Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the
International Aircraft Cabin Safety Symposium
February 3, 1997, Torrance, California

Thank you for inviting me tonight to address this most important conference, one that I have attended every year I've been Chairman. This is the first time I've spoken, however, before most of you have gone home.

It goes without saying that flight attendants are often the last line of defense between death or serious injury and successful escape from the aftermath of an aviation accident. And the flight attendant corps suffered many losses in the accidents we had during the last year.

Fourteen flight attendants were on duty on TWA flight 800, three lost their lives on the ValuJet plane and 1 was among the dead in the crash of Comair flight 3272. These 18 flight attendants who died in the line of duty do not count the many dead-heading crewmembers who also perished on TWA flight 800.

We are all in their debt, as we are to the thousands of other flight attendants whose work is often grueling, and always dedicated first to the safety of the passengers in their charge.

Unfortunately, in the four major accidents we've had in the last year, there have been no survivors. In three of them -- ValuJet, TWA flight 800 and Comair flight 3272 in Monroe County, Michigan - there were no cabin safety issues because the accidents involved either an inflight break-up or high impact.

Let's discuss some of our recent accidents. A report we issued last year on another commuter accident highlighted a problem that we feel should have been put to rest long ago - adequate intra-cabin communications. On August 21, 1995, an Embraer 120RT operated by Atlantic Southeast Airlines made a crash landing in a field in Carrollton, Georgia after a propeller separated from one of the engines and damaged the engine so severely that the aircraft could not maintain altitude. Eight people died.

The flight attendant received general acclaim for her performance during the accident sequence, and I think it is worthwhile for me to read one paragraph to show you what the Board thought.

• The Safety Board commends the exemplary manner in which the flight attendant briefed the passengers and handled the emergency. According to passengers, immediately following the loss of the propeller blade, the flight attendant checked with each passenger individually to make sure that they all understood how to assume the brace position, and she yelled instructions to the passengers up until the time of impact. After the crash, although she was seriously injured, she continued to assist the passengers by moving them away from the airplane and extinguishing flames on at least one passenger who was on fire.
  

The Board criticized the flight crew for one aspect of how they handled the emergency situation. Although it found no fault with their airmanship, the Board noted that the pilots informed the flight attendant 7 minutes before impact that they had declared an emergency for return to Atlanta and that she should brief the passengers. That was the last communication between them. Flight attendants must be given more accurate time-available information so that they can properly secure the cabin and make sure all are braced properly. The Board recommended that the advisory circular governing crew resource management training be amended to include guidance regarding the communication of time management information among flight and cabin crewmembers.

Ironically, this issue arose in another investigation concluded last year, but this time involving communications not on a single-flight attendant commuter flight but on a jumbo jet having a dozen flight attendants. On December 20, 1995, Tower Air flight 41, a Boeing 747, was substantially damaged during a rejected takeoff at Kennedy Airport in New York. Although the RTO came without warning, the Board believes that more than 3 of the 12 flight attendants should have been able to react to the emergency by shouting brace commands.

The inconsistent pattern of the flight attendants' emergency commands before the airplane came to a stop, the large cabin layout of the plane, and the large size of its cabin crew highlighted the importance of communication among flight attendants. The Board recommended that the FAA ensure that air carriers have adequate procedures for flight attendant communications, including those for coordinating emergency commands to passengers, transmitting information to flightcrews and other flight attendants, and handling postaccident environments in which normal communications systems have been disrupted.

The loss of TWA flight 800 in July not only plunged our nation into mourning, it plunged the aviation industry into a period of self evaluation. Information revealed from our investigation of the ValuJet crash added to this atmosphere. The public outcry over the possible causes of these tragedies and the increasingly vocal complaints from family members of the victims have resulted in an industry much different from the one that existed even earlier last year.

As you know, the President formed the White House Commission on Aviation Safety and Security during the summer, and I am honored to have been asked to serve as a Commissioner. I attended a Commission meeting last month, during which time Vice President Gore announced that Boeing had agreed to a major retrofit of its worldwide 737 fleet, going a long way to satisfying our recommendations on the subject. And, last week we met to formulate our final report.

Although a review of airline safety and security is warranted, we should never overlook the fact that we have an extremely safe system. In 1995, the major U.S. scheduled airlines had one fatal accident for every 4 million flights! But when things go wrong, it is the Safety Board's job to find out why.

The TWA investigation has been unprecedented in its human scope and in its expense. We have been on-scene for more than 6 months - a record. Our latest estimates are that this investigation will cost $27 million, not counting salaries of government employees that would have been paid anyway - that is, representatives from the NTSB, the FBI, the Coast Guard, the Navy, FEMA and others. Consider that the entire yearly budget of the NTSB is just over $40 million.

As far as the investigation itself, we will shortly begin constructing a three-dimensional mock-up of a major portion of the aircraft's wreckage. Although we have most of the wreckage, we are continuing trawling operations off the Long Island coast to find every bit of debris possible. We have just retained the California Institute of Technology to determine the explosive characteristics of the fuel that was aboard flight 800. We will continue to work closely with the FBI and all other parties until we are convinced we have pursued every possible credible scenario that could have led to the explosion.

