Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the National Air Transportation Association
Ft. Lauderdale, Florida, March 24, 1997
Thank you for inviting me this afternoon to
speak to this important conference.
When I took the job of National Transportation
Safety Board Chairman 3 years ago, I of course had no inkling
about the level of activity my agency was about the enter. July
1994 saw the end of an unprecedented 27-month period in which
the major U.S. scheduled airlines incurred no passenger fatalities.
In that period of time, they carried about a billion passengers
safely to their destinations.
The USAir accident in Charlotte, North Carolina
was followed by the crashes of USAir in Pittsburgh; American Eagle
in Roselawn, Indiana; another American Eagle near Raleigh-Durham;
American Airlines in Colombia; ValuJet in the Everglades; TWA
flight 800; United Express in Quincy, Illinois; and Comair in
Monroe, Michigan. This doesn't count the Birgen Air and Aeroperu
crashes that required our involvement in arranging deep-water
searches for flight recorders.
And don't forget, we also investigate major
accidents in the surface modes - marine, highway, railroad and
pipeline. It is quite a task for a 350-person agency.
And, on top of all that, I never dreamed I'd
spend a lot of time debunking misinformation, but thanks to Pierre
Salinger and others like him, that's become part of my duties,
I want to acknowledge the indispensable role
you play in supporting general aviation and the variety of services
NATA member-businesses provide at thousands of airports across
the country. Everything from aircraft and engine maintenance to
repair, flight training, avionics, air carrier service, fueling
and ground services. All are vital to the safety and growth of
general aviation and to the nation's economy.
And historically, it's important to recognize NATA's role in spearheading and supporting the Civilian Pilot Training Program in the early 1940's. Without your support, foresight and definition of private aviation's post-World War Two goals and objectives, general aviation might not exist as we know it today.
General aviation is now a fleet of approximately
170,000 aircraft representing over 75 percent of all flight operations
at U.S. airports, serviced by businesses employing over 270,000
people with an annual payroll of over $7 billion.
On a larger and more impressive scale, the
total general aviation employment in fixed base operators, manufacturers,
fuel suppliers, and supporting industries has been estimated to
total over 542,000 people with an annual economic impact to the
nation of over $45 billion.
The NATA, of course, also plays a significant
role in general aviation safety through your leadership and participation
on many of the FAA's Aviation Rulemaking Advisory Committees.
Your organization distributes safety information to both members
and non-members. They include training programs for line service
technicians, airport ground vehicle operations, refueling and
quality control procedures. However, as Chairman of the Safety
Board, I know that no organization can be really effective in
fulfilling its mandate or its leadership goals unless it has a
cadre of skilled and motivated people. That's why the Safety Board
is grateful to the many thousands of NATA front-line personnel
who contribute directly to the well-being and the safety of general
aviation every day.
A few years ago, most Americans didn't know
what the NTSB was or what it did. Today, we routinely find ourselves
on the front page or the top item on the nightly news. The National
Transportation Safety Board is one the federal government's smallest
agencies. In fact we have about 350 employees nationwide and cost
each U.S. citizen just 15 cents a year. I may be prejudiced, but
I think that's the best bargain in government.
Our job is to determine the probable causes
of transportation accidents and promote transportation safety.
Since its inception in 1967, the Board has investigated more than
100,000 aviation accidents, and at least 10,000 surface accidents
-- which include highway, marine, rail and pipeline. We also investigate
accidents involving the transportation of hazardous materials.
And we are the sole U.S. accredited representative at foreign
accident investigations under the provisions of the International
Civil Aviation Organization .
The Safety Board has issued almost 10,000 recommendations
in all transportation modes to more than 1,300 - everyone from
the Secretary of Transportation to local governments and companies.
We don't have regulatory or enforcement powers, but our reputation
for impartiality, insightfulness, and thoroughness has resulted
in more than 80 percent of our recommendations being implemented.
The Safety Board's employees investigate about
2,500 accidents a year -- the majority of which are in aviation.
Last year, there were 38 accidents involving part 121 carriers,
98 involving part 135 carriers, and 1,907 involving general aviation.
While many of these accidents are complex, time-consuming and
often involve first time circumstances and events, most of our
investigations ultimately result in a clear determination of probable
One reason is the Safety Board's accident investigation
and safety expertise, which I consider the best in the world.
