Testimony of Jim Hall, Chairman
National Transportation Safety Board
before the Committee on Appropriations,
Subcommittee on Transportation and Related Agencies
United States Senate
Regarding Aviation Safety and Security, April 16, 1997
Good morning Mr. Chairman and Members of the
Committee. It is a pleasure to be here today to represent the
National Transportation Safety Board.
It goes without saying that the past year was
dominated by catastrophic transportation accidents that have required
extraordinary efforts by the Safety Board and have strained the
agency's resources more than any time in its history. It is well
established that the TWA flight 800 Boeing 747 investigation has
been the most costly and complex in the Safety Board's history,
in terms of dollars spent for wreckage search and recovery, and
the level of investigative staff work.
Moreover, as a multi-modal agency, the Safety
Board has an important responsibility for the investigation of
surface transportation accidents. Our workload in that area has
also been unprecedented in the past year. Many of our laboratory
specialists support our multi-modal mission. For example, the
metallurgists working on TWA flight 800 are also working on surface
accidents. Also, one of our key engineers responsible for surface
transportation vehicle performance has been assigned full time
for several weeks to supervise the 3-dimensional mockup of the
TWA flight 800 wreckage.
Mr. Chairman, the TWA investigation provides
dramatic testimony to the wisdom of Congress 30 years ago when
it established a multi-discipline, independent accident investigation
agency, initially affiliated with the Department of Transportation,
to promote transportation safety by conducting independent accident
investigations and by formulating safety improvement recommendations.
However, because the Congress recognized the need to make it totally
independent from the Department of Transportation, the Independent
Safety Board Act of 1974 was passed.
The independence of the Safety Board and its
clear mandate to conduct in depth objective investigation, draw
conclusions from its findings, and to make recommendations to
improve safety, without bias or undue influence from industry
or other government agencies is essential to maintaining the safety
of the American traveling public. It is not unusual for the Safety
Board to address safety issues that are controversial or that
may be critical of government or industry standards or operations.
The Safety Board is charged by Congress with
investigating or causing to be investigated all civil aviation
accidents in the U.S. In 1994, the Safety Board's authority was
expanded to investigate government-operated aircraft as well,
except those operating in military or intelligence missions. In
addition, the Safety Board provides the U.S. Accredited Representatives
to overseas investigations involving U.S.-registered, -certified,
or -operated aircraft, and aircraft whose airframe, engines, and
major components were manufactured in the U.S.
Since the Safety Board began investigating
accidents, it has made more than 10,000 safety recommendations
to prevent accidents, save lives, and reduce injuries. While every
recommendation from the Board is developed to help improve safety
and prevent accidents, some have a greater potential to save lives
As you know, Mr. Chairman, it is the responsibility
of the NTSB to formulate recommendations to those parties that
can affect improvements in transportation safety, but it is the
responsibility of agencies like the Federal Aviation Administration
(FAA) to determine how best to implement those changes. In the
last 5 years, the FAA has adopted 84 percent of our recommendations.
We harbor no illusions that the FAA should
adopt ALL of our recommendations, nor do we seek to have our recommendations
mandatory. Frankly, Mr. Chairman, if the FAA adopted all of our
recommendations, then we would not be asking for enough. There
are bound to be some areas where the regulatory agency honestly
believes that a recommended change is not cost-effective - remember,
the FAA must conduct cost-benefit analyses of any proposed changes
- or that a better alternative can be found. This is not to say
that we don't strongly disagree with some of their actions, or
inaction, and that is what the Most Wanted list
is designed to at least partially address.
In order to identify those recommendations
with the greatest potential to improve transportation safety that
have not yet been acted on, the Safety Board in 1990 adopted a
Most Wanted program. Recommendations placed on the program
list will receive more intensive follow-up activity in order to
encourage government agencies and industry to act on the recommendations
as quickly as possible.
