Remarks by Jim Hall, Chairman
National Transportation Safety Board
before the International Aviation Club
Washington, D.C., January 21, 1998
Thank you so much for giving me the opportunity to address this important organization on current subjects surrounding international air transportation.
As you may know, the National Transportation Safety Board is an independent federal agency that I have been privileged to lead for more than 3 years. We investigate all aviation accidents and all major accidents in the surface modes – marine, highway, railroad and pipeline – as well as conducting safety studies on issues of national significance. From these, the Board makes recommendations to prevent recurrence of accidents. It is a simple, but a vital mission. The NTSB is also the lead agency for overseas investigations. It is quite a task for a 370-person agency.
As an agency that has no regulatory authority, the Safety Board gets results by its powers of persuasion. We are required by law to make our recommendations public, and that means that responses to those recommendations are also public. When those responses don’t agree with the recommendations, then a conflict is sensed by observers. What is lost in this view is that the public give-and-take of ideas on how best to assure the safety of the traveling public has been purposefully built into the system.
Much has been made in the past about the so-called "adversarial relationship" between the Safety Board and the Federal Aviation Administration. Particularly lately, this has been equated with a feeling among some that, because the Board has criticized the FAA on issues like smoke detection and fire suppression in cargo holds, and more recently flammability of fuel tanks, that this signals a "politicizing" of the Board.
Let’s go back 60 years to the passage of the Civil Aeronautics Act, which established our predecessor agency, the Civil Aeronautics Board. Even then, the benefits of an independent investigative agency were appreciated by no less a light than the President of the Air Transport Association, Edgar S. Gorrell. After noting that the CAB would not exercise safety regulatory or promotional functions, he stated:
"It will stand apart, to examine coldly and dispassionately, without embarrassment, fear or favor, the results of the work of other people…Thus Congress has recognized the virtue of providing a regularly established medium for self-criticism in government and has at the same time avoided the danger of imposing upon an administrative body essentially contradictory functions."
If there is a perception that we are more vocal in our criticisms of the FAA or other regulatory agencies, I think it is a function of the times. We live in a global media market. Statements are broadcast worldwide, and repeated many times a day. The New York Times Magazine earlier this month recounted how an emergency landing of a cargo aircraft in Orlando was trumpeted by the local media as, first, an emergency at the airport, then as a plane crash at the airport, and finally as a burning plane barely making it to the runway. All that actually happened was that the aircraft landed with its gear retracted and showered sparks as it stopped on the runway. This is a minor anecdote, but it symbolizes the importance the news media, and presumably their audience, place in any aviation story. Look at all the attention given every time the FAA issues an inspection order on any aircraft component.
The Safety Board has made its recommendations public for decades, and if those recommendations get more "play" now than in the past, that is because everything gets more play now than in the past. We do not let that obscure the fact that commercial aviation is extremely safe, and that by and large the airlines providing that service and the regulators overseeing that service have done a remarkable job in ensuring that magnificent safety record.
Many of you represent airlines that carry millions of passengers a year safely, but that accomplishment will not be the subject of international headlines. However, there will be headlines if one of your aircraft is unfortunately involved in an accident. That’s just the way the world works – none of us gets credit for the accident that did not occur, or the life that was not forever altered because of our previous accomplishments to make transportation safer.
There were no headlines during the 27-month period a few years ago in which the major U.S. airlines carried a billion passengers safely to their destinations without one fatality; but there were plenty when an airliner crashed in Charlotte, North Carolina, breaking that streak with the deaths of 37 persons.
Now we see that aviation is becoming an increasingly international industry, with carriers operating globally, with aircraft components being built by many countries, and with citizens of many nations aboard every flight. The International Air Transport Association has estimated that 1997 saw an 8 percent increase in passenger traffic worldwide, to almost one and a half billion passengers.
Increased traffic almost inevitably leads to increased activity by my agency. Just in the last year, the Safety Board has participated on-scene in 8 foreign accident investigations, and offered the services of its laboratory in 25 foreign accidents. We also provided technical support for scores of other investigations by foreign authorities in compliance with the Convention on International Civil Aviation.
The SilkAir Boeing 737 accident in December is the latest involving close coordination between my agency and a foreign government in accordance with international protocols. We sent 2 investigators to Indonesia, one of whom served as the U.S. accredited representative, and the Indonesians brought both flight recorders to our Washington laboratories. The FAA and Boeing also provided investigators to the U.S. team. Singapore sent investigators to the scene and to our laboratories because SilkAir is a Singapore airline. Further, Australia sent investigators to the scene and to our labs as part of an agreement to provide technical support to Indonesia.
