recipients. Our recommendations serve, to a great extent, as a main area of government transportation safety oversight. We don't only look at transportation companies or individuals when searching for a cause, we also look at the role the pertinent state or federal agencies might have played.

It is quite a task. While we often examine the safety programs of billion dollar corporations and government agencies having tens of thousands of employees, to give you an idea of our relative sizes, the annual budget of my 350-person agency would fund the Department of Transportation for just nine hours!

Just as forensic dentists conduct meticulous detective work to complete their tasks, Safety Board investigators, too, have had some impressive success stories. As one book aptly called them, they are, indeed, disaster detectives.

On January 13, 1982, an Air Florida Boeing 737 crashed while taking off from Washington's National Airport in a snow storm, hitting a major bridge before settling into the frozen waters of the Potomac River. While icing was an obvious culprit, statements by the pilots on the cockpit voice recorder were puzzling. As they were lifting off, a pilot was questioning the readings he was getting on his gauges. Could there have been an equipment problem in the cockpit, and not icing, as many believed?

Our engineers took that recording and filtered out all sounds except the background engine noise. They then used spectrographic analysis on the engine sounds to determine that the engines were not producing the power that the crew was indicating. Through this work, we were able to deduce that the engine inlet probe, from which the gauges read engine revolutions per minute, had iced over in the half hour between the aircraft's deicing and takeoff, and therefore were providing the crew with incorrect readings.

Yes, icing was the cause of the accident, but rather than it being a case of icing destroying the lift of the wings, we found that the crew didn't provide the proper amount of power to the engines because of the faulty reading from the iced-over probe.

On July 19, 1989, a United Airlines DC-10 crash-landed at Sioux City, Iowa after the fan disk on the tail-mounted, number 2 engine separated in flight, destroying the airplane's 3 hydraulic systems. Although more than 100 persons lost their lives in the accident, the landing is considered near-miraculous, resulting in almost 200 survivors.

It took about 3 months to find the separated disk, which was recovered by a farmer during the harvest. By then, we'd learned a lot about the history of that disk, thanks to the meticulous paperwork requirements of this nation's airline industry. Examining records going back almost 20 years, we knew that this disk was one of 8 made from the same ingot of titanium. One of those was destroyed at the factory due to a flaw in it. The 6 remaining sister disks were recalled after the accident; 2 of them were found to have what were called "rejectable anomalies."

Months of examination of the recovered disk enabled us to conclude that the failure originated in a metallurgical flaw that had existed since the disk's manufacture. A fatigue crack propagated from this flaw and grew until the disk failed. Discoloration of the crack found after the accident and metallurgical analysis convinced the Safety Board that the crack was present when the disk was last inspected by the airline 760 flights before the accident. The crack could have been detected if a proper inspection had been conducted.

When the need arises, we go to great lengths to gather evidence for our investigations. In the mid-1980s, one of our investigators led an expedition up a 20,000-foot mountain in Bolivia to retrieve the flight recorders of an Eastern Airlines Boeing 727 that had crashed. Although the expedition reached the crash site, the wreckage was under many feet of snow, making a meaningful search for the recorders impossible.

We have been involved in several deep-sea underwater searches in the Indian, Atlantic and Pacific Oceans. A year and a half after a cargo door blew off a United Airlines Boeing 747 over the Pacific Ocean, the Navy retrieved the door from the ocean bottom, 14,000 feet below the surface. The finding enabled us to determine that an electrical problem led to the accident.

Early this year, the Safety Board organized a successful underwater search after a foreign-registered Boeing 757 crashed off the coast of the Dominican Republic. This was the second fatal accident of a 757 in 6 weeks. Time was of the essence; if there was an airworthiness problem developing with this major airliner, we had to find out immediately.

Adding to the urgency was the fact that the wreckage was at the bottom of the ocean. The radio beacons on the flight recorders, even if they were in serviceable order, would last only 30 days. Without the signals they emitted, finding the recorders would be almost impossible.

We organized an international consortium of government agencies and private companies to fund a search and recovery mission. Within 2 weeks of the accident, a ship chartered by the U.S. Navy was steaming to the location, and the recorders were recovered shortly after that.

Because of our expeditious recovery and readout in our laboratory in Washington, we were able to determine very quickly that the aircraft apparently encountered an operational problem related to faulty air speed readings, and not an airworthiness issue involving the aircraft. This saved the investigating parties potentially millions of dollars by enabling us to determine that we did not have to undertake a massive wreckage retrieval effort.

As you can see, we at the NTSB deal with the hardware of an accident -- the structure of the plane, the engines, the pilot and maintenance records. But we also deal with the human element, be it the role of the crew in the accident, or the survival aspects for the passengers.

There is one group of people, however, who are often overlooked by government and industry, alike -- the victims' families. Which brings me to what you, as forensic dentists, can do to ease their burden.

Three times in the last two years, I have been to the scene of a non-survivable major airline disaster. These accidents -- in Pittsburgh, Pennsylvania; Roselawn, Indiana; and the Everglades -- have claimed the lives of 310 people.

Historically, while we could never forget the human tragedy that the accidents represented, we had maintained a professional distance from the families of accident victims, giving them all the factual information we had, but leaving other accommodations to the airlines.

We have seen a dramatic change in the nature of major aircraft accidents in recent years. The combination of a litigious society, aggressive 24-hour news coverage, and perhaps a mistrust of authority, all contribute to a very challenging environment surrounding major accidents.

