Remarks by Jim Hall, Chairman
National Transportation Safety Board
before the International Civil Aviation Organization
Montreal, Canada, June 13, 1997
Good afternoon President Kotaite, Secretary-General
Rochat, and other distinguished persons from the ICAO Council,
Air Navigation Commission, and Secretariat. It is a pleasure to
be with you today to discuss current safety issues and activities
at the National Transportation Safety Board.
This is my first visit to ICAO. As some of
you know, I have attempted to visit ICAO on several occasions.
Unfortunately, our significant accident investigation workload
in the past 3 years has caused me to cancel previous trips. In
fact, on October 31, 1994, soon after I became Chairman of the
NTSB, I was attending the ICAO 50th Anniversary meeting
in Chicago, when I was called away to the scene of the tragic
American Eagle ATR-72 accident near Roselawn, Indiana. Since that
time, our agency has been intensely involved in numerous catastrophic
accidents and other significant serious incidents.
For those of you who don't know, the NTSB,
created in 1967 as an independent agency within the DOT, is charged
by Congress to determine the probable causes of transportation
accidents and to formulate safety recommendations to improve transportation
safety. Because of some administrative links to the DOT and concerns
for full independence, in 1974, the Independent Safety Board Act
was passed to totally cut the NTSB's ties to the DOT. The Board
has no organizational connection to the FAA.
The FAA is responsible for the oversight and
regulation of our aviation system and the FAA participates in
our investigations in order to provide technical expertise and
to determine in a timely manner whether any of its areas of responsibility
were deficient and require remedial action. Other DOT agencies
have similar regulatory responsibilities for surface transportation.
The independence of the NTSB and its clear
mandate to conduct in-depth objective investigations, 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. As a result of this independent role, it is
not unusual for the NTSB to address safety issues that are controversial
and critical of government or industry standards or operations.
The NTSB is also the agency charged with fulfilling
the United States' obligations under Annex 13 to the Chicago Convention.
The NTSB provides the U.S. Accredited Representatives, who lead
our teams to support investigations conducted by overseas investigation
authorities. Of course, the FAA is always part of our team.
I need to point out that Mr. Schleede, who
is with me here today, continues to be the primary point of contact
at the NTSB for international civil aviation matters. Please feel
free to contact him at any time.
The NTSB is composed of five Members nominated
for five-year terms by the President and confirmed by the Senate.
Two of the Members are designated by the President to serve as
Chairman and Vice-Chairman for two-year terms. Our headquarters
are in Washington, D.C., with 6 Regional offices located in Chicago,
Dallas-Ft. Worth, Los Angeles, Miami, Seattle, and Parsippany,
NJ. Field offices are also located in Atlanta, Anchorage, and
We have about 360 employees of which roughly
one-half are dedicated to aviation investigations. Our budget
for 1997 was about $48 million, not much different from ICAO's
However, we will have spent more than $25 million on the TWA flight 800 investigation before the investigation is completed. Much of those funds will have to come from a supplemental appropriation from Congress.
Now let me talk about current events.
Many of you may have seen recent media reports
of our May 20th Board meeting at which we updated our
Most Wanted safety recommendation list.
The list, instituted seven years ago, focuses
attention on NTSB recommendations that have the most potential
to save lives. Recommendations elevated to the list receive more
intensive follow up activity to persuade government agencies and
industry to act on them quickly.
The NTSB added to the Most Wanted list safety
recommendations issued in December 1996, that resulted from the
TWA flight 800 investigation. In general, those recommendations
urge the FAA to adopt measures to reduce the potential for explosive
fuel/air vapor in aircraft fuel tanks. We acknowledge that these
recommendations may have wide-sweeping implications; however,
the evidence gathered to date in that investigation, as well as
other cases, suggests that extraordinary, and potentially costly,
actions need to be taken in order to eliminate the potential for
another explosion of a fuel tank in flight.
Although the TWA flight 800 investigation continues,
we have determined that the center wing fuel tank exploded and
that explosion caused the breakup of the airplane. We have not
determined the cause of the ignition of the tank; however, we
have recovered about 95% of the wreckage and we have reconstructed
the center section of the fuselage. There is no evidence of a
bomb or missile in the wreckage. We are continuing extensive work
to determine the ignition source.
The TWA flight 800 investigation has been the
most complex and expensive in terms of dollars and human resources
of any investigation in the history of the NTSB. It has also involved
extensive international cooperation. We have had investigators
from the United Kingdom, France, Australia, New Zealand, Russia,
Canada, and Singapore assisting us with the investigation. They
have not been just observers; they have all provided considerable
technical support to our investigation.
We also added to the Most Wanted list safety
recommendations that resulted from the May 11, 1996, Valujet DC-9
accident in the Everglades. Those recommendations urge the FAA
to require fire/smoke detectors and extinguishers in cargo compartments
of passenger-carrying aircraft. The NTSB first urged the FAA to
require such improvements following a 1988 passenger airplane
in-flight cargo fire. No actions were taken and the Valujet accident
reinforced the need for these changes. It appears that the U.S.
airline industry and the FAA are now moving forward to implement
these necessary changes.
