Remarks of Jim Hall, Chairman
National Transportation Safety Board
before the Second World Congress, Delft University of Technology
The Netherlands, February 19, 1998
I am very pleased to be here this morning before such a distinguished international group. As chairman of the United States National Transportation Safety Board, I welcome this opportunity and appreciate your hospitality.
You have asked me to address three major issues in the brief time I have with you this morning: an overview of the NTSB, including our use of the party system in investigating accidents; our safety recommendation process; and the victims family assistance function.
Last year marked the 30th anniversary of the Safety Board and I take pride in leading what many consider to be one of the finest transportation investigative bodies in the world. Over the past 30 years, in cooperation with other organizations in the United States and abroad, the Safety Board has raised the level of transportation safety. It has done so by improving and standardizing the investigative process in all areas of transportation, and has served as a model for other nations that have established similar agencies.
As you may know, the Safety Board is an independent agency of the United States government whose mission, since its creation in 1967, has been to determine the "probable cause" of accidents and to make recommendations to improve transportation safety and prevent future accidents. Over the years, our Congress has recognized the value of the agency, first establishing its primacy over investigations conducted by other Federal agencies and then broadening its inter-modal jurisdiction.
The independence of the Safety Board and its clear mandate to conduct in-depth investigations, draw conclusions from its findings, and make recommendations to improve safety, without bias or undue influence from industry and other government agencies, are essential to maintaining the safety of the traveling public. It is not unusual for the Safety Board to address safety issues that are controversial or that may be critical of government or industry standards or operations.
One highly publicized example of this was the Safety Board’s criticism of the FAA for not adopting recommendations issued during the previous decade that would require smoke detection and fire suppression systems in airliner cargo holds. The Board cited the FAA in its probable cause of the ValuJet accident of May 1996 for its failure to require those systems that, the Board felt, could have prevented or greatly mitigated the effects of that accident.
My goal as Chairman is to fully support and advance our mission to investigate accidents and make recommendations to prevent future accidents. I seek to foster relationships in the U.S. and abroad to further that goal. One way to do this is through conferences such as this where we can share experiences and information on accidents and recommendations.
I hope you will see through my presentation that information sharing and a common agenda are the backbone of the Safety Board’s investigations.
We share a common agenda with many different organizations – other safety agencies like the FAA and ICAO, the owners and operators of the transportation system, the Congress and the travelling public. In fact, this common agenda – to make air transportation as safe as possible – is one of the primary reasons that the Safety Board conducts its investigations using the party system. To illustrate how the party system works, let me use the example of a domestic airline accident. However, keep in mind that the procedure I’m describing is the same for accidents in all modes of transportation.
When an airplane crashes, there are many interested parties who wish to be part of the investigation – the Federal Aviation Administration; the air carrier; the aircraft manufacturer; the major component manufacturers; and the pilots, flight attendants and maintenance unions. All have a vested interest in learning what went wrong and what to do to correct it. It is this common concern that sets the stage for the party system or "team concept" used by the Board to investigate an accident. It also necessitates a high degree of organization and coordination before a proper investigation can begin.
When a major accident occurs, a "Go-Team," led by a NTSB investigator-in-charge (IIC), is dispatched from Washington, D.C. to the accident site within a few hours of notification. The Safety Board Go-Team for a typical aviation accident usually consists of about 10 specialists who will serve as group chairmen in specialty areas to be examined during the investigation. Examples of the groups include: powerplants, structures, systems, operations, air traffic control, weather, human performance and survival factors. Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) groups are formed in the Safety Board’s laboratories in Washington. Other groups are formed as needed. A Safety Board Member accompanies the team and serves as principal spokesperson for the on-scene phase of the investigation.
The Go-Team is complemented by substantive experts from the pertinent manufacturers, operators, unions, and the FAA – each of whom brings an array of resources and talent to a Safety Board investigation. It should be noted that, except for the FAA, party status to a Safety Board investigation is a "privilege," not a "right." No news media, lawyers, insurance or public relations personnel representing any party are permitted to participate in any phase of the investigation. Often more than 100 individuals will be working on a major investigation.
As the team is being organized and dispatched, there is already significant interaction between the Safety Board staff, FAA officials, and representatives of the other interested organizations. In the event of an overseas accident, similar communications take place with the officials of the country involved.
