of Jim Hall, Chairman
National Transportation Safety Board
Subcommittee on Aviation Committee on Transportation and Infrastructure
House of Representatives
Regarding Aviation Issues as a Result of the
Crash Involving EgyptAir Flight 990
April 11, 2000
Mr. Chairman and Members of the Committee, it is a pleasure to appear before you today on behalf of the National Transportation Safety Board to discuss the EgyptAir flight 990 crash and aviation issues that have arisen as a result of that crash and others, specifically the use of video recorders in cockpits, language communication problems, and psychological profiling of crew members. With me today are: Dr. Bernard Loeb, Director of our Office of Aviation Safety, and Dr. Vern Ellingstad, Director of our Office of Research and Engineering.
As you know, EgyptAir flight 990 crashed off the coast of Nantucket in the early morning of October 31, 1999 with 217 individuals on board, including 101 Americans. The NTSB, with the assistance of the Egyptian Civil Aviation Authority, the Egyptian government's designated representative, is still investigating the crash.
To date, the Safety Board has expended more than 2,400 hours conducting the investigation, excluding overtime, and we have expended more than $13 million in investigation-related expenses for the services of other agencies (including the Navy's search and recovery effort). We anticipate that the final total of those expenses will be about $17 million. Because we have not concluded our investigation and have made no final determination as its cause, my discussion of that crash will be limited. However, the Safety Board's investigation into several recent crashes has highlighted the need for recording images of the cockpit environment. The Safety Board believes that the availability of electronic cockpit imagery would help resolve issues surrounding flight crew actions in the cockpit.
For example, it would tell us which pilot was at the controls, what controls were being manipulated, pilot inputs to instruments (i.e., switches or circuit breakers), or what information was on the video displays (i.e., the display screens and weather radar). Video recorders would also provide crucial information about the circumstances and physical conditions in the cockpit that are simply not available to investigators, despite the availability of modern cockpit voice recorders (CVRs) and 100-parameter digital flight data recorders (DFDRs).
The Safety Board first discussed the need for video recording the cockpit environment in its report of the September 1989 incident involving USAir flight 105, a Boeing 737, at Kansas City, Missouri. In that report, we recognized that while desirable, it was not yet feasible. As a result, the Board did not make a recommendation on the use of video recordings at that time. However, in the almost 11 years since that incident, considerable progress has been made in both video and electronic recording storage technologies. Electronic recording of images in the cockpit is now both technologically and economically viable, and solid state memory devices can now capture vast amounts of audio, video and other electronic data.
In February 2000, as a result of an October 1997 accident involving a Cessna operated by the Department of Interior that was not required to have a CVR or FDR, the Board recommended that the Federal Aviation Administration (FAA) require crash-protected video recording systems on Part 135 aircraft not currently required to have a crashworthy flight recorder device.
To further address this issue, the Safety Board is today recommending that the FAA require Part 121, 125, or 135 aircraft currently equipped with a CVR and a FDR to also be equipped with a crash-protected cockpit image recording system. We should not further delay the implementation of available technology that may help us more quickly determine the probable cause of accidents - and, therefore, prevent future accidents.
I'd like to show you a brief video clip to illustrate some of what we expect to be recorded by a cockpit image recording system.
In the first segment, the camera is not fixed in the airplane, so the recording is uneven. As you can see, the video will show which crewmember is operating the controls or making selections, such as arming the spoilers. The video will also capture the interactive displays used by flight crews in the modern cockpit, but are not recorded by the FDR. You will notice that it is never necessary to focus on the crew's faces to capture this important information.
Mr. Chairman, the Safety Board is extremely sensitive to the privacy concerns that the pilot associations and others have expressed with respect to recording images of flight crews. As you know, the Board's reauthorization passed by this Chamber would require that the same protections already in place for CVRs be extended to image recorders in all modes of transportation. Under those provisions, a cockpit image recording could never be publicly released.
