Statement by Jim Hall
Chairman, National Transportation Safety Board
at the opening of the NTSB Investigative Hearing
Into the Crash of TWA Flight 800
Baltimore, Maryland, December 8, 1997
Good morning, and welcome to this investigative hearing of the National Transportation Safety Board.
On July 17, 1996, a Boeing 747-131, operated by Trans World Airlines as flight 800 to Paris, exploded and crashed into the Atlantic Ocean about 14 minutes after takeoff from New York’s John F. Kennedy International Airport. All 230 persons aboard lost their lives. While the shock of this event has slowly abated, the horror has not.
The NTSB launched the largest investigation in its history – indeed, it is the largest investigation of a transportation accident in our nation’s history. The Federal Bureau of Investigation began a parallel investigation to determine if the tragedy was a criminal act. As you all know, the FBI recently suspended its criminal investigation of the crash, and we are here in furtherance of the NTSB’s search, not only for the cause of this accident, but even more importantly, for ways to make sure such a tragedy never happens again.
It is difficult to put into words the enormity of this investigation. Besides the hundreds of employees from the NTSB and FBI that have worked on this every day for the last 17 months, staffing and logistical resources from the Federal Aviation Administration, the United States Coast Guard, the U.S. Navy, the Federal Emergency Management Agency, the CIA, Suffolk and Nassau Counties, the City of New York and the State of New York, as well as volunteers from the American Red Cross, selflessly devoted days, weeks and months to this investigation and to the public safety responsibilities associated with it.
Many of us are by now familiar with the scope of the search and recovery effort that resulted in the identification and return of all 230 victims to their loved ones – an unprecedented accomplishment – and the salvaging of more than 95 percent of the aircraft from 120 feet under the ocean.
In the 9 months of the recovery effort, there were 677 surface-supplied dives and 3,667 SCUBA dives, resulting in 1,773 hours of bottom time for the divers. In addition, there were 376 remotely operated vehicle dives. Thirteen thousand trawl lines covering 40 square miles gathered 20,000 underwater items. This was how we were able to recover pieces as small as a quarter.
This massive underwater activity permitted us to build the largest aircraft reconstruction in the history of civil aviation. Fully 94 feet of the 747’s fuselage was rebuilt, including the center wing tank, the heaviest structural part of the plane. The reconstruction, absent the supporting structure, weighs about 60,000 pounds and consists of almost 900 pieces, not counting the center wing tank, which in itself consists of more than 700 pieces.
The reconstruction and detailed lab work enabled our investigators to determine the sequence of events from the initial fuel tank explosion to the ultimate destruction of flight 800. You will hear a detailed report on those findings today.
While this effort was going on, the Safety Board participated in or conducted flight tests, explosion tests and laboratory examinations from airfields in England to California, and labs in Tennessee, New Mexico, California, Colorado, Ohio and Washington State. You will learn the results of these studies during this hearing.
This investigation also includes the most extensive radar data study in the Board’s history, involving the review of several hundred thousand radar returns from 9 radar locations in 5 States.
As you may know, the mystery of flight 800 has generated intense public interest. Among the more than 1,300 letters that my office alone has received on this accident are more than 500 letters from members of the public, from university professors to aviation enthusiasts to people who just think they have a good idea. I have directed that every letter be answered and all ideas explored.
These binders contain those letters. They include suggestions such as a smoker lit a cigarette in the lavatory and ignited fuel vapors; a mobile phone ignited gases in the air; the crash was caused by weather events like a cyclone, lightning or wind shear; by bird strikes; by an exploding tire; by a cargo door opening; by a laser beam; by a bullet from a high-powered rifle; by a malfunctioning fuel pump or vent; by contaminated fuel; by mechanical problems like bad rivet holes or failures in the cabin pressurization system; by metal fatigue; or even that the plane was too heavy.
Some of these theories are just not possible. But of those that were, I can assure you that we had already examined most of them, and we made sure we looked into all the rest. These letters were, for the most part, from people like you and me, well-meaning citizens trying to help us get to the bottom of this tragedy. We appreciate their assistance and their willingness to help.
So far, the Safety Board has obligated $30 million of the taxpayers’ funds – not including salaries and benefits for Safety Board personnel or any other federal employees involved in this effort. All of this in an effort to reach the two goals of this investigation – learning the ignition source that sparked the fuel tank explosion, and I believe even more important, finding the best means of reducing the likelihood of explosive fuel/air vapors from accumulating in airliner fuel tanks. Because, in the final analysis, had the vapors in TWA flight 800’s fuel tank not been explosive, this accident would not have occurred, no matter what the ignition source.