To be considered for the Most Wanted
list, a recommendation must affect transportation safety on a
national level, concern a safety issue of high visibility, or
be of great interest to the public. Also considered is the previous
loss of life or property as well as the potential for future losses,
and the extent of the exposure of the public to risk by the safety
problem. Previous action taken by the recipient is also taken
Currently on the Safety Board's Most Wanted list are five aviation related issues that include:
Last year the Congress acted on the issue of
pilot record sharing and the Safety Board will consider removing
this issue from the Most Wanted list. Unfortunately the
remaining four issues will remain. I would like to address two
of these issues in more detail.
Flight Data Recorders
Although not a new issue on the Most Wanted list, I would like to discuss the importance of enhanced flight data recorders (FDR). Almost two years have passed since the Safety Board issued its recommendations for enhanced FDRs, and the FAA has failed to enact any rulemaking on this important safety issue.
On July 16, 1996, the FAA issued the NPRM on
enhanced FDRs, with a 30-day comment period. NTSB comments on
the rule were generally favorable. However, the NPRM would not
require FDR retrofits to begin for at least another two years.
Further, no action was taken on the Board's urgent recommendation
to expedite the retrofit of Boeing 737 airplanes.
We are aware that a rulemaking package was
forwarded to the Office of the Secretary of Transportation on
February 7, 1997. However, the DOT and Office of Management and
Budget review process has been lengthy. How much longer must we
wait before action is taken?
We believe that expanded flight data recorders
are critical to accident and incident investigations. United Flight
585, which crashed in 1991 in Colorado Springs, Colorado, had
a 5-parameter recorder and USAir 427, which crashed in 1994, had
only 11 parameters. Vital information for investigators was simply
unavailable and that is unacceptable.
On March 25, 1997, a Gulfstream G-2 corporate airplane was cleared to land on runway 31 at LaGuardia Airport. About the time the G-2 was touching down on the runway, the tower controller advised its pilot to go-around. The G-2 was unable to execute a missed approach and it collided with an airport maintenance truck. The same tower controller had cleared a vehicle operator onto runway 31 about 40 minutes before the G-2 was cleared to land. The truck driver, his assistant, and the two G-2 pilots were not injured although the airplane and vehicle were substantially damaged.
Mr. Chairman, the circumstances of this accident
could very easily have involved a commercial air carrier resulting
in multiple fatalities. Although our investigation continues,
we have learned that the controller, who cleared the maintenance
truck and the incoming airplane, simply forgot about the truck
he had approved out onto the runway.
Forgetting is a human factor routinely found
in operational errors by air traffic controllers that cause incidents
virtually every day in our nation's air traffic system. This type
of human error has also been identified in past accidents. For
example, on February 1, 1991, a USAir Boeing 737 collided with
a Skywest Metroliner at the Los Angeles International Airport,
killing 34 passengers and crew. This accident occurred, in part,
because the air traffic controller cleared the USAir airplane
to land about 3 minutes after she had cleared the Skywest airplane
onto the same runway to hold for departure. She forgot the Skywest
And I regret to say that operational errors
and runway incursions have been increasing. Operational errors
in the terminal environment have increased 14 percent from 1995
to 1996. Similarly, runway incursions have increased 19 percent
from 1995 to 1996. These trends raise concerns about the progress
being made by the FAA in addressing the risks associated with
the potential for ground collisions.
Following several accidents and Safety Board
recommendations, in 1991, the FAA established a Runway Incursion
Action Plan to reduce surface errors at the nation's more than
570 airports. This plan was revised in 1995. The action plan focuses
on reducing human error, improving ground communications, and
developing and implementing technologies to increase airport surface
guidance and surveillance, as well as improved ground traffic
management procedures and equipment. One of the more important
components of the FAA's efforts is the Airport Movement Area Safety
AMASS, which is a system integrated into the
new ASDE-3 ground radar system, automatically tracks all operations,
compares each vehicle and aircraft movement, and provides visual
and audio alerts of potential conflicts. This is a real-time system
for preventing runway accidents in a dynamic airport environment.
