Remarks by Jim Hall, Chairman
National Transportation Safety Board
before the Air Line Pilots Association Air Safety Forum
Washington, D.C., August 19, 1998
Thank you, Captain Babbitt, and thank you all for inviting me to this prestigious occasion. I congratulate all of your Air Safety Award recipients.
As you may know, I fly between Washington, D.C. and my home in Chattanooga, Tennessee several times a month and have, on many occasions, made acquaintance with ALPA pilots along the way. Just last week, I was flying up here to Washington and got a nice note from the flight crew, Captain Jim Allen and First Officer Robert Ioan of USAir. I was touched by a message they sent back to me expressing their appreciation for everything I and the National Transportation Safety Board have done to make transportation safer for everyone.
Let me use this occasion to send a return note from me to you. I appreciate everything ALPA has done for transportation safety for the last half century, I appreciate all the help we get from ALPA in our investigations – particularly the support provided by Keith Hagy and his staff – and I look forward to working even more closely with ALPA in the future toward our common goal of eliminating aviation accidents.
May I digress here for just a minute to talk about one of your honorees, Captain John Cox of USAir. You might not know that he is the only Safety Board-recognized "Average Pilot." That came about at our second public hearing on the USAir flight 427 accident that I chaired. After hearing from Boeing and FAA test pilots on the wake vortex tests we conducted, Captain Cox was called as a witness. As he approached the podium, I noted that I have been called an average Safety Board Chairman, so he must be here to represent the average pilot. On a later occasion, after I spent a day flying with him, my staff met us at National Airport and presented Captain Cox with an NTSB plaque designating him "the Average Pilot." I’ll have more to say about that concept later.
To gauge our success over the years, you only need look at the safety record of our nation’s aviation system. We’ve heard all the "gee whiz" statistics about how many thousands of years you’d have to fly every day of the year before the odds of being killed in an airline accident catch up with you; about how even in a bad year there is one fatality for every 2 million passengers carried safely; and that in a relatively good year like 1997 there were more than 300 million passengers carried safely for every passenger fatality.
A more telling statistic is the accident rate, which, if it held steady for the last 30 years, would have resulted in a major hull loss every week. That, of course, has not happened because the industry gets safer and safer every year. In 1996 – a year with several high profile accidents – the fatal accident rate for the nation’s scheduled airlines per million aircraft miles was 1/24th that of the rate in 1960, and one-third that of 1981.
That remarkable improvement was the result of more than just NTSB recommendations or FAA regulations: it took a concerted effort by all of us, government, industry and organizations such as ALPA to get that job done.
Through ALPA’s participation in our investigations, you have shared your wealth of up-to-date operational experience with procedures, techniques and equipment. Through the years, you have been able to identify problem areas directly affecting pilots, such as:
• Approach design.
• ATC procedures.
• Unusual attitude recovery.
• Wind shear, and
• Wake turbulence.
Moreover, ALPA pilots and ALPA safety committees have routinely identified and proposed remedial actions for a variety of aviation safety issues. For example, ALPA experts have always worked closely with the NTSB and other aviation community specialists on air traffic control issues, forecasting and dissemination of severe weather information, instrument approach design and procedures, human performance, survival factors and airport safety.
I am particularly proud of the work ALPA and the Safety Board have accomplished together during my tenure as Chairman of the NTSB. The last 4 years have been extremely busy, and we have tackled safety issues to help pilots ensure the safety of their operations.
When I became Chairman, I had no inkling about the level of activity the NTSB was about to enter. July 1994 saw the end of an unprecedented 27-month period in which the major U.S. scheduled airlines incurred no passenger fatalities: a billion passengers carried safely to their destinations.
The USAir accident in Charlotte, North Carolina changed all that. It was closely followed by another USAir crash near Pittsburgh; and then crashes involving American Eagle in Roselawn, Indiana; another American Eagle near Raleigh-Durham; American Airlines in Colombia; ValuJet in the Everglades; Delta Air Lines in Pensacola; TWA flight 800; United Express in Quincy, Illinois; Comair in Michigan; and Korean Air in Guam. And, we’ve also lost two FedEx widebody planes and had another major cargo accident in Miami.