The Board is also aware of concerns regarding the treatment of all recorded media in foreign accidents. We share those concerns and will work aggressively with the International Civil Aviation Organization (ICAO) to improve the protections afforded to these recordings in other countries. In addition, on April 25 and 26, the Safety Board is holding a "Transportation Safety and the Law Symposium" that will address the issues of employee privacy and criminal inquiries and their impact on transportation safety. We are also open to suggestions this Committee may have to improve safeguards governing the use of these devices.
The second issue I would like to address is language communication problems. Although the Safety Board has had a longstanding concern about this issue, I must note we have no evidence of any language difficulties in the EgyptAir crash. However, the importance of this issue has been well documented in a number of accidents, including the January 1990 Avianca Airlines' accident in Cove Neck, New York and the December 1995 American Airlines' accident near Cali, Colombia. As a result of our recommendations following the Cali accident, ICAO's Air Navigation Bureau has formed a group that will hold its first meeting in October 2000, to specifically study English language issues.
Finally, the last item I would like to address today is the issue of psychological screening for pilots. Although such events are rare in commercial aviation, and there have been no documented cases of a U.S. pilot's deliberate actions causing an accident, there have been accidents and incidents that may have been caused by a pilot's deliberate actions.
· In 1994, an off-duty Federal Express pilot, riding in the jumpseat, attacked the flight crew with a hammer and a spear gun.
· In 1997, a SilkAir Boeing 737 crashed in Indonesia. The Indonesian investigative authority has sought the assistance of law enforcement authorities to look into this issue in that investigation.
· In 1999, an Air Botswana pilot, who had been grounded for medical reasons, took off in a company airplane and threatened to crash it into airline headquarters. The pilot landed the airplane, but deliberately collided with two other company airplanes.
Although it is not clear that any of these crashes would have been prevented by better pilot screening techniques, it is in everyone's best interests for the airlines and the FAA to ensure that only the most qualified and capable applicants are chosen to become airline pilots.
Mr. Chairman, that completes my statement and I will be happy to respond to any questions you and the Committee may have.
Mr. Chairman and Members of the Committee, it is a pleasure to appear before you today on behalf of the National Transportation Safety Board (NTSB) to discuss aviation issues arising out of the EgyptAir flight 990 crash. In particular, those issues are: the use of video recorders in cockpits, language communication problems, and psychological profiling of crew members.
Before addressing these issues, I would like to update the Committee on the Board's investigation of the crash of EgyptAir flight 990.
On October 31, 1999, EgyptAir flight 990 crashed about 60 miles south of Nantucket after departing JFK International Airport about 30 minutes earlier. Onboard were 217 passengers and crew, including 101 Americans. Because the crash occurred in international waters, the Government of Egypt, as the State of Registry under Annex 13 to the Convention on International Civil Aviation, was responsible for conducting the investigation. However, the Egyptian Civil Aviation Authority (ECAA), in accordance with Annex 13, asked the NTSB to conduct the investigation and to keep them informed of developments.
Based upon that delegation, we initiated an investigation under our rules and procedures. To date, the Board's staff have conducted an extensive investigation into the cause of this crash. Our structures experts have examined the recovered wreckage, systems engineers have examined flight control systems components and explored potential failure scenarios, airplane performance engineers completed computer simulations and other calculations of the airplane's performance, electrical/acoustical experts analyzed the sounds on the cockpit voice recorder (CVR), and human performance experts have reviewed all available background information on the pilots, analyzed the voice recorder and interviewed witnesses. Examination of engine data from the digital flight data recorder (DFDR) and visual inspection of the engines indicate that the engines were operating properly. In addition, Safety Board staff traveled to Egypt to examine maintenance and operations records and, at the request of the FBI, traveled to England to interview an EgyptAir pilot who has requested asylum there.
The NTSB has expended more than 2,400 work days, excluding overtime, on the EgyptAir investigation. In addition, the NTSB has incurred costs as a result of this investigation in excess of $13 million, and we anticipate costs of the entire investigation to be approximately $17 million.
