Remarks by Jim Hall, Chairman
National Transportation Safety Board
before the 15th Annual International Aircraft Cabin Safety Symposium
Oklahoma City, Oklahoma, February 5, 1998
Thank you for inviting me back for the fourth time to address you on a subject dear to the hearts of many of us at the Safety Board, cabin safety and post-crash survivability.
I always look forward to meeting with the Southern California Safety Institute, and I must say that, while this is a lovely setting, this year’s meeting seems to be a little far from the beach.
I’d like to discuss several topics that have arisen since I last spoke to you.
As you may know, because the Safety Board is not a regulatory agency, our effectiveness in promoting safety improvements is dependent on our ability to get our safety message out to the traveling public. We have been criticized in the past for not making our information more readily available. I am proud that the Safety Board not offers most of its information on its web site – www.ntsb.gov.
Included on the site are general information about the Board and its Members, press releases, speeches and testimony, the "Most Wanted" list of safety issues and recommendation acceptance rates, a synopsis of more than 38,000 aviation accident investigations, aviation accident statistics, and other information of interest to the American people. By April, we expect that the full texts of all major accident reports and safety studies adopted by the Board in the past two years will be available on our web site.
At the time of the TWA flight 800 investigative hearing in Baltimore, Maryland last December, the entire hearing docket – minus the cockpit voice recorder transcript – was available on the Board’s web site and on CD Rom the day before the hearing began. The CVR transcript was added when the hearing opened. We also provided a summary of each day’s testimony at the close of that day’s business. Our normal weekday visitors to our web site number about 1,100; the week of our hearing, we had 78,000 visitors. We expect to continue to improve our web site and make it one of the best in the government.
There have been two major changes at the Board since the summer of 1996, which saw the crashes of ValuJet flight 592 in the Florida Everglades and TWA flight 800 in the Atlantic Ocean off Long Island. The first was the implementation of a 24-hour communication center at the Safety Board, which, among other things, has relieved our investigators of launch logistics nightmares by coordinating travel, lodging, on-scene command center, and telephone and equipment needs. Previously, the Investigator-in-Charge had to handle much of these matters from his home before departing on the investigation.
The operation runs interference for the en-route Go-Team, gathering accident information and alerting local police and fire/rescue personnel of the team’s arrival. In addition, accident survivors or victim family members are provided with an after-hours human contact to expedite communications to the Board’s family assistance team on site.
Which leads me to the second major change, our Family Assistance Office. In October 1996, Congress passed and President Clinton signed the Aviation Disaster Family Assistance Act, which gave the Board the additional responsibility of coordinating the federal effort for the families of aviation accident victims. Since that time, we have hired a family affairs staff, developed, in concert with family advocacy groups and the aviation industry, a Safety Board family assistance plan, and provided family assistance to 4 accidents: the November 1996 United Express runway collision in Quincy, Illinois; the January 1997 Comair commuter plane crash in Monroe, Michigan; the August 1997 crash of Korean Air flight 801 in Guam; and the October 1997 crash of a Scenic Airlines air taxi in Montrose, Colorado.
Although we did not seek this authority, I believe federal intervention was required because of the indifferent or sometimes callous treatment that family members received after airline accidents, and the reluctance of the industry to offer a workable alternative. I believe the NTSB was chosen to take on this task because of its 30-year history of being the eyes and ears of the American people at accident sites. Family members of accident victims deserve a prompt, compassionate and truthful response after an accident and I am proud of the work the Board’s staff has done on family issues. We have heard from other countries that are considering similar actions.
I invite all of you to attend the Safety Board’s International Symposium on Family and Victim Assistance, to be held September 28 and 29 in Arlington, Virginia. It is the first meeting of its kind and will promote an understanding of the federal government’s role with victims and their families at major transportation disasters. We hope to educate individuals and organizations responding to these events by asking them to publicly discuss experiences and new techniques in disaster resource management.
After an extremely tragic year in 1996, last year saw fewer U.S. airline deaths, but 1997 was not without tragedy, particularly with the loss of all 29 persons aboard Comair flight 3272 on approach to Detroit, Michigan in January. Of course, although not a U.S.-registered airliner, the crash of KAL flight 801 in Guam was the deadliest accident we investigated last year, with the loss of more than 200 passengers and crew. I’ll discuss that accident shortly.