But many of our investigations, particularly in general aviation,
could not be adequately conducted or successfully concluded without
the cooperative efforts of many of NATA's members. You help us
directly, as parties to an investigation, or indirectly, through
use of engine, airframe, avionics, and other maintenance or repair
facilities for purposes of post-accident testing, teardown and
The safety of general aviation has improved
steadily over the years, with the accident rate diminishing from
a high of about 15 accidents per 100,000 flight hours in 1974
to an all-time low of 7.77 in 1990. While total yearly accidents,
for the most part, continue to show steadily declining numbers,
the accident rate since 1990, based on the FAA's most current
estimate of flight hours, has been somewhat erratic. It climbed
to 9.11 in 1994, then dropped to 8.06 for 1996.
Some of this accident rate increase, particularly
for 1995 and 1996, may be accounted for by the Safety Board's
increased number of investigations of accidents involving public
use aircraft, for which the Federal Aviation Administration (FAA)
does not include estimated flight hours. Another is the increased
numbers of accidents involving experimental airplanes. More importantly,
however, 1996 was general aviation's safest year in recent history
in terms of the fatal accident rate (1.51) and the number of lives
lost (631), which were the lowest they have been in the past 15
However, we should all be aware that accident
rates based on preliminary flight hour estimates, which are published
for the most recent years, are sometimes misleading and subject
to change. The Safety Board is particularly concerned with large
changes in estimated flight hours and is working to make sure
that general aviation accident rates published by the Board are
as accurate as possible.
First, I have instructed the Safety Board's
staff to coordinate with FAA to get a better insight into the
way it estimates flight hours and to recommend any improvements.
Any suggestions you have are most welcome.
Second, I have asked our staff to scrutinize
FAA's flight hour estimates and accident rates. If the computed
rates deviate significantly from expectations based on recent-year
trends, the staff will discuss them with the FAA and industry
representatives, before publication, in an attempt to explain
the deviation. If no credible explanation can be found, our staff
will bring the issue to the attention of the Board for resolution.
The safety record of scheduled Part 135 commuter
operations has also shown dramatic improvement over the years.
The accident rate, for example, has decreased form 0.960 per 100,000
hours in 1991 to 0.445 in 1996. Even more importantly, while there
were 8 fatal commuter accidents with 99 fatalities in 1991, they
have also steadily decreased. Only one fatal accident occurred
last year. That's one fatal accident based on more than 3 million
departures and almost 2 ½ million hours of flight resulting
in the lowest fatal accident rate in 15 years. Sure, statistics
can, and often do change dramatically, but a reduced commuter
accident trend has been clear over the years. You have had a large
part in this improved safety and should rightly be proud of your
However, statistics never tell the whole story,
certainly not the human side of the story. Just when we begin
to believe that we've reached some sort of safety plateau, we
confront a stark, tragic reality like the accident at Quincy,
Last November 19, a United Express Beech 1900C
operating as a scheduled passenger flight under Part 135, collided
with a King Air A90 at the Quincy Municipal Airport. The airport,
which has 3 runways, does not have a control tower but utilizes
UNICOM for pilots to make position and advisory reports. The Beech
1900 was completing its landing roll on runway 13, and the King
Air was in its takeoff roll on runway 4 when the collision occurred
at the intersection of the runways.
Both airplanes were destroyed by the impact
and fire. But evidence revealed that some occupants of the Beech
1900 survived the impact and moved to the forward air stair door.
The airport has no airport rescue and fire firefighting. People
at the airport who attempted to open the air stair door were unsuccessful.
The 10 passengers and 2 crewmembers aboard
the Beech 1900 and the 2 crewmembers aboard the King Air died.
Our ongoing investigation has not yet determined
why attempts to open the exit door were ineffective. But the Board
concluded that the externally mounted instructions that currently
exist for opening the exit door on the Beech 1900 from the outside-PUSH
BUTTON AND TURN HANDLE TO OPEN-are not conspicuous, easily understood,
or complete. This deficiency needed to be addressed immediately.
So, on January 3 the NTSB urged the FAA to issue an airworthiness
directive to all Beech 1900 operators to (1) conspicuously identify
the external air stair exit door button with highly visible markings,
(2) indicate that the button must be depressed while the handle
is rotated, and (3) include an arrow to show the direction that
the handle must be moved to open the door.
Less than a week after we issued that recommendation,
our investigators launched on another deadly commuter accident,
and it soon became clear, from an investigative point of view,
that this accident was going to be a tough one.
On January 9, Comair flight 3272, a scheduled
commuter flight from Cincinnati to Detroit, crashed near Monroe,
Michigan, killing the 3 crew members and all 26 passengers aboard.