Based on the evidence we have seen thus far - the DFDR, the CVR, radar data, computer simulations, and the wreckage recovered (approximately 90 percent by weight) - we have found no indication of a mechanical or weather-related event that could have caused this crash. We are not yet prepared, however, to state the cause of the crash and we are continuing the investigation with the assistance of the Egyptian government.
I would now like to turn to a discussion of the three issues I mentioned earlier, beginning with the need for video recorders.
The Safety Board first discussed the need for a video recording of the cockpit environment in its report of the September 8, 1989, incident involving USAir flight 105, a Boeing 737, at Kansas City, Missouri. In this incident, the airplane collided with four transmission cables during approach. The crew executed a missed approach and landed uneventfully in Salina, Kansas. The Board determined that the probable cause was the flightcrew's failure to adequately prepare for and execute a nonprecision approach and their subsequent premature descent below minimum descent altitude. Our report pointed out the limitations of existing flight recorders to fully document the range of the flight crew's actions and communications. An image recording of the cockpit environment would have established the availability and use of the appropriate checklists and approach charts, the use of hand signals by the flight crew to communicate commands for airplane configuration changes, and what configuration changes were made. This data would have provided investigators insight into the nature of the crew's briefing and approach chart review as they prepared for the localizer back course approach. The report also noted that the introduction of aircraft with electronic "glass" cockpits and the use of data link communications would enable the flight crew to make display and data retrieval selections that would be undetectable by the CVR and DFDR - but could be captured by a video recording.
On October 8, 1997, a Cessna 208B, operated by the Department of the Interior, experienced a loss of control and crashed about 18 miles from Montrose, Colorado. This aircraft did not have, and was not required to be equipped with, a CVR or DFDR. Further, there were no recorded communications between the accident aircraft and air traffic control or other aircraft. A cockpit image recorder may have provided crucial information about conditions in the cockpit and the crew's actions. The Safety Board's investigations of several accidents involving Cessna 208s and similar turbine-powered aircraft in recent years have been hampered by the lack of DFDR and CVR information. An image recorder would have provided investigators with critical factual information such as altitude, airspeed, engine power, flight control inputs, aircraft configuration plus human factor and atmospheric conditions. On February 8, 2000, the Safety Board recommended that the Federal Aviation Administration (FAA) require, within 5 years of a technical standards order's (TSO) issuance, the installation of a crash-protected video recording system on all turbine-powered nonexperimental, nonrestricted-category aircraft in 14 Code of Federal Regulations Part 135 operations that are not currently required to be equipped with a crashworthy flight recorder device. Although the installation of conventional DFDRs and CVRs on these types of aircraft has been economically impractical, recent technological advancements have made cockpit image recording a viable alternative solution. Advances have occurred in video compression technology, solid state memory, and the availability of high quality, inexpensive cameras. Further, third generation flight recorders are capable of recording data, voices or images. Solid state technology coupled with video compression techniques will now permit the storage of a video recording in a crash hardened recorder. In addition, recent advances in camera technology will provide miniaturized cameras capable of recording under a wide range of lighting conditions at a variety of optical focal lengths and fields of view. The need for recording of cockpit images has become more evident with the lack of valuable cockpit information in several recent major investigations, including ValuJet flight 592 that crashed near Miami on May 11, 1996, and EgyptAir flight 990 that crashed off Rhode Island on October 31, 1999, as well as foreign investigations involving SilkAir flight 185 that crashed in Indonesia on December 19, 1997, and Swissair flight 111 that crashed near Halifax, Nova Scotia on September 2, 1998. In each of these investigations, crucial information about the circumstances and physical conditions in the cockpit was simply not available to investigators, despite the availability of good data from the DFDRs and CVRs. In the case of ValuJet flight 592, a cockpit image recorder may have provided critical information about the exact smoke and fire conditions present in the cockpit during the last few minutes of the flight. A cockpit image recorder may have also shown the smoke and fire conditions and the status of the flight instrument displays in the cockpit of Swissair flight 111 that led to the crew's decision to descend from cruise flight and divert to Halifax. Because there is no data on the CVR and DFDR for the final minutes before the SilkAir flight 185 crash, the Indonesian investigation has been hampered by a lack of information concerning what occurred in the cockpit. The availability of a cockpit image recording may have allowed them to focus their investigative efforts more effectively.