Family members are demanding more accountability and more services from those of us involved in the various aspects of an accident. I believe that most of these demands are just common sense. On a personal note, I lost two friends on the ValuJet crash; I cannot imagine how it feels to lose a family member under such circumstances.

We have recently become more directly involved in dealing with family members. We set aside dedicated seating for them at our public hearings, and, as in the example of ValuJet, we try to arrange visits to the accident sites for them. My feeling is that these people, while they may be going through personal trauma, are taxpayers. They pay my salary and they pay for the investigative work of the Safety Board. Within reason and within the resources available to us, I believe we must be responsive.

This is where you can provide a great service to these people. Forensic dentistry is gaining wide acceptance as an indispensable part of any post-mortem team. As has been noted by others, it is ironic that while teeth seem to be among the most troublesome structures of the body while we live, they are among the most durable after death.

The science of forensic dentistry has gained world acclaim for its roles in making identifications after major air disasters like the collision of two Boeing 747s in Tenerife, where 90 percent of the charred bodies were identified. Other high-profile cases, like the Symbionese Liberation Army shoot-out in California in the 1970s, were solved through forensic dentistry.

I was even surprised to see that the first time forensic dentistry was used in this country was in 1776, and the practitioner was Paul Revere!

You can assist us directly in our investigations, because our survival factors group works closely with forensic pathologists and their investigators to assist us in determining why people did or did not survive the accident. Our techniques used during aviation accident investigations do not differ significantly from those used during investigations that involve trains or intercity buses. Impact dynamics might differ but injury biomechanics are remarkably similar.

What is often the case is that the very high impact forces inherent in aviation disasters precludes any other methods of identification. Thus, forensic dentistry becomes the primary positive identification method with the forensic odontologist playing a critical role in the process. Rates of identification of unknown bodies based solely on dental records in mass disasters have climbed significantly in recent decades. For example, over 80 percent of the passengers of Northwest flight 255, which crashed in Detroit in 1987, were identified by dental records. A similarly destructive crash in Maryland in 1963 yielded only 12 percent identification through dental records.

In many cases, admittedly, if it takes forensic dentistry to identify a body, then we at the Safety Board won't learn much from that identification. However, in cases where the remains are mostly whole but severely burned, identification is important because we might be able to learn where the victim was located at the time of the accident and use information about injuries and toxicology results to shed light on the circumstances surrounding the accident.

For example, on February 16, 1996, a commuter train collided with an Amtrak train in Silver Spring, Maryland, killing 8 passengers and the 3 crew members on the commuter train. Those victims were burned beyond recognition but positively identified through forensic dentistry.

The importance to our investigation was that we were able to document where the victims were sitting, based on survivors' accounts, and where they ended up. We were also able to determine which of the victims were the crew members. This information will help us determine what happened in those final seconds.

But, our investigations aside, I believe your skills are most useful in providing closure for the family members. Your expertise paid off in an accident for which I was the Board Member on-scene, the crash of American Eagle flight 4184 in Roselawn, Indiana. As you know, because of the high speed at which the aircraft struck the ground, body fragmentation required forensic dentistry to determine the identities of people's remains. Incredibly, while only 9 percent of the victim's teeth were recovered, medical examiners were able to identify the remains of half of the 68 people aboard.

Similar work has been done by your colleagues time and again in other aviation disasters. You heard earlier in this conference from Dr. Joe Davis about the importance of forensic dentistry to the ValuJet post-mortem activities. I am told that quite a few of the identifications made after the USAir Pittsburgh Boeing 737 accident in September 1994 were accomplished through forensic dentistry, as well.

In May 1979, the nation experienced its worst domestic aviation accident when a DC-10 crashed on takeoff from O'Hare Airport right here in Chicago, killing all 271 persons aboard and 2 more on the ground. Within 3 weeks, mostly on the basis on dental records, all of the victims had been identified.

Why is this important? In a recent USA Today article, an expert in grief is quoted as saying that without a body, "you may have a tendency to think the death has not occurred." Another grief counselor said that a burial is an important element in the grieving process.

To fully appreciate the value of what forensic dentists contribute following an airline disaster, you must place yourself on the scene of one of these tragedies. The combination of a litigious society, aggressive 24-hour news coverage, and perhaps a mistrust of authority all contribute to a very challenging environment surrounding major accidents.

In this environment are thrust individuals who have just been traumatized to learn that a loved one has died in an unexpected manner. They want nothing more at that time than to claim their loved one and return to the familiarity of home and family. Identification is also necessary for the completion of official records, the settlement of estates and for insurance claims. In the most devastating of these accidents, only you can provide them the closure they need.

The identification of the deceased represents a humane and moral responsibility that often comes to rest on the shoulders of the practicing dentist. Therefore, in this age of mass travel, there is a heavy obligation upon every dentist -- even those who do not work in forensics -- to keep detailed and accurate records. When the individual family dentist does not maintain accurate and detailed records and charts, then the forensic dentist cannot make a positive identification.

Yours is still a fairly exclusive profession. I understand there are about 450 practicing forensic dentists in this country, fewer than 100 Board certified. Nevertheless, communities all around the country should include forensic dentistry in their disaster plans. The Roselawn and ValuJet experiences can be instructive to them.

I would like to offer the services of our survival factors investigators to work with you to determine how best you can assist us in future investigations. I want to thank you for all the help you have given us and will give us in the future, and if I may be so bold, I think I can thank you on behalf of all the families who were able to close a particularly painful chapter of their lives due to your professional expertise.

Thank you for inviting me here today.

Jim Hall's Speeches