According to research from the FAA, the International Civil Aviation Organization, and Boeing, civil aviation is expected to grow about 4 to 6 percent per year in the United States, with even higher growth overseas. That growth will not occur without accidents, and organizations like yours will help mitigate the effects of those accidents, if we can develop improved cabin safety designs and at the same time educate the traveling public about how they can best maximize their chances of surviving that rare accident that does occur.
You help accomplish that task through research and symposiums like this; we do our part through accident investigations. I’d like to talk about a few of those investigations and highlight cabin safety issues that have arisen.
On November 19, 1996, United Express flight 5925, a Beechcraft 1900C, collided with a King Air at the airport in Quincy, Illinois seconds after landing. The airport had no control tower. All 12 persons aboard the 1900 died, as did the 2 pilots on the King Air. The occupants of both aircraft died from the effects of smoke and fumes from the post-crash fire even though they survived the impact.
A pilot employed by the airport’s FBO and two Beech 1900C-qualified United Express pilots who had been waiting for the flight to arrive were the first people to reach the accident scene. One of those pilots said that he opened the left aft cargo door of the United Express and black smoke poured out. Another said the cabin itself appeared to be full of dark smoke. They then ran to the forward left side of the commuter’s fuselage where the captain was asking them to "get the door open."
The FBO pilot stated that he found the forward airstair door handle in an unlocked position and attempted unsuccessfully to open the door by moving the handle in all directions and pulling on the door. He said that he did not see any instructions for opening the door, but he was able to rotate the handle upward only as far as the 5 o’clock position. The United Express pilot then intervened, depressing the button above the handle while rotating the handle from the 3 o’clock position downward to the unlocked position. Although he thought the handle felt normal, he was unable to open the door. Other attempts were also unsuccessful.
Although there was a small sign saying, "PUSH BUTTON AND TURN HANDLE TO OPEN," the Safety Board believed that these instructions were inadequate in an emergency situation. On January 3, 1997, the Board issued an urgent safety recommendation to the FAA that would require carriers to attach conspicuous signs with highly visible markings, explicit directions and an arrow to show the direction the handle must be moved to open the door.
The following month, Raytheon Aircraft Company issued a service bulletin, and the FAA an airworthiness directive, complying with that recommendation, which we closed as "Acceptable Action" in April.
The Quincy investigation prompted the Board to revisit an issue it had previously addressed in 1994. Quincy Municipal Airport is an uncontrolled airport owned and operated by the City of Quincy, about 10 miles away. The airport holds an FAA-issued limited airport operating certificate. Although a 500-gallon capacity aircraft rescue and fire fighting truck was located at the airport, full-time ARFF services were not present or required at the time of the accident.
The first units of the Quincy Fire Department arrived on scene about 13 minutes after being notified of the accident. By then, both aircraft were completely engulfed by flames. The airport’s fire truck is staffed 15 minutes before to 15 minutes after the arrival or departure of an air carrier aircraft with more than 30 passenger seats. United Express flight 5925, having fewer seats, did not qualify for this protection. The Safety Board found that, had the airport’s fire truck been staffed for the arrival of the commuter flight, it could have arrived at the scene of the accident in no more than a minute. Fire fighters might have been able to extinguish or control the fire, perhaps buying time for some occupants to escape.
The Board reiterated its 1994 recommendation to the FAA to permit scheduled passenger service only at airports meeting standards contained in Part 139 of the Federal Aviation Regulations. While some communities might not be able to afford this level of fire protection, the Board believes the FAA should come up with ways to assist in that funding. After all, according to the budget request submitted to Congress this week, the American taxpayer will be spending $1.7 billion in airport grants in fiscal year 1999. Surely some of that can be used for firefighting equipment and personnel.
Last summer, Safety Board resources were again strained when we launched a major investigation into the crash of a Boeing 747 halfway around the world in Guam. On August 6, Korean Air flight 801, en route from Seoul, crashed on approach to Agana. Of the 254 occupants on board, 228 died.
At the time of the accident, the glide slope associated with the instrument landing system was out of service and the crew was conducting a "localizer only" approach when the plane crashed 3 miles from the airport.
The Safety Board will be conducting a public hearing on this accident in March. Among the major issues to be discussed is the crash/fire rescue operation, the timeliness of the response to the accident, the command and control structure, the emergency response plan for the Island of Guam, emergency response communications between the various rescue agencies, the diverse terrain and hazardous sawgrass environment at the site, and the narrow dirt road that was used to gain access to the wreckage.