AMASS would have provided the means to prevent accidents similar
to the ground collisions that occurred February 1, 1991, at Los
Angeles, November 22, 1994, at Bridgeton, Missouri, and March
25, 1997, at LaGuardia. Unfortunately, except for a prototype
at San Francisco International Airport that is operating with
a limited capability, AMASS installations are not yet in place.
In a February 28, 1995, safety recommendation
letter to the FAA, the Safety Board expressed its concerns about
delays in AMASS installations. In that letter we cited FAA testimony
before Congress on March 6, 1990, in which the FAA stated that
it had entered a contract for design and manufacture of AMASS
that would be fast tracked with the project operational in 1992.
In the February 28, 1995, letter, the Safety Board expressed its
concerns that "this important project [AMASS] has been effectively
paralyzed as a result of a succession of changes."
The latest information published by the FAA
on the status of AMASS is not encouraging. The prototype testing
in San Francisco has been on-going since May 1996. Under a contract
awarded in June 1996, three full-scale AMASS systems are due to
be installed in Detroit (September 1997), St. Louis (November
1997), and Atlanta (February 1998). Another 20 systems that are
currently in initial production are scheduled to be delivered
for installation between July 1998 and July 1999. There are options
for 16 more AMASS systems; however, the funding is not available
at present. We believe these are two important safety issues that
must be addressed by the FAA.
TWA Flight 800 Investigation
On July 17, 1996, TWA flight 800 tragically crashed into the Atlantic Ocean near East Moriches, New York, killing all 230 people on board. The aircraft wreckage in this accident was ten miles off the coast at a depth of 120 feet, making this investigation anything but typical.
To ensure the safety of the divers and to identify
the location of the wreckage, the area had to be thoroughly mapped
before the full scale underwater recovery effort could begin.
Heavy wreckage was not lifted from the ocean floor until early
August. By the end of October, the divers had cleared the debris
fields of all large pieces of wreckage. On November 3, scallop
trawlers were brought in to drag the ocean floor. To date, an
area of over 28 square miles has been trawled, with some areas
having been gone over in excess of 20 times. A second pass is
being made over the entire area: trawling will continue until
substantial amounts of wreckage are no longer being recovered.
Based on the condition of the wreckage from
the center forward section of the airplane and that surrounding
the center wing tank, the investigators were particularly interested
in this area and have created 3-dimensional mock-ups of this section.
Three sets of scaffolding were erected on which this section of
airplane was reassembled in order to give the investigators a
better picture of what occurred. The fuselage surrounding the
center wing tank was on one, the top and sides of the center wing
tank on another, and the floor center wing tank was on the third.
Following these initial efforts, it was decided to construct a
full scale 3-dimensional mockup of a major portion of the airplane,
including the fuselage skin. The mockup being constructed with
the assistance of contractors to the Safety Board will be about
92 feet long, the largest in the world ever constructed. That
work has been essentially completed.
It is apparent that an explosion occurred in
the center wing tank, but the origin of the explosion is not yet
known. To date, with over 90 percent of the airplane recovered,
there is no physical evidence of a bomb or missile strike.
Based on the examination of the wreckage and other evidence, on December 13, 1996, the Safety Board issued four safety recommendations to the FAA aimed at reducing the flammability of the ullage in airliner center wing tanks, with specific emphasis on the Boeing 747 center wing tank. The recommendations urged the FAA to:
The FAA responded to these recommendations
on February 18, 1997. In general, the FAA's response stated that
the recommendations propose major changes in the requirements
for fuel tank design and fuel management of transport category
airplanes. The FAA stated, the airworthiness standards of 14 CFR
Part 25 assume that fuel vapor is flammable, and the design requirements
dictate the elimination of ignition sources within the fuel tanks.