The need for a video recording of the cockpit environment is most evident in the EgyptAir investigation. Staff believes that electronic cockpit imagery would help resolve issues surrounding the flight crew's actions in the cockpit that resulted in the changes in the aircraft's controls as well as the circumstances that prompted those actions.
Considerable progress has been made in the 10 years since the Kansas City, Missouri, accident in both video and electronic recording storage technologies. Electronic recording of images from the cockpit environment is now both technologically and economically feasible, and practical solid state memory devices have been developed that will capture enormous quantities of audio, video and other electronic data.
The use of a cockpit image recording system would permit the recording of controller-pilot data link (CPDL) communications. Current analog CVRs cannot record CPDL messages. Therefore, they will need to be replaced by other systems on all aircraft using CPDL. In addition, the communication system architecture on many aircraft will make it difficult and expensive to record CPDL messages directly onto a flight recorder. In these instances, the video recording of the cockpit CPDL display would be an acceptable and cost effective means of complying with regulatory requirements.
The international aviation community is also aware of the safety benefits of crash-protected video recorders. ICAO's Flight Recorder Panel agreed, in November 1998, that the use of video recordings in aircraft cockpits would be very useful. The panel further noted that the European Organization for Civil Aviation Equipment (EUROCAE) was developing minimum operational performance specifications (MOPs) for such recorders.
As a result of the Montrose, Colorado, accident, the Safety Board issued a recommendation to the FAA to incorporate EUROCAE's performance standards for a crash-protected video recording system into a TSO. The Safety Board believes the FAA should work with EUROCAE to help expedite the finalization of the MOPS and to incorporate the performance standards defined in the MOPS into an FAA TSO for a crash-protected cockpit image recording system as soon as practicable.
The Safety Board is sensitive to the privacy concerns that have been expressed by pilot associations and others with respect to recording images of flight crews. In order to protect crew members' privacy, the Safety Board, in its request for reauthorization, has asked Congress to apply the same protections that exist for CVRs to the use of image recorders in all modes of transportation. Under these provisions, a cockpit image recording would be not be publicly released. The Board is also aware of concerns regarding the treatment of video (as well as other types of recordings) in foreign accidents and will work with ICAO to improve protections afforded to recorded information on an international level. However, the Board believes that given the history of complex accident investigations and the lack of crucial information regarding the cockpit environment, the safety of the flying public must take precedence.
In the 1960s, the support of airline pilots and the aviation community were instrumental in ensuring that accurate, complete information of cockpit communications was secured for accident prevention purposes. Many of the advances in aviation safety since that time can be directly traced to the installation of CVRs and the critical information captured by these devices. Imaging technology has advanced to the point that the aviation safety community will have access to a new generation of recorders that can lead to an even greater understanding of the root causes of accidents and build upon the solid safety foundation made possible by CVRs.
Language Communication Problems
The Safety Board's investigation of the tragedy involving EgyptAir flight 990 has found no evidence that there were any communication problems between air traffic controllers and the pilots on the aircraft. Nonetheless, the Safety Board has had a longstanding concern about pilots whose native language is not English communicating with United States controllers, and with English-speaking pilots communicating with controllers in non-English speaking countries. The International Convention of Civil Aviation (ICAO) has not established English as the standard language of aviation. However, it has been informally understood for many years that English is the language used to provide guidance to both pilots and controllers.