We could not have investigated these accidents without the support and expertise of your organization and others. ALPA’s participation in our major aviation investigations has led to many changes in hardware and operations that have helped keep the accident rate on a declining line for more than 3 decades. For example, ALPA joined us in supporting the installation on our nation’s airliners of Enhanced Ground Proximity Warning Systems, especially following the tragic American Airlines crash in Colombia in December 1995. Since then, the industry has announced it will voluntarily install EGPWS without waiting for federal regulations. This will give pilots a state-of-the-art tool to help rid the world’s airline system of controlled-flight-into-terrain accidents.
During the investigation of the 1994 crash of an ATR-72 in Roselawn, Indiana, ALPA actively supported the tanker icing tests that led to changes in the design of that aircraft and in our understanding of flight in icing conditions. ALPA assisted us with engineering expertise to develop factual information about the airframe icing-related problems with the ATR 42 and 72. You provided the Safety Board with valuable documentation that identified an icing problem with the airplane and expressed the concerns of your membership to the FAA about certification and operation of the airplane in icing conditions.
Just as that investigation was beginning, the Safety Board completed a safety study on commuter airlines, and concluded that they should be included under the same operating regulations as the major airlines. The phrase, "One Level of Safety," was coined by ALPA, and ALPA’s support of the NTSB’s efforts enabled us to achieve significant changes in commuter air carrier regulations. I count passage of the new regulations that adopted this concept as one of the highlights of my years as Chairman.
I don’t have time to go into detail about investigations before my time at the Board in which ALPA’s assistance proved invaluable. Just a brief list of issues that were dealt with by ALPA and the Safety Board in the past is impressive:
• first-generation Ground Proximity Warning Systems,
• wind shear detection and pilot training,
• air traffic control communications,
• airport signage and lighting, and
• training and maintenance procedures for propeller engines.
And ALPA is also assisting with a number of our major current investigations:
The investigation of TWA flight 800 is on-going, and it’s unclear when we will be ready to issue a final report, although I suspect it will be sometime in 1999. What is important is that, with the help of ALPA and all the other parties to our investigation, we have learned much about what happened that tragic night and have identified mechanisms that would make such an accident less likely in the future.
So far, we have spent over $30 million on this investigation – not counting what the FBI spent when they were investigating the accident. Those funds were used in the mammoth recovery of victims and wreckage from the bottom of the ocean, the largest aircraft reconstruction in the world, and the many detailed and cutting edge tests going on in laboratories around the world.
ALPA has been with us all along in this investigation – living on the recovery boats, working on the reconstruction, and participating in the laboratory examinations. We have made important discoveries. We learned early on that heat from the air conditioning packs can push the vapors in the center wing fuel tank above their flammable limits, while adjacent wing tanks remain below the temperature required for flammability. That discovery resulted in four safety recommendations issued in December 1996, calling for the FAA to correct the problems.
We have not given up trying to find an ignition source, and our problem has been the large number of potential sources found. We are still painstakingly working through the numerous scenarios.
But even without a known ignition source, we have accomplished a great deal. Based in large part on NTSB recommendations and support of organizations like ALPA, the industry and FAA have a greater and more realistic understanding of the potential danger of fuel/air mixtures in nearly empty fuel tanks. Although we all now agree that much has to be done to further reduce ignition sources, the question has become whether in the final analysis all of them can be eliminated.
At last count, including both final or proposed actions directly related to TWA flight 800 and those in related areas – such as with the Boeing 737 wiring conduits – there have been no fewer than 18 airworthiness directives or notices of proposed rulemakings, 37 Boeing/Douglas Service Bulletins and All Base Messages, and 20 vendor service bulletins, such as for the fuel pumps.
And, one of the major by-products of our work on the TWA accident results from the concern of our investigators about aging electrical components and wiring. The FAA is on the verge of inaugurating an "aging wiring" program, similar to what happened for aircraft structures after the Safety Board investigated an accident involving an Aloha Airlines Boeing 737 in 1988.