During this week-long hearing, you will hear testimony on our efforts to find the ignition source. You will hear about the work designed to determine whether two possible external ignition sources could have been involved – a small explosive charge or a high-speed particle such as a fragment from a missile, space junk or a meteorite. You will also hear about 4 mechanical possibilities involving the center tank scavenge pump, static electricity, the fuel quantity indicating system, and/or a fuel tank electrical conduit.
It should be noted that whatever caused the crash of flight 800, the explosion of a center wing tank in any aircraft is an extremely rare event. While our entire civil aviation fleet is extremely safe, the Boeing 747 in particular has registered an admirable safety record. There are currently about 970 747s worldwide. In the almost 30 years that the 747 has been operating, the fleet has accumulated more than 52 million flight hours and 12 million flights.
Almost a year ago, the Safety Board issued recommendations aimed at minimizing the possibility of having explosive vapors in airliner fuel tanks. As you know, the FAA last week replied to our recommendations. Although under our procedures the entire Board must respond to the FAA’s statement, I think I can say that, while I am disappointed that the FAA continues to reject short-term operational solutions, I believe the letter sets a new tone and places the FAA with those of us who believe that the elimination of explosive vapors is at least as important as designing out ignition sources. These issues will be fully explored here this week.
Since the accident, the industry and the FAA have moved on several fronts to address concerns raised during the investigation. The FAA convened a two-day conference on fuel flammability, a subject that was not as well understood as previously thought. The FAA proposed an airworthiness directive last month that would require the installation of components to suppress electrical shorting in aircraft wiring that is connected to fuel tanks. This would also involve inspections of the fuel quantity indicating systems for purposes of avoiding electrical arcing.
A separate AD requires the immediate inspection of scavenge pump wiring on some older 747s; the scavenge pump from flight 800 has not been recovered.
Boeing Commercial Aircraft Corporation has recommended that B-747 operators check all wiring to fuel tanks during their next major inspection, and has said it intends to replace a fuel probe on some older model 747s that it says has exhibited faulty wiring on some models.
All of these actions are welcome, and they show a commitment on the part of the industry and the FAA to reduce as many potential ignition sources as possible. This has always been the design philosophy adopted by the FAA and industry, and laudable as it is, it is a goal that is extremely difficult to attain if, indeed, it is possible at all.
We continue to believe that the FAA and the aviation industry do well to try to eliminate every possible ignition source, but they should also endeavor to eliminate explosive vapors in fuel tanks, a more attainable goal that would prevent another accident like TWA 800. The industry has been attempting to eliminate ignition sources for many decades with great success. But as TWA 800 shows, they have not been completely successful, and I for one don’t see how every ignition source can ever be eliminated. As I said, I am hopeful after reading the FAA’s letter to us last week that we all are now moving in the same direction.
In our 30-year history, the Safety Board has conducted more than 120 public hearings on major aviation accident investigations, including the 1979 DC-10 crash in Chicago, which is the deadliest aviation accident in American history; the 1987 MD-80 accident in Detroit, which until flight 800 was the second deadliest aviation accident in U.S. history; and the 1994 Boeing 737 accident near Pittsburgh, which actually had a two-session hearing. This week’s hearing, as with those, is being held for the purpose of supplementing the facts, conditions, and circumstances discovered during the on-scene investigation. This process will assist the Safety Board in determining the probable cause and in making any recommendations to prevent similar accidents.
Public hearings such as this are exercises in accountability: accountability on the part of the Safety Board that it is conducting a thorough and fair investigation, accountability on the part of the FAA that it is adequately regulating the industry, accountability on the part of the airline that it is operating safely, accountability on the part of manufacturers as to the design and performance of their products, and accountability on the part of the work force – pilots and machinists – that they are performing up to the standards of professionalism expected of them.
These proceedings tend to become highly technical affairs, but they are essential in seeking to reassure the public that everything that can be done is being done to ensure the safety of the airline industry.
This hearing is not being held to determine the rights or liability of private parties, and any matters dealing with such rights and liability will be excluded from these proceedings.
Over the course of the hearing, we will hear reports from some of the Safety Board’s investigators and receive sworn testimony from experts on safety issues arising from this accident. Specifically, we will concentrate on the following issues:
1. Examination of cockpit voice recorder, flight data recorder and radar data, and sequencing
2. Fuel tank design philosophy and certification standards
3. Flammability of Jet-A fuel
4. Ignition sources
5. Potential flammability reduction techniques/procedures
6. Aging Aircraft
We expect to hear from almost 50 witnesses over the next five days, many of them in panels discussing one of these issues.
At this point, I would like to introduce the other members of the Board of Inquiry. They are: Dr. Bernard Loeb, Director of the Office of Aviation Safety; Dr. Vernon Ellingstad, Director of the Office of Research and Engineering; and Mr. Barry Sweedler, Director of the Office of Safety Recommendations and Accomplishments. Mr. Dan Campbell, the Safety Board’s General Counsel, is also at this table.
