Remarks of Chairman Jim Hall
National Transportation Safety Board
at PROMIT 97 International Expo and Congress
Miami Beach, Florida, April 15, 1997
Thank you for that warm introduction.
It is fitting that I come before an organization
dedicated to sharing solutions for preventing and mitigating the
devastating loss of life and property caused by disasters, because
the National Transportation Safety Board has just celebrated 30
years of doing just that. In those three decades, we've investigated
more than 100,000 aviation accidents and tens of thousands of
accidents in the surface modes of railroad, highway, marine and
Our investigations are aimed at preventing
future accidents and mitigating the effects of those accidents
that still occur by trying to make them more survivable. We do
this by encouraging thorough and professional planning; planning
in original vehicle design, in proper procedures, in training
and in emergency response.
Eighty five years ago today, man's belief that good intentions were more important than mundane planning bore its terrible and inevitable result. The loss of the RMS TITANIC showed that failing to be prepared for any predictable eventuality can one day lead to tragedy.
All of these factors combined to bring about
one of the most shocking tragedies of the century. But one more
factor ensured that the TITANIC disaster would forever be remembered
for shortsighted planning. Although it took the ship almost 3
hours to sink, more than 1,500 persons perished in the freezing
waters, most because there weren't enough lifeboats for them.
Although inconceivable today, such lack of
foresight can still be seen in the failure of regulators to benefit
from lessons learned through accidents or even because of close
calls, the failure of companies to promote a corporate culture
of safety, and the failures of individuals to make sure they are
well rested and otherwise fit for duty. These are some of the
problems we see in every accident we investigate.
As all of you know, transportation is one of
the largest and most dynamic segments of our economy. According
to the U.S. Department of Transportation, it accounts for about
11 percent of our annual gross domestic product - that's about
$700 billion. All of us 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.
Most of you know the National Transportation Safety Board because
of our high-profile aviation accident work - especially the ValuJet
and TWA flight 800 accidents last year - but the Board also investigates
highway, rail, pipeline and marine accidents. The NTSB was established
as an independent agency 30 years ago by Congress to determine
the "probable causes" of transportation accidents and
issue recommendations to prevent future accidents.
And despite the inevitable scare stories that
you read after a major accident, we actually have an extremely
safe transportation system. Just a few years ago, the major airlines
went an incredible 27 months without a single passenger fatality;
that was 1 billion consecutive passengers carried safely to their
destinations. Depending on the year, the major airlines suffer
one fatal accident for every 2 to 5 million flights.
And, with as many highway crashes as we have,
the accident rate continues to decline. In 1995, the highway fatality
rate reached 1.70 per 100 million vehicle miles traveled, a 65
percent decrease since 1970.
This safety record is due in no small part
to the efforts of the men and women of the NTSB, and the recommendations
issued after every major accident to prevent future accidents.
That is why I noted at the beginning how appropriate it is to
be here; we have mitigated the effects of accidents in all modes
of transportation. Let me give you a short list of aviation improvements
you're probably familiar with that came out of NTSB recommendations:
And in the surface modes:
All this has been accomplished by a 350-person
agency that has no regulatory or enforcement powers. Yet, despite
this lack of direct regulatory authority, I'm proud of the fact
that more than 80 percent of our safety recommendations have been
adopted by government regulatory agencies. Although we oversee
the safety programs of billion dollar corporations and federal
agencies having tens of thousands of employees, to put our relative
sizes into perspective, the Safety Board's entire yearly budget
could fund the U.S. Department of Transportation for 9 hours of
a single 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 of the nightly news. I may be
prejudiced, but I think the 15 cents a year each citizen pays
to fund us represents the best bargain in government.
It is truly a good feeling to know that what
we do every day helps to save lives. The frustrations we encounter
are when lessons learned from accidents are either forgotten or
ignored, allowing history to repeat itself. Unfortunately, that
might be our ultimate finding in a tragedy very close to home
here, the crash last year of ValuJet flight 592 into the Everglades.
You are by now familiar with the circumstances
of that accident. A fire broke out in the cargo hold shortly before
or after takeoff. The plane crashed while attempting to return
to Miami. The 110 fatalities represented a tragedy felt all over
the country, but most keenly here. And many of us at the Safety
Board were reminded of a similar circumstance, one that had a
much happier ending, but nevertheless foreshadowed what occurred
in the Everglades.