The importance of standard aviation phraseology was demonstrated in the accident involving a Boeing 707, operated as Avianca flight 052, that crashed in Cove Neck, New York on January 25, 1990, after running out of fuel. The Captain on that flight, who was the pilot flying, designated the First Officer as the pilot to communicate with United States air traffic controllers. After a series of in-flight delays due to weather, the flightcrew became concerned about their increasingly low fuel state and their urgent need to land. The Captain ordered the First Officer to declare an emergency to air traffic controllers; however, the First Officer, whose command of English was good, did not use the word "emergency," but instead, advised controllers that the flight required priority handling due to the low fuel state. This term did not convey the urgency of the situation, and after additional delays, the airplane ran out of fuel and crashed on approach to JFK airport.
As a result of the Avianca accident, the Safety Board recommended that the FAA notify all pilots that they must have a thorough knowledge of standard phraseology when operating in the U.S. National Airspace System. The Board also asked the FAA, in coordination with ICAO, to develop a standard glossary of definitions, terms, words, and phrases to be used regarding minimum and emergency fuel conditions. The FAA issued the requested notice to pilots, and it developed and submitted such definitions to ICAO. The Board closed these two recommendations on June 28, 1994, and classified each response as "Acceptable Action."
Unfortunately, ICAO's Air Navigation Bureau concluded that the current phraseology for urgent and distress communications was adequate to facilitate communications between pilots and controllers in the situation described in the safety recommendation. The Bureau agreed that it would be useful to include a specific example of a fuel shortage emergency in its Manual of Radiotelephony, but decided not to accept the FAA proposal to use the term "fuel remaining" because it determined that the established term "fuel endurance" was more acceptable.
On December 20, 1995, American Airlines flight 965, a Boeing 757, crashed into mountainous terrain while descending for an approach into Cali, Colombia. The NTSB participated as the accredited representative to the investigation conducted by Aeronautica Civil of Colombia. Although investigators concluded that the local controller "provided clearances in accordance with applicable ICAO and Aeronautica Civil rules and requirements," they believed that he lacked, "the English language fluency needed to probe the flightcrew, from the subtle hints in the inconsistencies of their responses to him, to learn of the extent of their difficulties (in determining their location.)." Consequently, the Safety Board recommended to the FAA that it work with ICAO to develop a program to enhance the English language fluency of controllers to enable them to more effectively interact with and assist English-speaking pilots.
In response to this recommendation, the FAA encouraged ICAO to work to improve controllers' English language proficiency. The Board closed the recommendation on March 10, 1998, and classified the response as "Acceptable Action" after the Secretary General of ICAO asked its Air Navigation Bureau to conduct a comprehensive review of all aspects of civil aviation communication, including procedures, phraseology, and English proficiency. The Air Navigation Bureau issued a plan to review all international air/ground and ground/ground voice communication to identify any deficiencies and shortcomings. The plan's objective is to develop ICAO procedures as needed to enhance communications and the use of standard phraseology; to explore English language testing requirements for routine and non-routine communication, and to improve skill levels using procedures that already exist.
Two working groups will accomplish this work. ICAO tasked the phraseology issues to a group composed of representatives from FAA, EuroControl, and NavCanada. Their task is to update the current ICAO standard phrases, and modify the current ICAO Handbook on Radiotelephony Procedures, which provides guidance by listing standard phrases without specifying what language that they be spoken in. A report will probably be sent to ICAO member states for comment later this year.
ICAO has also formed a working group to specifically study the English language issues. Generally, such a study group has a narrow focus, and states with expertise are invited to nominate representatives to the group. In this case, the task is more broad, and ICAO has invited countries representing the major language groups (e.g., Asian, Spanish, European, Slavic, etc.) to participate. The group will hold its first meeting in October 2000, but members are currently compiling their ideas and recommendations.
We continue to believe that as international flight operations increase, more American citizens fly overseas and more foreign pilots operate in the United States and in the airspace of other English speaking countries, the need for proficiency in the English language by all airspace users will increase in importance. This is and will continue to be a critical safety concern for international civil aviation operators and their passengers, and it remains an important issue for the Safety Board.