As the year drew to a close, the world’s attention was captivated by an accident over the Pacific Ocean. On December 28, 1997, a United Airlines Boeing 747 experienced severe turbulence about 950 miles east southeast of Tokyo. One passenger was killed and 14 passengers and 3 flight attendants sustained serious injuries. Investigators from Japan’s Aircraft Accident Investigation Commission, assisting us in our investigation, interviewed 7 passengers who were hospitalized in Tokyo after the plane returned; all 7 stated that their seatbelts were not fastened.
The Safety Board has investigated 99 turbulence accidents and incidents involving U.S. and international air carriers since 1983. These accidents resulted in 2 fatalities and 117 serious injuries. The injuries have included fractures to the spine, skull and extremities; some have resulted in paralysis. Most of the injuries were completely preventable if the occupants had been restrained. Although some injuries occurred to passengers who were out of their seats, many occurred to seated – but unrestrained – passengers.
We have also investigated accidents in which unrestrained occupants have been killed or injured during pilot-induced oscillations, collision avoidance maneuvers, decompressions and auto-pilot problems. For example, the Safety Board investigated an MD-11 accident near Shemya, Alaska, on April 6, 1993, that was the result of inadvertent slat deployment at altitude. Two passengers died, and 60 persons were seriously injured.
While efforts are made to reduce the possibilities of injury during such incidents – and we are still investigating circumstances of the United Airlines accident – I think the easiest, common sense answer at this time is for everyone to remain belted while they are seated.
We recently concluded our investigation of an engine failure accident that involved a significant cabin safety issue. On July 6, 1996, Delta Airlines flight 1288, an MD-88, suffered an uncontained engine failure while on its takeoff roll in Pensacola, Florida. Shrapnel from the engine penetrated the cabin and killed two passengers.
After the airplane came to a stop, the first officer attempted to contact the tower and the flight attendants but was unsuccessful because electrical power had been lost. The flight attendants in the aft cabin initiated an evacuation after seeing fire and smoke, the serious airframe damage and passenger injuries, after first attempting unsuccessfully to contact the flightcrew by interphone. All of the overwing exit hatches were opened. However, the captain was not aware of the ongoing evacuation in the rear of the airplane and did not immediately shut down the engines. The evacuation was eventually stopped by the captain as there was no longer the risk of fire, and most passengers exited the aircraft using stairs that were brought up to the aircraft.
As a result of this accident, the Board recommended that the FAA require that all newly manufactured airliners be equipped with independently powered evacuation alarm systems operable from each crewmember station, and establish procedures and provide training to flight and cabin crews regarding the use of such systems. We also recommended that airliners be equipped with cockpit indicators connected to emergency power showing open exits, including overwing exit hatches.
This leads me to my final subject today, a safety study the Board is beginning on emergency evacuations of commercial aircraft. The NTSB has long been concerned about emergency and passenger and crew egress from commercial airplanes. This concern was heightened by the 1990 runway collision between two Northwest Airlines planes in Detroit, Michigan, and the 1995 runway engine failure on a ValuJet aircraft in Atlanta. And we all remember the tragic results of the runway collision at Los Angeles in 1991, where 21 persons who survived the impact died before they could evacuate the burning plane.
These three evacuations, and the partial evacuation following the Pensacola accident, occurred during serious events and were examined in detail by the Safety Board. Each year, however, many evacuations occur under less severe circumstances. Because these events receive less scrutiny, much less is known about them. In 1993, the Safety Board issued an investigative alert seeking information on emergency evacuations from Part 121 and 135 aircraft. Staff reviewed 142 reports of evacuations that occurred during the 3-year alert period. The majority of these evacuations – about 75 percent – occurred because of fire or suspected fire. Although there were no fatalities in these evacuations, 174 persons were injured. Common injuries included fractures of the lower limbs, hip and spine.
During this survey, the Safety Board received 18 reports of problems encountered during evacuations; most of these were mechanical problems like slides failing to deploy or jammed doors. The second most common problem was passengers failing to comply with flight attendant instructions.
Our study will enhance the Board’s understanding of the incidence of evacuations and evacuation-related injuries. We will also study the performance of commercial aviation evacuation equipment and the effectiveness of current evacuation procedures.
We are just formulating our study protocols now. This study will probably take 2 years to complete. We probably will be working with some of you along the way.
Thank you again for inviting me to speak to you today. Your organization
is at the forefront of disseminating information on cabin safety issues,
and we look forward to many more years of close cooperation in our common
goal of making an already safe aviation system as safe as is humanly possible.