The 737 is the world’s most widely used airliner, with approximately 3,000 worldwide, almost half of them operating in this country. It is imperative that any airworthiness concerns brought out in an investigation be dealt with immediately. The U.S. has a clear obligation to verify the airworthiness of aircraft manufactured in this country. Similar information on an Airbus or Embraer or Saab could affect the safety of millions of travelers. This demonstrates the importance of multinational cooperation in accident investigations.
International economic concerns also bring increasing pressure to find out what went wrong in an accident and, if an airworthiness issue is involved, to fix it immediately. The U.S. Department of Transportation estimates that civilian aircraft, engines and parts provided $26 billion toward our balance of payments in international trade in 1995, the latest figures available. No manufacturer – indeed, no manufacturing country – wants a repeat of the Comet experience in the 1950s, when the world’s first commercial jet passenger airliner suffered a series of baffling crashes. By the time the problem was found and corrected, confidence in the aircraft had disappeared, the United Kingdom had lost its brief leadership in jet transportation, and other jet models were poised to garner the lion’s share of world airline orders.
So, we see the news centering on dual interests. First is the enormous economic implications of a significant airline accident. Second, though, is the emotional dimension of such a tragedy. Along those lines, increasingly, the plight of the family members of those who perish in airline accidents has become a more prominent element of news coverage. At the same time, legislation has propelled my agency into the middle of this issue, and has given your carriers more specific responsibilities, as well.
Before October 1996, when Congress passed and President Clinton signed the Aviation Disaster Family Assistance Act of 1996, the Safety Board’s primary mandate was to investigate transportation accidents. The new law gave the Safety Board the additional responsibility of aiding the families of victims of aircraft accidents occurring in U.S. territory.
What brought about this change? As a member of the NTSB, I have visited the scenes of four major non-survivable airline crashes: USAir flight 427, which killed 132 just outside of Pittsburgh, Pennsylvania; American Eagle flight 4187, which killed 68 in Roselawn, Indiana, on October 31, 1994; ValuJet flight 592 that killed all 110 aboard in the Florida Everglades, on May 11, 1996; and TWA flight 800 that killed 230 off the coast of Long Island, New York, on July 17, 1996.
In all four accidents, as in past aviation crashes, the unpleasant duty of notifying next of kin, making arrangements for transporting family members to a location near the accident site, and returning victims’ remains has been the responsibility of the carrier. The local community responded with necessary emergency services and were followed by individual and group volunteers providing services such as grief counseling and food services. We at the Safety Board arrived to investigate the accident.
For those who have been involved with a major aircraft crash, I do not need to tell you that some past responses lacked organization and coordination among the participants. Based on Congressional testimony and other forums, we’re all familiar with the experiences many family members have had: continuous busy signals from the airline’s 800 accident information number; misidentified remains and personal effects being mishandled; unidentified remains not handled with dignity, including mass burials without informing families; and the use of confidential information obtained through this grief process against families in court.
I think we all agree that this type of treatment of family members cannot be tolerated. The world has changed and all of us involved in the events following major accidents have to change with it. For instance, the recent SilkAir accident in Sumatra and the turbulence accident involving United Airlines were both major international media events. Family members of victims, not just in the United States, are demanding more accountability in the aftermath of accidents such as these. Their five major concerns are in the areas of initial notification of the accident, recovery and identification of victims, disposition of unidentifiable remains, return of personal effects, and access to information.
These concerns are shared by family members of victims of accidents that occur in the United States, Africa or Asia – it is a common human need that goes beyond international borders.
The Board did not seek the responsibility it was given in 1996 but the task was assigned to the NTSB because of our long and respected history at crash sites as the eyes and ears of the American people. Our family assistance plan has been used four times since passage of the law:
• United Express accident in Quincy, Illinois – 14 fatalities.
• Comair accident in Monroe, Michigan – 29 fatalities.
• KAL 801 in Guam – 228 fatalities
• Scenic Airlines in Montrose, Colorado – 9 fatalities.
Our new Office of Family Assistance fills that void that I previously mentioned - as a coordinator to integrate the major resources of the federal government and other organizations to support the efforts of the local and state government and the airline to meet the needs of aviation disaster victims and their families. Family counseling, victim identification and forensic services, communicating with foreign governments, and translation services, are just a few of the areas in which the federal government can help local authorities and the airlines deal more effectively with a major aviation disaster.