The Board of Inquiry will be assisted by a Technical Panel made up of NTSB investigators. These persons are Thomas Haueter, Chief of the Major Investigations Division; Al Dickinson, Investigator-in-Charge; and the following NTSB group chairmen:
Debra Eckrote, Norman Wiemeyer, Malcolm Brenner, James Wildey, John Clark, Frank Hilldrup, David Mayer, Burt Simon, Henry Hughes, George Anderson, Doug Wiegman, Mitchell Garber, Merritt Birky, Dan Bower, Dennis Crider, Robert Swaim, Charles Peraira, Deepak Joshi and Larry Jackson.
Neither I nor any other Safety Board personnel will attempt, during this hearing, to analyze the testimony received nor will any attempt be made at this time to determine the probable cause of this accident. Such analyses and cause determinations will be made by the full Safety Board after consideration of all of the evidence gathered during our investigation. The report on the aircraft accident involving flight 800, reflecting the Safety Board’s analyses and probable cause determinations, will be considered for adoption by the full Board at a later public meeting.
We have a number of Safety Board employees here to assist those of you attending this hearing. You will recognize them by the salmon colored credentials they wear around their necks. Please contact them for any administrative concerns you may have.
I am pleased to see the large number of news media here to cover this hearing. In fact, due to the interest this investigation has generated, we have issued more than 500 press credentials, which means that there are about 40 percent more media representatives here than there are employees in the entire National Transportation Safety Board.
This is a public proceeding and much of our nation will rely on you in the media to learn what transpires here. I will ask you, however, not to conduct any interviews here in the auditorium; all interviews should be conducted outside this room. Also, there are meeting rooms upstairs for NTSB staff and for family members of those who perished on TWA flight 800. News media representatives are not authorized access to these rooms.
The Safety Board’s rules provide for the designation of parties to a public hearing. In accordance with these rules, those persons, governmental agencies, companies and associations whose participation in the hearing is deemed necessary to the public interest and whose special knowledge will contribute to the development of pertinent evidence are designated as parties. The parties assisting the Safety Board in this hearing have been designated in accordance with these rules.
As I call the name of each party, will its designated spokesperson please give his or her name, title and affiliation for the record:
Department of Transportation, Federal Aviation Administration
Air Line Pilots Association
Trans World Airlines
Boeing Commercial Airplane Group
International Association of Machinists and Aerospace Workers
On December 1, the Board of Inquiry held a prehearing conference in Washington, D.C. It was attended by the Board’s Technical Panel and representatives of the parties to this hearing. During that conference, the areas of inquiry and the scope of the issues to be explored at this hearing were defined and the selection of witnesses to testify on these issues was finalized.
Copies of the witness list are available at various locations around the building.
The Safety Board is a public agency engaged in the public’s business and supported by public funds. The work it does in the business of aviation safety is open for public review – our investigation is an open book. Yesterday, the Safety Board opened the docket of this investigation, and placed 4,000 pages of documentation into the public record. A substantial portion of this, representing those exhibits to be used at this hearing, is available free of charge to the public through our home page on the Internet. The docket can be accessed by entering www.ntsb.gov, then hitting the button indicating the TWA flight 800 hearing section. There you will find not only the exhibits, but the witness list, biographical information on all of us here on the Board of Inquiry and the Technical Panel, and other general information concerning the hearing.
Paper copies of the docket may be obtained here for purchase by contacting Kinko Corporate Document Services, 300 North Charles Street, (410) 625-5862. Paper copies may also be ordered for purchase through our Public Inquiries Section in Washington at (202) 314-6551.
The witnesses testifying at this hearing have been selected because of their ability to provide the best available information on the issues to be addressed. The Board’s Investigator-in-Charge will summarize certain facts about the accident and the investigative activities that have taken place since then, and then we will call our first witness.
The witnesses will be questioned first by the Board’s Technical Panel, then by the designated spokesperson for each party, and finally by the Board of Inquiry.
As Chairman of the Board of Inquiry, I will be responsible for the conduct of the hearing. I will make all rulings on the admissibility of evidence, and all such rulings will be final.
Anyone wishing to purchase the transcript of this hearing, including parties to the investigation, should contact the court reporter directly.
Finally, I would like to say a word to the family members of the victims who are here with us today or are watching the proceedings on C-SPAN. While all of us have felt enormous sympathy for your grief these many months, we cannot claim to know what you have gone through since the night of July 17, 1996. We can, however, make sure that we dedicate all possible resources to finding out what happened that night and what we can do to make sure it doesn’t happen again. This hearing is a major step toward those goals.
With all exhibits having been entered into the docket, I will ask Mr. Al Dickinson, the Investigator-in-Charge of this investigation, to present his opening statement.