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 Denver.

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 budget.

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 issue.

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 manner.

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 environments."

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 your questions.



Jim Hall's Speeches