Recently, the Aviation Regulation Advisory Committee reported on our fuel flammability recommendations. Although we haven’t had a chance to study the report as carefully as we need to, we’re disappointed that the ARAC did not offer actions aimed at the existing fleet. Nevertheless, there is now recognition by all concerned that it is better not to have volatile vapors in fuel tanks, somewhat of a sea change over the last two years.
Next Thursday, we will hold a Board Meeting to discuss a final report on the January 9, 1997 crash of Comair flight 3272 in Monroe County, Michigan. This investigation has again raised concerns about operating turboprop aircraft in icing conditions, and with ALPA’s help and encouragement, the Safety Board conducted flight tests at Embraer to learn more about flying characteristics of those aircraft in icing conditions. I urge you to look for an abstract of our final report on our web site, www.ntsb.gov, which should be available following our meeting on August 27th.
We are also completing what is currently the longest investigation in our history, that dealing with the crash of USAir flight 427 in Aliquippa, Pennsylvania almost 4 years ago. All 132 persons aboard the Boeing 737 died. Our investigation has been hampered by the limited number of parameters – 11 – recorded by the airplane’s flight data recorder. As you’re probably aware, many newer airplanes, including 737s, record over 100 parameters. This is an issue on our Most Wanted list, and my number one priority as NTSB Chairman.
ALPA has been instrumental during this investigation in assisting the Board conduct wake vortex flight tests; it was ALPA pilots – including Captain John Cox – at the controls of the test aircraft. As a result of those tests and flight simulations, as well as extensive laboratory tests, the Safety Board has issued safety recommendations addressing both pilot training and aircraft components.
We found that pilots may not have been adequately trained and periodically tested to respond to sudden events that can cause an airplane to assume an unusual attitude. In another important safety improvement brought about by the collaboration between the Safety Board and ALPA, this training is now given to airline pilots.
Additionally, the investigation has uncovered several safety concerns in the Boeing 737 rudder system components. As you know, in response to an airworthiness directive issued August 4, 1997, the entire Boeing 737 fleet, over 2,800 airplanes, is being modified with an improved rudder PCU servo valve. In addition, in August 1997, the FAA published a final rule that requires installation of a newly designed rudder-limiting device and yaw damper system by August 2000. Although we are pleased with this action, we are concerned that the FAA is not requiring the installation until the year 2000.
We also hope to complete our investigation into the crash of Korean Air flight 801 on Guam late this year or early next. Among the issues being examined in this investigation are controlled-flight-into-terrain accidents, airline procedures and training in that area, and air traffic control procedures. Although ALPA is not a party to the investigation, you have been extremely helpful to us in our examination of the instrument approach procedure design. One of your captains with extensive experience in this area provided valuable data during testimony at our public hearing in March.
In closing, let me restate something I said at the outset. You might remember that I spoke of Captain John Cox, the so-called "average pilot." But the fact is, when an engine fails two seconds after rotation, or a landing gear stubbornly refuses to come down, or an airliner’s electrical system goes on the blink, there is no average pilot. The fact that our airline system and its safety record are the envy of the world tells me that every one of the men and women at the controls of America’s air carrier aircraft are professionals who routinely exhibit extraordinary skills.
I value my brief meetings with your membership during my travels around the country, and thank you all for making my job a little easier, whether it is by preventing an accident through skillful airmanship, or by helping the Safety Board during difficult investigations.
I do not for a moment forget the fact that, before many of the safety improvements we’ve talked about came into being, a tragic accident occurred that exposed a safety problem in our system. I have dedicated my years at the Safety Board to ensuring to the best of my ability that not one more person should die once we’ve identified ways to eliminate a potential danger. I also know that you are equally dedicated to eliminating potential accident causes, and I thank you for your help in the past, and I pledge my help to you, in turn.
Thank you for the opportunity to join you tonight on this wonderful occasion, when you honor the best among you.