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, too.

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 cause.

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 evaluation.

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 years.

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 achievement.

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, Illinois.

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 possible.

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 1980.

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 rules.

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 industry.

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 industry.

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, include:

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 accidents.

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.

Jim Hall's Speeches