The airplane, an Embraer-120, was being operated under instrument
meteorological conditions and was on approach to Detroit runway
3R at the time of the accident.
There were reports of light to moderate rime
ice in the area and visibility at the Detroit airport was about
¾ mile in light snow and mist.
This accident has proven to be very complex
and nothing short of a complete and intensive technical investigation
is going to yield a logical unfolding of the circumstances and
cause. We continue to investigate various areas including aircraft
systems, operating procedures, aircraft performance, autopilot
performance, and airframe icing. However, with respect to the
propellers, I can tell you that our investigation has disclosed
no similarity between this accident and the accident involving
the in-flight loss of a propeller blade on an Embraer-120 that
occurred at Carrollton, Georgia in 1995.
In contrast to the commuter air carriers, there
were 27 fatal accidents in 1996 involving on-demand air taxi operations
resulting in 59 fatalities and the highest fatal accident rate
in the past 15 years. Historically, the accident record for on-demand
air taxis has been somewhat better than for general aviation as
a whole -- the segment of aviation it is often allied and identified
with -- and I think we need to recognize that fact. The accident
rate for 1996, for example, was 4.57. However, from the commercial
air carrier perspective, safety improvements for air taxis have
been less dramatic than for the commuters and, perhaps due to
the nature of these operations, more difficult to achieve because
of equipment and operating limitations.
One such operating limitation is the current
Part 135 regulation prohibiting IFR operations in passenger-carrying
single-engine aircraft. The practical results of this regulation,
however unintentional, may not be to improve safety, but may actually
contribute to or result in unnecessary or unintentional occurrences
of VFR flight into marginal weather. This accident profile is
the most significant cause of fatal accidents in Alaska and a
serious problem for single-engine aircraft nationally.
The Safety Board has been concerned with this
problem for some time but believes that it may be resolved in
the near future, thanks in part to the participation and leadership
of the NATA on an aviation rulemaking advisory committee.
Last December the FAA issued a Notice of Proposed
Rulemaking primarily as a result of recommendations issued by
the Safety Board following a special study of aviation safety
in Alaska. The Safety Board evaluated the adequacy of the instrument
flight rules system and determined that enhancements were needed
to reduce the reliance of Alaska's commuter airline and air taxi
operations on visual flight rules.
In this study, the Safety Board recognized
that a regulatory change by the FAA approving commercial, passenger-carrying
IFR operations using single-engine airplanes could improve aviation
safety in Alaska by reducing the volume of VFR flights in marginal
weather and instrument meteorological conditions. The Board cited
the very low rates of in-flight engine failure experienced by
several models of single-engine airplanes powered by turbine engines.
These results indicated that approval of commercial, passenger-carrying
IFR operations using these airplanes appeared to offer a favorable
reduction in exposure to VFR flight into instrument meteorological
conditions in exchange for a very small risk of engine failure
in instrument meteorological conditions. It suggested that the
FAA should move forward with approval for these operations.
Further, the Safety Board recognized that because
most commuter airline and air taxi operations in Alaska will continue
to utilize single-engine airplanes powered by a reciprocating
engine, the FAA's approval of commercial, passenger-carrying IFR
operations with these airplanes also might provide a net improvement
in safety. In its recommendation the Safety Board requested that
the FAA evaluate changes and determine whether they would have
a positive effect on safety.
The FAA completed this evaluation. The Board
concurs with the FAA's conclusion that a positive effect on safety
would be obtained by approving commercial, passenger-carrying
IFR operations in single-engine airplanes powered by both turbine
and reciprocating engines, subject to additional equipment and
operating limitations. Those limitations include engine wear and
trend monitoring, and a redundant supply of electrical energy.
The Safety Board urges the FAA to issue a final rule as soon as
The Board has had a long-standing interest
in commuter airline safety and has issued numerous safety recommendations.
The recommendations followed the Board's 1972 study of air taxi
safety, its 1980 study of commuter airline safety, and investigations
of accidents involving commuter airline operations. These recommendations
and other initiatives have resulted in an improved safety record
for scheduled Part 135 airlines. The accident rate per 100,000
departures in 1993 was one-fourth the accident rate observed in
However, despite efforts to bring about safety
improvements, accident rates for the commuter airlines continued
to be higher than the rates for domestic part 121 airlines. The
higher accident rate, the differences in regulatory standards
between Parts 135 and 121, and the Safety Board's findings resulting
from investigation of a spate of 14 fatal accidents in the 26-month
period from December 1991 to January 1994 sparked renewed interest
by the Board. These accidents involving scheduled commuter flights
and commuter training flights highlighted the need for additional
safety improvements. In 1994 the Safety Board conducted a special,
updated study of commuter safety.