Thanks to memoranda of understanding with six cabinet level agencies, the resources of the entire federal government have been made available to supplement local responders. These resources included a fully-equipped mobile morgue. In nearly every city and town in this country, the local coroner or medical examiner would be overwhelmed if a fully loaded airliner crashed. The Board sees its duty as not taking over, but rather as integrating federal services and support into the local response.
As many of you know, Congress recently passed legislation amending the Aviation Disaster Family Assistance Act of 1996 to require foreign carriers flying in or out of the United States to file family assistance plans and fulfill the same family support requirements as required by their domestic counterparts. This disparity in the 1996 legislation was brought to light and corrected as a result of the Board’s experiences at the August 1997 crash of Korean Air Flight 801 on the island of Guam.
At the time of the accident, Korean Air was not required to file a family assistance plan with the United States government and the airline’s management was not aware of the Board’s new responsibilities. In addition, when the 747 crashed on Guam, killing more than 200 persons, KAL did not have a plan of its own to support the approximately 500 family members who immediately came to the island. It took a few days for Board family affairs personnel to coordinate with the airline and the local government the establishment of a more organized family support structure.
Nevertheless, I believe that, once its family assistance effort was established, Korean Air did a commendable job for the families. Virtually everything was thought of, from installing phones in the family center – so that relatives could call back to Korea free of charge – to providing free undergarments and toiletries to the families during their stay on Guam. The airline also provided free transportation and lodging for the families.
Consistent with our responsibilities and our belief that keeping the families informed is critical, the NTSB conducted daily briefings not only on the investigative process but also on the grueling task of recovering bodies and making positive identifications. The crash occurred during typhoon season and weather conditions were horrendous, hindering recovery efforts. Because the airline was unable to provide Korean interpreters for us, we relied on Korean-American residents of Guam, who volunteered their services. I mention this problem as a good example of the kinds of issues that arise at accident scenes that can be avoided if planned for.
This leads to an important issue. Not only was KAL’s response hampered by its lack of knowledge of the NTSB’s family assistance program, I am confident that any emergency plan it had on hand would have been enhanced had it been submitted to the Board for review, as is now required.
As you are well aware, the NTSB does not have the ability to reject an airline’s plan. We do, however, have the right to comment on any plan, offering suggestions based on our years of accident response and our recent experiences with family assistance programs. In short, we function as a form of institutional memory for the airline industry, able to point out past failures and successes.
Within the next few weeks, the Department of Transportation will send all foreign carriers having authority to serve the United States a letter reminding them of the passage of the Act and of what their responsibilities are under that law.
On September 28 and 29, the Safety Board will host an international symposium in Arlington, Virginia for industry, government and community officials to promote a better understanding of the federal government’s role with respect to families at a transportation disaster and to allow individuals and organizations that might have to respond in the event of such an accident to discuss experiences and learn new techniques in disaster resource management. I urge all of you to attend what will be the first international gathering of this kind ever conducted.
The NTSB’s Family Affairs Office is available to assist all of you. Mr. Gary Abe and his staff can be reached by calling (202) 314-6185.
You know, three years ago, when family organizations turned to the Safety Board for help for what they believed was cruel or at least indifferent treatment by airlines following major accidents, I pledged my agency’s cooperation in finding a solution that would accommodate the needs of all parties involved. I’m proud of the work done by our family affairs personnel, first Peter Goelz, who did a lot of the work by himself in the early days, and then our family affairs staff under Col. Abe.
This was new territory for us, and we had to proceed slowly to maintain a proper separation between our investigative responsibilities and our new responsibilities with the families. We probably made some mistakes along the way, but it is a credit to our staff that those mistakes were relatively minor.
We are servants of the American people, and I follow the dictum of Benjamin Franklin, who said, "The man who does things makes many mistakes, but he never makes the biggest mistake of all – doing nothing." I don’t ever want the American people to think that, when a need is identified – as it was in the case of family assistance or as it can be in any number of safety-sensitive issues that will arise in the future – we did nothing.
Many of you have never experienced what happens at an accident scene, and I pray that none of you ever will. We go to them many times a year. That’s why Congress placed the family responsibilities with the NTSB. Please let us know what we can do to help prepare you, should an accident occur to one of your aircraft.
Thank you again for inviting me.