On February 3, 1988, American Airlines flight
132, a DC-9, departed Dallas/Fort Worth International Airport
for Nashville with a midcargo compartment loaded with, among other
things, a 104-pound fiber drum of undeclared and improperly packaged
During the flight, a flight attendant and a
"deadheading" first officer notified the pilots of smoke
in the passenger cabin. The cabin floor above the cargo compartment
was hot and soft, and the flight attendants had to move passengers
from the affected area. Fortunately, the aircraft landed and a
successful evacuation was conducted.
The airworthiness of the airplane was threatened
by the fire. Excessive temperatures reached critical flight and
engine control cables, floor beams and the passenger cabin floor.
We believe that the cargo compartment did not meet the intent
of the regulations designed to contain such a fire.
The passengers and crew of this particular
aircraft were fortunate that day. While no one was seriously injured,
the potential for a catastrophic accident was present. And even
this incident wasn't the first of its kind. Less than 2 years
earlier, an undeclared shipment of 35 percent hydrogen peroxide
solution was shipped in drums with no outside markings to warn
about the presence of hazardous materials. The shipment had travelled
from Florida to Seattle on its way to the Philippines when cargo
handlers found several packages had leaked. This was one of more
than 2,000 hazardous materials incident reports involving air
transportation filed with the DOT in the 17 years leading up to
the American Airlines occurrence in 1988.
Despite Safety Board recommendations to the
FAA to require fire detection systems, and fire extinguishing
systems, and better fire blocking materials in cargo compartments,
the sad fact is that the crew of ValuJet flight 592 had no more
equipment available to warn them of a fire or to fight it than
did the crew of that American Airlines flight 8 years earlier.
On May 31, 1996, the Safety Board issued urgent
safety recommendations to the FAA to evaluate airline practices,
including training, for detecting the shipment of hazardous materials,
and to the FAA and another DOT agency to prohibit the transportation
of oxidizers in cargo compartments that do not have fire or smoke
In January, Boeing and the airline industry
announced that they would voluntarily install smoke detectors
in cargo compartments that did not currently have them. Although
this is a step in the right direction, it still fails to address
the issue of fire suppression, and the announced two-year installation
timetable has not yet started to run.
The point of all this is that, as tragic as
any fatal accident is, it is doubly so when we as a society have
been granted a warning and we ignore it. It is now 9 years since
the Nashville incident, and passenger airliners are still flying
every day without a means for the flight crew to fight a cargo
fire if it erupts, and even worse, without a means for the crew
to even know that a fire has erupted. Although some airlines are
ordering airplanes with smoke detection and fire suppression systems,
no action has yet been taken that I know of to retrofit the existing
The loss of TWA flight 800 two months after
the ValuJet tragedy not only plunged the nation into mourning,
it plunged the aviation industry into a period of self-evaluation.
As you know, President Clinton formed the White House Commission
on Aviation Safety and Security shortly after the TWA accident,
and I was honored to have been asked to serve as a Commissioner.
In February, we concluded our work by issuing more than 50 recommendations
addressing security and safety issues. But these recommendations
won't be worth anything unless they are enacted as expeditiously
as practicable. The President and Vice President Gore have expressed
their commitment to getting our recommendations implemented.
The TWA investigation has been unprecedented
in its human scope and in its expense. We have been on-scene for
9 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 are
completing a three-dimensional mock-up of a major portion of the
aircraft's wreckage, the largest effort of its kind in the world.
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 retained the California Institute of Technology
to determine the explosive characteristics of the fuel that was
aboard flight 800. Explosives tests are being conducted in Great
Britain. We have had assistance from experts from all around the
world, including France, the Netherlands and Russia. 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 in the center wing fuel tank.
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
have been overlooked in the past by government and industry, alike
- the victims' families. Four times in the last two and a half
years, I have been to the scene of a non-survivable major airline
disaster. These accidents - in Pittsburgh, Pennsylvania; Roselawn,
Indiana; the Everglades and Long Island - have claimed the lives
of 540 people. Two other recent non-survivable accidents in Illinois
and Michigan have claimed another 43 lives.
Historically, while we could never forget the
human tragedy that the accidents represented, the Safety Board
has maintained a professional distance from the families of accident
victims, giving them all the factual information we have, but
leaving other responsibilities to the airlines. Basically, 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 return of victims' remains.
