Remarks of Jim Hall
Chairman, National Transportation Safety Board
at the 1997 National Conference of the U.S. Coast Guard Auxiliary
Dallas, Texas, September 4, 1997

Good morning. Commodore Tucker, senior leadership of the United States Coast Guard Auxiliary, and guests.

I would first like to thank you, Commodore, for inviting me to speak here today. You are well known and admired by us at the Safety Board because of your contributions to the National Recreational Boating Safety Coalition, as well as your efforts in Virginia in support of a variety of boating safety initiatives.

You have undoubtedly heard about the National Transportation Safety Board because of tragedies like the crashes of TWA flight 800 and ValuJet flight 592. We recently adopted our final report on ValuJet and you probably saw the news coverage on TV. But, I would like to take this opportunity to tell you about the NTSB that you don't hear about on the evening news.

The National Transportation Safety Board is an independent agency within the United States government established in 1967 to investigate major transportation accidents. This independence lends credibility to the investigation in the eyes of the public and the policy makers who must act to correct deficiencies uncovered by the investigation. Without support from the public, including the news media, the changes necessary to improve safety are often difficult if not impossible to achieve.

While major aviation accidents may get the headlines, the Safety Board also investigates major marine, highway, railroad, pipeline, and hazardous materials accidents, and even accidents related to space transportation, such as the Challenger disaster. We are neither a law enforcement nor a regulatory agency; our investigations are structured solely for the improvement of transportation safety, not for any purposes of litigation.

Other countries have realized the benefits of our system and have established their versions of NTSB-like agencies. Canada and the Netherlands are just two countries that have set up such organizations, and Mexico is contemplating a similar move.

Since its inception in the late '60s, the Safety Board has investigated more than 100,000 aviation accidents, and thousands of surface transportation accidents as the world's premier transportation accident investigation agency. Many of the Board's staff of 360 employees are on-call 24-hours a day, 365 days a year. Safety Board investigators travel throughout the U.S. and the world to investigate significant accidents. Our most important product are safety recommendations aimed at preventing future accidents. Many of these have led to concrete safety improvements.

For example, in the marine mode, Safety Board recommendations led to new regulations that for the first time required commercial fishing vessels to carry specific life-saving devices. These improvements are having a dramatic impact on the safety of this industry. In Alaska, there was a 53 percent decline in lives lost in just one year.

Other improvements include anti-collision devices on aircraft, safer school bus construction standards and greater protection for tank cars that carry hazardous materials.

We have found that the most effective and efficient way to accomplish independent accident investigation is to have one agency responsible for investigations in all modes of transportation. This allows for the sharing of safety information, accident investigation techniques, and the more efficient use of technical experts. For example, specialists in certain fields such as human performance, meteorology, survival factors, and the release of hazardous materials can work on investigations in more than one mode. This has allowed the Safety Board to play a major role in improving safety by the transfer of safety lessons from one mode of transportation to another. For example:

    • The safety lessons learned in the rail mode about alcohol and other drug misuse are now being applied to the problem in the aviation and marine modes. Additionally, many boating- while-intoxicated laws are modeled after drunk driving statutes.
    • The development and installation of nonflammable seat and wall coverings, improved emergency exits, and emergency lighting in all passenger carrying vehicles, whether they be airplanes, buses, passenger vessels or railroad passenger cars.
    • We are today working with the Coast Guard at the International Maritime Organization to speed up the adoption of standards for voyage event recorders, or "black boxes," on sea-going vessels. We share our knowledge and experience in the recovery and use of cockpit voice and data recorders after an aviation accident.
    • After a fire aboard a DC-9 in 1983, the Board recommended, among other things, that floor level escape lighting be installed on all airliners. That has been done. In a 1989 safety study, the Board recommended that low power, small emergency lights be placed on all cruise ships to mark passageways to emergency exits; cruise ships are now required to install low level emergency lighting.
In the U.S., each transportation industry operates in a different regulatory climate. For example, the aviation industry is heavily regulated at the federal level by the Federal Aviation Administration. Conversely, in the highway mode and in recreational boating, much more control for safety lies individually with the 50 States. Because of these differences, the Safety Board sends its recommendations to different agencies and levels of government in each mode of transportation.