To ensure a continuous flow of information throughout the fact finding or on-scene portion of an investigation, the IIC holds progress meetings at the end of each day during which all parties come together and report to the full investigative team on their findings to that point in time. This allows all participants in the investigation to have all of the available information, enabling them to continue their work more efficiently and with a broad understanding of the known events.
Through nightly meetings with all investigative parties, the Safety Board acts as a filter through which only information that can be documented will be released. Generally, after the daily progress meetings, the Safety Board Member on-scene will convene a press briefing to provide an update on the status of the investigation. By having just one voice serving as spokesperson for an accident, we assure that the public is receiving only factually based information from official sources. The inevitable speculation in the news media can therefore be distinguished from the information coming from the investigation itself.
Throughout the investigation, every fact is shared with the parties, giving them an opportunity to dispute the evidence and share their perspectives. Indeed, we invite them to submit their analyses, proposed findings, probable cause, and safety recommendations to us. In the end, however, it is the Board and the Board alone that develops the final report and probable cause determination of an accident.
The party system has been challenged and reevaluated over the years. But we believe that in terms of addressing a common agenda when an accident occurs, this system is clearly the most efficient and productive means of sharing and receiving information. This system also provides an opportunity early in the investigation to immediately identify and correct problems that can prevent similar accidents from occurring.
Throughout the process, parties are required to keep the IIC apprised of ongoing or potential corrective actions. For example, airline and manufacturers’ service letters or bulletins and FAA directives that result from the parties’ participation must be shared with the Safety Board as the information is developed. No restrictions are placed on the timely development of corrective actions by the parties; we merely ask that the Board be informed as they are developed.
If the Safety Board determines that corrective action needs to be taken as a result of information gathered during an investigation, it issues a safety recommendation letter with the necessary factual information to support the recommended action. In many cases, urgent or interim safety recommendations are developed early in an investigation based on initial findings. Each recommendation designates a person or party expected to take action, describes the action recommended, and clearly states the safety need to be satisfied. Although our recommendations are not mandatory, their importance is such that Congress requires the U.S. Department of Transportation to respond to each recommendation within 90 days. Although non-DOT organizations are not required to respond to our recommendations, they, too, have adopted a large majority of them.
Since our first recommendation more than 30 years ago, more than 10,700 others have followed and 3,900 of them have been targeted to aviation. They have been issued to government agencies, manufacturers, operators, pilots, engineers, flight attendants and labor unions and others – more than 190 different recipients over the past 30 years.
More than 82 percent of all of our recommendations over the years have been implemented, resulting in a safer environment for everyone who travels, both in the United States and worldwide.
The success of the safety recommendation program is also due in large part to the Congress, the media, and an aggressive follow-up program. It would be naïve to think that the public does not play a significant role in the success of our recommendation program. Often as the result of media scrutiny, public pressure is brought to bear on the recommendation recipient. If the recipient is unable to move quickly because of institutional roadblocks, the Congress often responds to lift those roadblocks -- making way for the needed changes. For instance, recommendations regarding pilot record sharing have been largely adopted by the FAA, but only after Congress mandated that the agency take action.
To put this process in context, let me give you a real world example of how this process works.
On July 17, 1996, at approximately 8:30 p.m., TWA flight 800, a Boeing 747, blew up shortly after takeoff from New York's John F. Kennedy Airport, killing all 230 persons aboard. That night, the Safety Board launched the largest investigation in its history.
This investigation has marked a lot of firsts for the Safety Board. It has been by far the most expensive and extensive in the Board’s history. It was also the longest on-scene investigation – well over a year and a half – and has involved more Safety Board staff than any investigation – almost 1/3 of the Board’s 370 employees.
Five months into the investigation, the Safety Board identified a potentially dangerous situation and issued four recommendations to the FAA urging short- and long-term actions to reduce the potential for a fuel/air vapor explosion in the center wing fuel tanks of B-747’s, as well as in fuel tanks on other aircraft. Although the industry did not initially embrace our recommendations, since our hearing last December, they are now examining their practicality and developing measures to meet the recommendations’ intent.
It is important to understand that although we may never pinpoint what sparked the explosion of the center wing fuel tank on flight 800, we have identified possible means of preventing similar explosions in the future.