Whether or not this way of doing business 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, aggressive 24-hour news coverage,
and perhaps a mistrust of authority, all contribute to this very
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. Late last year, Congress gave the Safety Board the
authority to provide liaison services between these family members
and government agencies. We have now had the experience of two
accidents since the passage of that law, and are developing agreements
with public and private agencies to provide services to these
people in the weeks following the accident. We know we can't really
alleviate the grief they are going through, but we want to make
sure no government actions add to their burden.
I want to talk to you about our family assistance
responsibilities, because I think it can be helpful to many of
you in other industries. It is just a fact of life that our nation's
institutions, and that includes the public and private sectors,
have to sensitize themselves to the needs of individuals who have
suffered loss. With the heightened emotions that accompany these
tragedies, it can be difficult to avoid offending people in the
performance of your duties. Officials in San Diego might very
well have been surprised by the criticism they encountered from
the families of the deceased after releasing video tape of the
scene of the mass suicide there last month. All of us have to
decide how far we can and should go to alter our procedures in
light of the nation's heightened awareness of victims' rights.
In a way, even though our family assistance
responsibilities are new, they have not forced the Safety Board
to radically change its procedures, probably because we have always
maintained some contact with family members.
Under the new law, the role of the NTSB can
generally be described as a coordinator to integrate the resources
of the federal government and other organizations to support the
efforts of the local and state government and the airline. Family
counseling, victim identification and forensic services, communicating
with foreign governments, and translation services, are just a
few of the areas in which the federal government can help local
authorities and the airlines deal with a major aviation disaster.
Under our draft plan, which should be finalized
in a few weeks, local officials will maintain the same jurisdictional
authority they have always had, such as accident response, recovery,
security, cleanup and medical examiner operations. The Safety
Board will, of course, still lead the aviation accident investigation.
The airline continues to have a fundamental
responsibility to the victims and their families. The airline
is still primarily responsible for family notification and all
aspects of victim and family logistical support.
We believe it is imperative that all personnel
involved in providing services to assist the victims and their
families must demonstrate compassion, sympathy, technical expertise
and professionalism. Information provided by family members and
victims through discussions, interviews, counseling and other
exchanges of personal information must remain confidential and
be used only for the intended purpose.
There are many family assistance mission tasks
following a major accident, and they are similar to those that
will confront you in any industry:
You will have to decide the best way to respond
to the needs of family members. Specific tasks that have been
assumed by the Safety Board's Director of Family Assistance after
an accident are:
Our draft plan also spells out the responsibilities
of the airline and each of the federal agencies that would mobilize
after a major aviation disaster: the Department of Health and
Human Services, the Department of Defense, the Department of State,
FEMA, and the Department of Justice.
The American Red Cross has been designated
as the organization responsible for providing mental health support.
Through common sense and good organization,
this plan can work. We have had two accidents since passage of
the law that have caused us to institute our plans - the November
runway collision in Quincy, Illinois that killed 14 people, and
the January commuter crash in Monroe, Michigan that killed 29.
The victim identification went relatively quickly in both cases,
and we have received compliments from family members for how the
painful post-accident events were handled.
Improvements in how victims and their families
are treated after accidents since passage of the Family Assistance
Act can be demonstrated:
I urge all of you to consider in your post-disaster
plans how victims and their families will be accommodated. Whether
one's loved one dies in an airplane crash, a hotel fire or a dam
break, many of the lessons we are applying can be instructive
to you. Please let us know if we can help you.
Of course, our most important accomplishment
would be making sure the accident doesn't happen in the first
place. That will be possible only with the commitment of the governmental
regulatory agencies, the operating companies, the vehicle and
component manufacturers, the appropriate labor unions, and the
individuals into whose hands we entrust our lives every day.
When I spoke about the TITANIC at the outset,
I said that even today there exist corporate cultures that, far
from promoting safety, actually invite disaster. Is it that far
from an ocean line's management not providing enough lifeboats
to an airline that doesn't oversee its own maintenance? Is there
much of a difference between not providing watchmen binoculars
to not training tow boat operators in the use of the radar that
sits before them?
To that end, I have directed my agency to convene
a symposium in Washington next week on the effects of corporate
culture on safety. I hope some of you can join us in exploring
this fascinating and emerging topic.
Thank you for allowing me to be a part of this
valuable conference. I hope we can do this again.