Because the FAA considered the control of flammability
characteristics of fuel vapor in airplane fuel tanks as a major
change in design concept, it elected to evaluate the safety recommendations
by means of soliciting information about the effectiveness and
practicality of implementing the recommendations. The FAA stated
that it would publish a public notice in the Federal Register
within 30 days.
The September 8, 1994, accident involving USAir
flight 427 near Pittsburgh, Pennsylvania, which killed all 132
people on board, continues to be on of our most complex investigations.
It has been one of the most far-reaching investigations in the
history of the Safety Board, with NTSB investigators and party
participants working continually over 2 years to try to understand
the very complex circumstances of this tragic event. The investigation
has involved tens of thousands of staff hours and numerous flight
tests, resulting in 20 safety recommendations.
The Safety Board is aware that Boeing is actively
engaged in a redesign of the main rudder power control unit for
the existing Boeing 737 series at an estimated cost to Boeing
of $120 million to $140 million.
In January 1997, Boeing and the FAA announced
that the primary and secondary slides of the PCU servo control
valve would be redesigned to preclude the potential for reverse
rudder operation. The FAA plans to issue an airworthiness directive
(AD) that would require the Boeing 737 fleet to be retrofitted
with the new valve within two years.
We are encouraged by Boeing's commitment to
move forward. We are concerned, however, that there may be a delay
by the Federal Aviation Administration in issuing a final rule,
or that the final rule might allow more than 2 years for operators
to complete the installation of the new servo control valve. On
February 20, 1997, the Safety Board issued three additional safety
recommendations to the FAA regarding the Boeing 737 aircraft.
Those recommendations state:
This investigation continues, and I am proud
of the dedication of the investigative team. I believe these recommendations
reflect, in part, the progress we are making. Safety Board staff
hopes to have a final report regarding this accident before the
Board for consideration this year. We will, of course, keep the
Committee advised of developments.
I want to turn now to what has become a new
responsibility for the Safety Board, assistance to family members
of victims of air disasters.
Since the dawn of commercial aviation, the
unpleasant duty of notifying next of kin after airline accidents
has fallen upon the airline involved in 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 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.
In September 1996, President Clinton issued
a directive naming the Safety Board as the coordinator of federal
services to the families of victims of transportation accidents,
and in October he signed legislation that gives us that responsibility
for aviation disasters. The Safety Board did not seek this responsibility;
in fact, I had hoped that it could be handled without federal
intervention. But the families, the President and the Congress
have entrusted us with these responsibilities and we will do the
Under this new authority the Safety Board:
The following federal agencies will cooperate
fully with the Safety Board in these efforts: the Department of
State, Defense, Justice, Health and Human Services, Transportation,
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. The first meeting of the task force is
scheduled for the end of this month.
Let me describe two recent experiences since
passage of the Family Assistance Act. On November 19, 1996, a
United Express Beech 1900C collided with a King Air at intersecting
runways in Quincy, Illinois. All 14 persons on both aircraft died
in the accident.
Although this was a relatively low-fatality
accident as major airline disasters go, it still had a significant
impact on local resources and facilities. The coroner had no medical
expertise, and no facilities or staff at his disposal. Under an
agreement with the Department of Health and Human Services, we
arranged for a mobile morgue that was fully equipped, supplied,
and staffed. This service was set up inside the airport's vacant
firehouse, and served as the mortuary.
Despite the fact that all 14 victims were badly
burned, they all were identified and returned to their families
within four days. This would not have been possible had local
resources not been augmented.
Although most families did not come to the
scene, those who did were taken to the accident site on the second
full day. The city provided us with police escorted transportation
for the family members. The families who were on scene were briefed
by Safety Board and our Investigator In-Charge. Those family members
who did not travel to Quincy were briefed by staff members by
On January 9, 1997, a Comair EMB-120, a Brasilia,
crashed on approach to Detroit, killing all 29 persons aboard.