A safety recommendation is just that, we cannot compel compliance. However, with an overall acceptance rate of 80 percent plus, it is obvious that our recommendations are taken seriously by the transportation industry and regulators. And, to highlight those improvements that can provide the most benefits to the traveling public in the shortest amount of time, the Board publishes a "Most Wanted List" every year.

One of those Most Wanted issues is recreational boating safety, which has been a goal of both of our organizations for many years. There are approximately 20 million boats and 70 million boaters in the United States, with the numbers increasing each year. Hundreds die every year; in 1996, about 700 recreational boaters died in the U.S., and that was down dramatically from the 830 who died in 1995.

A study we conducted in the early 1990s found that 37 percent of the vessel operators involved in fatal accidents were known or strongly presumed to have consumed alcohol before the accidents.

As disturbing as this high incidence of alcohol involvement is, the minimal use of personal flotation devices is even worse. Of the 478 fatalities in the accidents examined in our study, 351 were reported by the States to be the result of drowning. Of those who drowned and for whom information on PFD use was available, fully 85 percent did not wear life jackets! The Safety Board's focus has been to try to obtain passage of State laws to require all children ages 12 and under to wear life jackets.

The Board's 14-year effort has resulted in strengthened alcohol and boating safety programs in 48 States, 4 Territories and the District of Columbia. Currently, 31 States and a territory require the mandatory wearing of life jackets by children, although the ages differ by State.

In the United States, an operator of a recreational boat is not required to demonstrate an understanding of the rules of the road or an ability to operate the boat. In fact, about 81 percent of recreational boat operators in the study sample, for whom information was available, had not taken any type of boating safety education course.

I want to take this opportunity to congratulate the Auxiliary for providing a trained force of more than 10,000 instructors to teach boating safety around the country. This is just one manifestation of your support for boating safety.

Both the Safety Board and the Coast Guard Auxiliary supplement their efforts to improve boating safety through membership in the National Recreational Boating Safety Coalition. I urge all of you to work in your State to make sure your law enforcement officials have the legislative authority to enforce comprehensive boating safety laws, including boating-while- intoxicated provisions and mandatory PFD use by children.

Many of the Auxiliary's activities in support of the Coast Guard also further Safety Board goals. Among your many accomplishments last year was your quick response to support land, water and air missions following the TWA 800 accident. Without the unwavering assistance from local, State and Federal volunteer organizations, like the Coast Guard Auxiliary, what was an extremely difficult mission would have been an impossible situation. The contributions of both the Coast Guard and Coast Guard Auxiliary were at the highest level of professionalism. You have my deepest respect and appreciation for a job well done.

I like to look at the bottom line; what does it cost the tax payers to support a government program? I have always been proud to tell my audiences that for all the things that the National Transportation Safety Board accomplishes each year it cost just 15 cents for each American citizen. I believe funding the Coast Guard Auxiliary for a year costs each American citizen less than 5 cents. This is outstanding value! And Congress is getting the message.

The Coast Guard Auxiliary Act of 1996 broadened the authority in which the Commandant of the Coast Guard can use the Auxiliary. I trust that Congress's action shows that the Coast Guard Auxiliary will be with us for a long time to come.

However, with an expanded role for the Auxiliary comes the public's expectations that it will meet a level of responsibility similar to the regular Coast Guard. One of NTSB's roles is to oversee the operations of the modal transportation agencies. During the course of our accident investigations, we often must examine what role other government agencies might have played in the accidents. The Coast Guard is no stranger to this scrutiny and, when on official Coast Guard orders, the Coast Guard Auxiliary should be prepared for such examination.

The Safety Board traditionally sends recommendations to the Coast Guard concerning its regulatory responsibilities for both commercial and recreational boating safety matters. Less frequently, we will issue recommendations concerning other Coast Guard mission areas, such as search and rescue, vessel traffic service, and aids to navigation, when they are at issue as a result of a marine accident.