And, yes, those three possible scenarios you've heard about for so long - a bomb, a missile or mechanical failure - are still on the table. We have identified a potential mechanism by which the center fuel tank of Boeing 747s could explode, but we don't know if that happened in this case.

As you know, we held a public hearing on the ValuJet accident in November, and have issued recommendations to prohibit the transportation of oxidizers and to train airline personnel in the acceptance of hazardous materials shipments. Since then, the Department of Transportation has banned the shipment of oxygen canisters that are suspected of having played a role in the ValuJet crash.

All of us hope we never see another year like 1996, which registered more passenger service fatalities than any other year in more than a decade. Unfortunately, 1997 was only 9 days old when a Comair EMB-120 crashed into a field in Monroe County, Michigan while on approach to Detroit. All 29 persons aboard were killed. Although snow was reported at the time, we don't know if weather was a factor in the accident. We are fortunate to have a multi-parameter flight recorder to work from.

I want to turn now to what has become a new responsibility for the Safety Board, the treatment of family members of victims of air disasters. We have always made special efforts to keep families informed on the progress of our investigations, but the information they receive from other parties has often been lacking, in their estimation.

Since the dawn of commercial aviation, the unpleasant duty of notifying next of kin after airline accidents has fallen upon the airline that had the accident, and that carrier often made arrangements for the transportation of family members to a location near the accident site, and for the shipment of victims' remains.

Whether or not this modus operandi was ever adequate to address the needs of victims' family members, it is clear that the way things used to be done is not adequate today. The world has changed and all of us involved in the events following major airline accidents have to change with it. The combination of a litigious society, expanded and aggressive 24-hour news coverage, and perhaps a mistrust of authority all have contributed to this new environment.

The watershed event was the December 1988 bombing of Pan American flight 103 over Lockerbie, Scotland. Family members who believed they were not treated with the sensitivity and respect they expected and felt they deserved, and believed that the government had not done all that it could, formed a support group. Among the findings of a Presidential were recommendations on the treatment of families.

As a result, the State Department recognized that families of American citizens who die in an aviation disaster overseas deserve some services from their government. When an American Airlines Boeing 757 crashed in Colombia in December 1995, the State Department dispatched a Fly-Away Team to do what was necessary to facilitate repatriation of the victims, including body identification.

Domestic family support groups were established after the USAir accident near Pittsburgh and the American Eagle accident in Roselawn, Indiana, both in late 1994. After meeting with the families at our Pittsburgh hearing, I became convinced that the government and the airlines must address their legitimate concerns. Similar groups were formed after the ValuJet and TWA 800 accidents.

In September 1996, President Clinton issued a directive naming the NTSB as the coordinator of federal services to families of victims of transportation accidents, and in October he signed legislation that gives us that responsibility for aviation disasters. I did not seek this responsibility for the Board; I had hoped that it could be handled without federal intervention. But Congress and the President have spoken, and I intend for the Board to fulfill its new responsibility with the same professionalism that has characterized its investigative activities for 3 decades.

Under this new authority:

• The NTSB will coordinate the provision of federal services to the families of victims.

• These could include, but are not limited to, providing speedy and accurate information about the accident and recovery efforts, ensuring the families who wish to travel to the accident site receive all necessary assistance, and arranging opportunities for counseling and other support.
• The NTSB will work with State and local authorities and with private relief organizations to ensure appropriate coordination of the services they provide with those of the federal government.
• The following federal agencies will cooperate fully with the Safety Board in these efforts: the Departments of State, Defense, Justice, Health and Human Services and Transportation, and FEMA.

Another provision of the Act calls on the Secretary of Transportation to appoint a task force composed of family members and representatives of government and private relief agencies. This task force will have quite a full plate before it. It is charged with developing a model plan to assist airlines in responding to aircraft accidents. This includes recommendations on:

• Methods to ensure that attorneys and the news media do not intrude on the privacy of families;
• Methods to improve the timeliness of the notification provided by air carriers to the families of accident victims;
• How families of non-American citizens can receive appropriate assistance; and
• How the military can be used to aid in body identification.

I have directed Safety Board staff to go one more step beyond this task force, by forming an advisory committee of family members who will consult with us on such issues as the handling of personal effects and the desirability of aggressive DNA testing on all recovered remains. We will want the family members themselves to come up with the best procedures so that future activities will be directed with the benefit of their first-hand experience.

We launched our first family assistance team since passage of the Act with our Go-Team to the runway collision at Quincy, Illinois last November, and then sent another team to Monroe County, Michigan in January. We are continuing to formulate how best to carry out our responsibilities. One problem is that, although agencies and private organizations are only too happy to help us, they will do so only on a reimbursable basis, and Congress appropriated no funds for the support of this responsibility.

Recently, as I was contemplating the upcoming 30^th anniversary of the Safety Board, I looked back at airline accident statistics and noted that the accident rate had fallen 63 percent from 1967, the year the Board opened its doors, to 1995. That impressive improvement is due in part to the dedication of the professionals in my agency, but it is also due to the thousands of men and women in government, industry and organizations like yours that have made the U.S. transportation system the envy of the world.

Thank you, and good night.