In this instance, nearly all families came to the scene. The Michigan
State Police took care of security at the accident site, at the
morgue, and at the hotel where the family members were staying.
The identification of victims began on the
second full day following the accident, Saturday, and continued
through Wednesday. All 29 victims were identified. This was an
extremely difficult task because of the severe fragmentation of
the remains and the extreme cold temperatures in the days following
the accident (wind chills for many days after the accident were
well below zero). A team of 125 people worked in the ad hoc morgue
set up in a hangar for 20 hours a day. The mobile morgue was flown
in the morning after the accident. Personal effects were recovered
by teams of volunteers. The local Mental Health office provided
counseling for family members and for rescue personnel.
What we have seen in these two accidents has
been evident in many accidents in the past. Local jurisdictions
are not prepared for the consequences of a once-in-a-lifetime
event like a major airliner crash. This is no criticism of them.
You cannot build an infrastructure to be prepared for such a rare
event; it would deprive communities of resources needed elsewhere
for more pressing community needs.
The Monroe County crash of the Comair commuter
in January brought that county its highest death toll in a single
event in more than 150 years. Any individual airline might go
decades between fatal accidents; it is difficult for them, too,
to be completely prepared for such an event.
The Safety Board deals with many major accidents
every year. And we've been doing this for 30 years. That is why
we were placed in charge of coordinating government services to
the families, and that is why we are optimistic that once we have
agreements in place with the many government and private agencies
that can provide needed services, and once we have this program
funded, we can fulfill the obligations given us by the American
people though legislative directive.
I can say that both of the recent accidents
taught us lessons, but they also demonstrated the benefits of
our involvement; many who have participated in previous incidents
commented on how far things had come and how much better off families
were under this more-organized on-scene effort.
I would like to point out that we have structured
our family assistance program to ensure that our new responsibilities
and authorities do not interfere with or adversely affect the
well-established process of managing major investigations.
Mr. Chairman, let me now address some financial
issues that are important to the Safety Board. As you know, the
1997 enacted appropriation level for the Safety Board is $42.4
million and 370 FTES. Not included in this amount is the $6 million
1996 supplemental earmarked primarily for reimbursement to the
U.S. Navy for TWA Flight 800 recovery costs. In 1997 we requested
approval for an additional TWA 800 related supplemental of $23.2
million. This would have covered investigative expenditures through
the end of the fiscal year, as well as allowing us to start our
family assistance efforts. OMB approved $20.2 million for inclusion
in the President's Budget. I realize, Mr. Chairman, this is not
a budget hearing but I did not want to miss a chance to make our
Our emergency fund, which has been funded at
a $1 million level, is used to pay for extraordinary recovery
and investigative tasks. OMB has approved expanding the fund next
year to $2 million. The simple truth is that this fund does not
begin to cover the extraordinary costs of our investigations.
Aircraft tragedy investigative costs are usually born by both
the Federal Government and by the carrier through its insurance
underwriters. If the aircraft crashes on land, the carrier is
generally responsible for wreckage recovery and removal. If we
deem that the wreckage is vital to our investigation, we see that
the critical parts, or all of the wreckage, are removed to a secure
location for examination. In general, payments for this is made
by the insurance underwriters.
In accidents occurring over water, or where
the probable cause may be criminal in nature, the responsibilities
are not so clear. For example, in the TWA Flight 800 investigation,
I asked for the early financial participation of the carrier,
manufacturers, and engine supplier and all declined. The federal
government has in fact borne all of the extraordinary costs in
this investigation outside of the party's participation.
I would also be remiss if I did not mention
the outstanding support of the state, and local authorities and
agencies at the accident scenes. In New York, Florida, and in
Michigan, costs have been incurred on behalf of the accident that
are currently being borne by the states and localities. They are
not insignificant and I believe that a system or process needs
to be in place to address the legitimate local costs associated
with aircraft disasters.
Mr. Chairman, this concludes my testimony and
I will be happy to answer any questions.