Remarks of Jim Hall, Chairman
National Transportation Safety Board
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 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
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
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
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
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
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:
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:
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 30th
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
Thank you, and good night.