Remarks by Chairman Jim Hall
National Transportation Safety Board
before the International Society of Air Safety Investigators
Barcelona, Spain, October 19, 1998
Thank you Jim [Stewart, Chairman of the Seminar], and President Stone [Captain Dick Stone, president of ISASI, Delta Airlines retired]. Thank you Senor Luis Felipe de la Torre, for your welcoming remarks.
I want to thank you for inviting me to speak to you here today, and for the opportunity to take part in this meeting in such a lovely setting. It is quite fitting that, only last week, we in the United States celebrated "Columbus Day," commemorating that courageous journey to the Americas by Christopher Columbus, just over 500 years ago. Although he had the full support of Queen Isabella and King Ferdinand, he did not have a GPS to guide him, yet he still managed a successful round trip.
On a more recent note about Spanish-American cooperation, at the 32nd Assembly Meeting of ICAO in Montreal last month, the U.S. and Spain worked together to achieve adoption of an important resolution regarding the need for an international solution to dealing with the affairs of victims and their families, following tragic airline accidents. It is a sincere pleasure to personally express my thanks to Senor Luis Felipe de la Torre and the government of Spain during my short visit.
What a marvelous opportunity this is to speak today before the best experts in aircraft accident investigation in the world—bar none! Just three short years ago, I used the same introductory words when I spoke to you in Seattle, Washington. They still apply.
Another reason that I am pleased to be attending this seminar is to show my support for ISASI and its goals and objectives. As many of you know, I recently approved the NTSB becoming a Corporate Member of ISASI; again to show my support for your society and the work it does.
Before I continue, let me introduce the NTSB staff here with us today.
Jamie Finch, Director of our Office of Government, Public, and Family
Ron Schleede, Deputy Director, Office of Aviation Safety, International Affairs;
Jim Wildey, Chief of the NTSB Materials Laboratory; and,
Richard Wentworth, Senior Air Traffic Control Investigator.
Unfortunately, because of our unprecedented workload, other NTSB investigators were unable to attend.
I had originally planned to focus my remarks today on the issue of assistance to the accident victims and their family members because of the importance of that issue. Certainly, no one can deny that it is the victims of accidents and their families who are affected the most when there is an accident.
I am aware of concerns and questions often raised by air safety investigators and other aviation officials regarding the family assistance program of the NTSB. For example, does the program adversely affect the investigation? Does it take resources away from the investigations? The answers are quite simply no.
When the NTSB was given these new responsibilities, I established clear policies that the family assistance program would be totally separate from and would not interfere with the NTSB investigation processes that have proven their worth over many years. I will not permit these new important responsibilities to diminish in any way the technical excellence of our investigation programs.
As a matter of fact, the family assistance program has proven to be of assistance to our investigators. For example, our human performance and survival factors investigators have been able to conduct more timely interviews due to better access to family members and survivors through the program. Because the family assistance program responsibilities rest with the NTSB, I can control these factors. If they rested with another agency, it might be far more difficult.
Although there might have been understandable grounds for skepticism in the early days of this program, I think our record so far should allay any fears you had that the quality of investigations would suffer because of this new responsibility.
Jamie Finch and I will be here all week and we will be pleased to meet with any of you to explain our family affairs program and answer any questions you might have. There is also information about the program on our Internet web site, www.ntsb.gov.
As I mentioned at Seattle in 1995, communications is one of the hallmarks of my Chairmanship at the NTSB. I have attempted to foster better communications within my agency, among our U.S. aviation community, and between the NTSB and our international colleagues. I believe that this seminar and its theme, "Pushing the Envelope Towards Improvement" are excellent means for improving communication, with the ultimate goal of accident prevention. I look forward to hearing the technical presentations this week and to meet with all of you. I hope my short remarks will provoke discussions and thoughts about how we can work together to improve communication.
Since I spoke at the ISASI Seminar in 1995, air safety investigators around the world have been extremely busy. There have been several catastrophic accidents in most regions of the world. NTSB investigators have worked on accidents on 5 continents. Investigators from more than 30 nations have worked with NTSB investigators on many investigations. In fact, on just one day last summer, there were representatives from 5 nations working in our laboratories.
The increasingly international flavor of aviation has been highlighted by the fact that investigators from many countries have been working on accidents such as TWA flight 800, Silk Air and Swissair flight 111.
I believe that recent significant developments related to the Swissair flight 111 crash are quite relevant to the theme of this seminar and warrant a discussion. The Swissair investigation is still underway under the leadership of the Canadian Transportation Safety Board and we are participating in accordance with ICAO Annex 13. Consequently, I will not speak about the findings or progress of the investigation.
Rather, my remarks pertain to the need for timely notification, and investigation and reporting, of serious incidents and accidents by an authority that is fully independent from the organization that regulates civil aviation. I am aware of ICAO guidance in this regard and European and other States’ initiatives to form independent investigation authorities. Nevertheless, I wanted to revisit this issue with you today.
As many of you are probably aware, there has been considerable recent media coverage about the flammability of airliner thermal insulation blankets. These discussions center around flammability tests conducted by the Federal Aviation Administration (FAA) in 1996 at the request of the U.S. aircraft industry following events involving fires and flame propagation on thermal insulation blankets that occurred on 5 airliners between 1993 and 1995.
The NTSB participated in fire investigations conducted by Denmark and Italy. We concentrated on determining the ignition sources and on developing methods to eliminate those sources, rather than on the fire propagation. Although the flammability of the thermal insulation blankets was evaluated and addressed by those investigations, and the FAA conducted some tests, no positive corrective actions were taken.
Three of the fire events occurred in China and the Chinese government did not notify the NTSB of them. Consequently, we were not aware of the findings of those investigations and thus were not able to make an independent comparison with the findings of the previous two cases. That said, the Chinese did an excellent job of investigating all three events and forwarded their findings to the aircraft manufacturer and the FAA, along with recommendations for further actions related to the flammability of thermal insulation blankets. The FAA conducted further tests and issued a technical report in September 1997. Although the tests illustrated serious concerns about the flammability of the materials tested, no corrective actions were mandated until last week when the FAA announced a program for future replacement of airliner thermal insulation blankets. As you can expect, this program could have enormous economic implications, besides the serious safety concerns involved.
Whether this issue is relevant to the Swissair accident has yet to be determined. However, the accident certainly prompted the FAA to take these precautionary actions.
We have brought with us many examples of the significant benefits of timely notifications and independent investigations by the NTSB that have led to significant safety payoffs in a recently updated document, We Are All Safer. It is also available on our Internet web site at www.ntsb.gov.
I am fully aware that your society and this seminar are dedicated to improving the science and the art of accident investigation and prevention. I wish you success and offer the assistance of the NTSB to achieve your goals. Accident prevention should be a top priority for all of us.
I would like to add a note regarding inter-modal cooperation in accident investigation and prevention. On May 3 to 5, 1999, the NTSB is sponsoring an international symposium on improving the use of recorders, not just flight recorders, to improve the prevention of accidents in all modes of transportation. I hope you can join us there.
Thank you again for the opportunity to speak to you today. I look forward to a very productive week.