Several of the accidents involved issues addressed
previously by the Safety Board -- pilot situational awareness,
pilot experience and training, crew pairing, company oversight,
and FAA oversight.
Seventeen safety recommendations were issued
as a result of the commuter study, to the FAA, the U.S. Department
of Transportation, U.S. domestic air carriers, and the Regional
Airline Association concerning among other things:
Most important, we urged the FAA to eliminate
the regulatory differences between the safety standards for commuter
and major airlines.
The FAA responded and the final commuter rule
became effective on December 20, 1995. It required that all airplanes
with 10 or more passenger seats and all turbojets operated in
scheduled passenger service operate under and comply with all
FAR Part 121 operational requirements. These included dispatch
requirements and certificated dispatchers, new flight and duty
time rules, manuals and procedures for both flight and ground
personnel, cabin safety and flight attendant requirements for
20 to 30-seat airplanes, maintenance duty limits, and new training
With the 15-month, March 1997 recertification
deadline at hand for operators of 10 to 30-seat aircraft , those
of you who have been affected already know the rest of the story
concerning the commuter rule. I thank you for the tremendous effort
you have put forth in connection with this recertification effort.
I also appreciate the considerable cost required to comply with
the new rules.
But I also believe that the cost of these changes
over the next 15 years, which have been estimated as 62 cents
per passenger in 10 to 19-seat aircraft, and 30 cents per passenger
for 20 to 30-seat aircraft, are reasonable. Sooner rather than
later this will result in a high level of public confidence and
increased growth and profits in the vital regional air carrier
Moreover, the economic impact of the commuter
rule on maintenance revenue may be significant. As NATA's vice-president
Andy Cebula indicated last year, FAA regulatory initiatives, such
as the commuter rule, including cockpit voice recorder and flight
data recorder requirements, are opportunities for the maintenance
While improved accident statistics are comforting,
no one has ever been able to completely rationalize the occurrence
of even a single accident, particularly family members of the
accident victims-something you and I never forget. Technology
has clearly been one of the principle agents responsible for improved
safety, but the potential for continued improvements down the
road may be diminishing. We need to evaluate and challenge ourselves
to find new and innovative, perhaps yet untapped, ways to continue
our historical accident reduction trend.
Another topic of increasing interest to the
Safety Board is corporate culture and transportation safety --
or how the organizational management philosophies and practices
of government, industry, and academia directly affect the day-to-day
operations of our nation's transportation system.
Over the past few years, we have begun to probe
what role corporate culture plays in the cause of the accidents.
Some of the safety issues examined in connection
with these accidents involving fundamental human error, as well
as the direct or indirect influence of corporate policy and communications,
The Safety Board issued safety recommendations
concerning these issues to the FAA.
Just as we know that cockpit resource management
(CRM) is an important parameter in the safety equation, so too
is maintenance resource management, in our efforts to improve
maintenance communication, teamwork, and safety. The human factors
elements of both concepts are essentially the same: situational
awareness, error chain detection and analysis, communication skills,
team concepts and synergy, decision-making, and stress management.
I was particularly impressed with an article
concerning this subject in the October 1996 issue of Aviation
Maintenance entitled "Human Factors Training for Maintenance
Personnel". While all of us are aware that human error is
cited in a majority of accident occurrences, the article further
highlighted the importance of maintenance resource management,
citing estimates indicating that the world's airlines lose around
$2 billion a year just from damage to aircraft and equipment on
airport ramps -- more than twice as much as they lose due to flight-related
Of course, hindsight is 20/20, but we clearly
recognize that individual human errors do not occur in a vacuum
If we can determine how organizational culture influences safety,
we can begin to focus on prevention.
To bring this issue to the forefront, the Safety
Board will hold a symposium on this subject on April 24 and 25
near Washington, DC. We have gathered a group of experts from
academia and industry who are internationally recognized for their
work in this area, and have asked them to talk about what works,
what doesn't, and what we can do about it. We invite members of
NATA to attend and share the benefit of their expertise with us.
Thank you for allowing me to share my incites
about how NATA does now and can in the future play a major role
in the safety of our aviation system. I look forward to working
with you in the near future.