Lastly, we added to our Most Wanted list recommendations
regarding improvement of certification standards and testing of
aircraft ice protection systems, especially for turbopropeller
aircraft. These recommendations also urge the development of a
new generation of anti-icing and deicing systems. Similar recommendations
were issued in 1981, following a fatal accident and a special
study of airframe icing by the NTSB. No substantive actions were
taken since 1981; however, the FAA is now moving forward on this
During the May 20th Board Meeting,
the NTSB also reiterated its urgent call for a retrofit of all
older Boeing 737 aircraft with updated flight data recorders (FDR).
This recommendation was added to the list in
1996, when the NTSB said that the FAA was not moving quickly to
retrofit these airplanes. The timetable for this retrofit suggests
that this action will not be completed until at least the year
2000-five years later than our recommended deadline.
As many of you know, the lack of adequate FDRs
in two Boeing 737 accidents has hampered our investigations into
their causes. Although several safety recommendations have been
issued and numerous corrective actions have been taken relative
to the safety of the Boeing 737, the lack of definitive FDR data
has precluded the development of timely accident prevention measures.
I am aware that ICAO has been very active in
the area of improving standards for FDRs and cockpit voice recorders,
and our staff are working with ICAO to continue to improve those
standards. I can't over-emphasize the need for state-of-the-art
FDRs with expanded parameters on transport category aircraft for
the purpose of preventing future accidents. I applaud ICAO its
efforts to upgrade the standards for recorders.
Three issues of note that remain on our Most
Wanted list from previous years pertain to air traffic control
issues, particularly regarding operations in the terminal areas
where congestion is significant and increasing.
One item addresses the need for automated collision
avoidance systems for airport terminal areas using the Mode C
logic from aircraft transponders. The technology has existed for
many years to implement this recommendation; however, the dollars
have not been made available to install the systems in a timely
Another item addresses the need for safe separation
between large aircraft and following small aircraft to avoid wake
vortex encounters. As aircraft are compressed in the terminal
area, the possibility of a serious wake vortex encounter is increased.
The third air traffic issue pertains to the
need for safer control of aircraft on the ground. As with the
other two air traffic issues, airport congestion and the potential
for a catastrophic collision dictate the need for remedial actions
to reduce the hazards. Although there are measures being taken
to design and install automated ground collision (runway incursion)
equipment to prevent such accidents, the air traffic system today
continues to rely essentially on the performance of pilots and
controllers, who are subject to human factors failures.
Now, I would like to mention a safety issue
that was identified during the investigation of the American Airlines
Boeing 757 accident near Cali, Colombia, on December, 20, 1995.
This issue involves ICAO and we need your help.
The Aeronautica Civil of the Republic of Colombia
and NTSB issued several safety recommendations as a result of
that tragic accident. One of the recommendations issued by the
NTSB urged the FAA to develop, with air traffic authorities of
Member States of ICAO, "a program to enhance controllers'
fluency in common English language phrases and interaction skills
sufficient to assist pilots in obtaining situational awareness
about critical features of the airspace, particularly in non-radar
One of the recommendations issued by Colombia
asked ICAO to urge Member States to "encourage its pilots
and air traffic controllers to strictly adhere to ICAO standards,
phraseology, and terminology in all radio telecommunications between
pilots and controllers."
Although the Colombian government accident
report did not cite controller-to-pilot English language fluency
as a factor or cause of the American Airlines accident, the NTSB
determined that conversations between the pilots and air traffic
controller served to confuse rather than enlighten the flightcrew
to its loss of situational awareness. No one can dispute that
the loss of situational awareness was involved in the multiple
causes of this tragic accident. The air traffic controllers are
an important part of the overall equation for accident prevention.
We need to ensure that they have the tools and the ability to
perform their tasks effectively.
The NTSB is aware that there are means to evaluate
and improve the English language fluency of pilots and controllers
to ensure clear understanding of communications and situational
awareness. We believe that programs should be developed to enhance
the ability of air traffic controllers throughout the world to
play a more effective role in enhancing situational awareness
for both pilots and controllers. I ask ICAO and the Member States
to work with us to address this important safety issue for the
benefit of all international airline operations.
I sincerely believe that clear and open communications
are an essential part of our mutual goal for accident prevention.
Please feel free to communicate with me or any of the NTSB staff.
Along those lines, because of the events of
1996, the NTSB decided to create a 24-hour Communications Center.
The Communications Center was opened in part because of the NTSB's
new responsibilities to act as the coordinator of federal services
to the families of victims of transportation accidents. In October
1996, President Clinton signed legislation that gave the NTSB
this responsibility for aviation disasters. In general, under
this new authority, the NTSB will provide family members with
speedy and accurate information about the accident and recovery
efforts, supplement local efforts in the recovery and identification
of victims, and other assistance as deemed necessary.
Our procedures to meet this new responsibility
have been developed in cooperation with multiple federal agencies
and the airline industry. I have provided the U.S. Mission a full
set of materials relevant to this program, if you wish to learn
more about it. I need to point out that this new function for
the NTSB will in no way interfere with our primary mission of
accident investigation and prevention.
Again, thank you for the invitation to meet
with you today. I would like to formally invite any of you to
visit our offices in Washington, D.C., or any of our Regional
Offices. At this point, Mr. Schleede and I will be happy to answer