The Safety Board addressed the issue of risk assessment during a Coast Guard search and rescue mission in its investigation of the January 11, 1991, capsizing and sinking of the fishing vessel SEA KING. As a result of that accident, the Board issued a safety recommendation asking that the Coast Guard:

Incorporate into the training of search and rescue personnel procedures to ensure the gathering and dissemination of pertinent information by all appropriate SAR personnel to facilitate a thorough assessment of the potential risks to persons involved in a search and rescue mission. The NTSB investigated three rescue efforts conducted by the U.S. Coast Guard during August 1993. The vessels in distress were two pleasure craft and one tug boat. Four persons died, three civilians and one Coast Guardsman. As a result of these investigations, we determined that some of the Coast Guard personnel involved in each SAR operation did not properly assess the risks. We recommended that the Coast Guard: Provide risk assessment training to all Coast Guard personnel directly involved in search and rescue missions. Last year, we concluded an investigation that directly concerned the Coast Guard Auxiliary. On August 21, 1994, a disabled 18-foot Questar motorboat with the vessel's owner and one passenger on board capsized while being towed by the Auxiliary vessel PUPPET in Lynn Canal, near Juneau, Alaska. The Questar's owner was trapped inside the vessel's cabin and was drowned. The passenger was not injured.

In examining the Coast Guard's safety management during the 1994 Golden North Salmon Derby and the incident involving the 18-foot Questar, the Safety Board identified five significant safety issues: communications, the policy on the use of the Coast Guard Auxiliary resources in hazardous weather and sea conditions, the policy on removal of passengers from towed vessels, the risk assessment training of Coast Guard Auxiliary personnel involved in search and rescue operations, and the policy on post- accident toxicological testing of Coast Guard Auxiliary personnel involved in marine accidents.

We determined that the probable cause of the Questar's capsizing was the flooding of the vessel due to the use of improper towing procedures by the Auxiliary Operator of the PUPPET. Contributing to the accident was the failure of the Auxiliary Operator of the PUPPET to properly assess the risk before deciding to tow the vessel in hazardous sea conditions. Contributing to the loss of life was the failure of the Auxiliary Operator to remove the Questar's occupants before towing the vessel.

The Safety Board made the following recommendations to the U.S. Coast Guard that will be of interest to this organization:

  • Develop written policies on the use of Coast Guard Auxiliary resources.
  • Revise Coast Guard search and rescue policy to require or recommend removal of occupants from towed vessels before beginning the tow if it is safe to do so.
  • Provide risk assessment training to all Coast Guard Auxiliary personnel involved in search and rescue missions.
  • Revise Coast Guard Auxiliary policies on units rendering assistance to vessels to ensure that all people who remain on board a towed vessel are situated to ensure their safe exit in the event of an emergency.
  • Revise Coast Guard regulations to require mandatory post accident toxicological testing of Coast Guard Auxiliary personnel involved in marine accidents while operating under Coast Guard orders.
  • Incorporate the lessons learned from this accident into a case study training exercise for Coast Guard search and rescue units, including Coast Guard Reserve and Auxiliary commands.
  • Publicize the circumstances of this accident to all Coast Guard units responsible for search and rescue.
  • Disseminate a copy of this report to all Coast Guard Auxiliary personnel involved in search and rescue missions.
I am pleased that the Coast Guard has responded positively to our safety recommendations. I understand that several of these recommendations may already be satisfied and I am especially pleased that the Coast Guard is aggressively pursuing risk assessment training and trainer qualification within the Coast Guard Auxiliary.

In closing, I want to thank Commodore Tucker for the opportunity to talk with you this morning. I would just like to say that I believe, on a dollar for dollar basis, the Coast Guard Auxiliary is a gold mine for the Coast Guard and the American public. You provide experienced seamen operating on dependable platforms in support of Coast Guard missions, all in the spirit of volunteerism.

However, along with the flag and authority granted to the Coast Guard Auxiliary goes the responsibility to meet the expectations of the public in the way you carry out your missions, just like any other member in uniform. Please continue the good work you do. I wish you a very safe and successful year.

Jim Hall's Speeches