Let me illustrate the importance of international cooperation in aviation investigations by citing a recent example. 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 who served as the U.S. accredited representative, together with investigators from the FAA and Boeing. The Indonesians asked us to read-out both flight recorders in our Washington laboratories. Singapore sent investigators to the scene and to our laboratories. In addition, Australia sent investigators to the scene and to our labs as part of an agreement to provide technical support to Indonesia.
Such cooperation between nations is imperative. The 737 is the world’s most widely used airliner, with approximately 3,000 worldwide. It is imperative that any airworthiness concerns brought out in an investigation are dealt with immediately. My country has a clear obligation to verify the airworthiness of U.S.-manufactured aircraft. Similarly, information on an Airbus, Embraer, Fokker, Bombardier or Saab could affect the safety of millions of travelers, and those particular States of manufacture have similar concerns. Obviously, our common concerns will continue to require multinational cooperation in accident investigations.
I would like to discuss one last issue before I close -- the Safety Board’s new role of coordinating assistance to the families of accident victims.
For those of you who have been involved with a major aircraft crash, I do not need to tell you that some past responses lacked organization, coordination, and far too often, compassion. Based on Congressional testimony and other forums, we’ve heard numerous horror stories -- continuous busy signals from the airline’s 800 accident information number; misidentified remains; personal effects being mishandled; unidentified remains not handled with dignity, including mass burials without informing families; and the use of confidential information obtained during this grief process against families in court. I think we can all agree that this type of treatment should not and cannot be tolerated.
Family members of victims, not just in the United States, are demanding more accountability in the aftermath of accidents. Their concerns are rather basic and reasonable -- timely notification of the accident and information on the process for the recovery and identification of victims, disposition of unidentifiable remains, and return of personal effects. Yet, more often than not, this fundamental desire for information has been ignored in the past.
The NTSB’s experiences while at accident sites and the increasing activism on the part of victims’ families brought their perceived mistreatment to the Nation’s attention. To rectify the problem, in September 1996, President Clinton named the Safety Board as the coordinator for federal services to families of victims of transportation accidents. The following month, Congress enacted legislation that gave us the family affairs responsibilities for aviation disasters. Although the Board did not seek that responsibility – it was assigned to us because of our long and respected history at crash sites as the eyes and ears of the American people.
Our new seven-person Office of Family Assistance coordinates and integrates the resources of the federal government and other organizations to help support local and state governments and airlines to meet the needs of aviation disaster victims and their families. Federal resources can provide assistance in areas such as family counseling, victim identification and forensic services, communicating with foreign governments, and translation services, to help local authorities and airlines support victims’ families more effectively following a major aviation disaster.
Since passage of the law in the U.S., our family assistance plan has been used 4 times including the KAL flight 801 accident in Guam. As a result of that accident, 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 U.S. air carriers.
On September 28 and 29, 1998, the Safety Board will host an international symposium in Washington, D.C. for industry, government, and community officials to promote a better understanding of the federal government’s family assistance role after a transportation disaster. It will also allow individuals and organizations to discuss their experiences and learn new techniques in disaster resource management. I invite all of you to attend what will be the first international gathering of this kind. Information on the conference will be available this Spring on our Internet home page, www.ntsb.gov.
In closing, I am reminded that my predecessor, Carl Vogt, spoke before this Congress in 1992 and urged closer ties with other independent agencies and expressed his belief that there needs to be more such agencies, preferably inter-modal, because our experience testifies to their efficiency and economy.
I strongly believe that since the First World Congress six years ago, we have seen the benefits of working closely together. Since that time, the International Transportation Safety Association (ITSA) has been founded and joined by 7 independent investigation authorities. We now meet annually to share information, discuss common concerns, and look for ways to refine and enhance the information sharing between our agencies.
Globally, all of our citizens board airplanes, buses, ships and trains in pursuit of recreation and business. It is our mission and duty to maintain a constant and vigilant effort to keep transportation safe for all of the world’s travelers. This task will be much easier if we work together to achieve this end.
In closing, let me state that one of the founders of my nation, Thomas Jefferson, said, "The care of human life and happiness is the first and only legitimate object of good government." I believe it is this simple phrase that describes the mission and goals of the National Transportation Safety Board and independent accident investigation agencies worldwide.