Screening Pilots for Psychopathology
As you may be aware, in 1996, Congress directed the FAA to appoint a task force to study standards and criteria for pre-employment screening of the mental and physical abilities of pilot applicants. The FAA referred this study to an Aviation Rulemaking Advisory Committee (ARAC). Although the ARAC deliberated over a variety of selection issues and conducted an industry survey of current selection practices, it did not address the issue of psychopathological screening.
Although rare in commercial aviation, deliberate actions by a pilot have created dangerous situations. On April 7, 1994, an off-duty Federal Express pilot, travelling on a scheduled Federal Express DC-10 cargo flight, attacked the flight crew with a hammer and spear gun in an apparent attempt to take over the control of the airplane and crash it into Federal Express headquarters in Memphis, Tennessee. Although seriously injured, the flightcrew managed to gain control and safely land the airplane.
On December 19, 1997, a Boeing 737 operated by SilkAir crashed in Palenbang, Indonesia. Although the flight recorders did not record the departure from controlled flight, we have been informed that Indonesian investigators have sought the assistance of law enforcement authorities in this investigation.
Finally, on October 11, 1999, an Air Botswana pilot, who had apparently been grounded for medical reasons, took off in a company ATR-42 and threatened to crash it into Air Botswana headquarters. He eventually landed the airplane and deliberately collided with Air Botswana's other two ATR-42s. The pilot was killed and a post-crash fire destroyed all three aircraft.
Although the Safety Board's investigation into the crash of EgyptAir flight 990 is not complete, Safety Board investigators have determined that the airplane's autopilot was disconnected and the airplane "nosed over" into a dive toward the ocean. Recorded data of the airplane's flight path and the performance of its systems are consistent with a deliberate action on the part of one of the crewmembers. However, the Board has not determined the probable cause of the crash; further, if the evidence were to indicate that a deliberate act by a pilot was involved, it would not necessarily indicate that this was due to mental instability or psychopathology.
Although it is not clear that any of these crashes could have been prevented by better screening techniques, it is in everyone's best interests for the airlines and for the FAA to ensure that the most qualified and capable applicants are chosen to become airline pilots. In the past, many individuals seeking jobs as airline pilots had previously served as pilots in the military. Thus, airlines had some assurance that they had already been screened by the military. Today, because fewer airline pilot applicants have military experience, this pool of "pre-screened" candidates is shrinking. Consequently, airlines must rely on their own selection tools to screen candidates for piloting jobs. Although all major airlines have elaborate selection procedures including extensive interviews, small carriers are less likely to employ sophisticated selection tools or to have in-house expertise available.
In the U.S., candidates for airline pilot jobs are required to have background checks and their driving records are reviewed for impaired driving convictions. Many airlines' background investigations also include a check of the applicant's criminal history, and all pilots are required to have frequent medical examinations. Although these checks might provide clues about an applicant's mental fitness, the Safety Board is not aware of any airline that formally screens pilots for possible mental illness. Some airlines do require candidates to take pencil-and-paper personality tests and cognitive ability tests. These tests, when properly administered and interpreted, can provide indications of some forms of mental illness, but they are primarily designed to assess personality traits, not mental fitness.
This is not to say that the airline industry is without the capability to detect mental illness among pilots. Newly trained airline pilots generally serve a probationary period. During this period, usually a year, these probationary pilots are paired with captains who are encouraged to assess their performance in the cockpit. At many airlines, these Captains may send performance reports to the training department concerning the probationary pilots they fly with. If these Captains notice erratic or unusual behavior, they may include these observations in their reports for company follow up. Further, any pilot who notices another pilot performing or behaving in a manner that could suggest that he or she is mentally ill or unstable, may advise the appropriate association's professional standards committee. These committees investigate reports concerning pilot fitness, and can remove a pilot from duty, if warranted. These peer observations certainly do not replace formal psychopathological screening techniques, but they can provide a mechanism for detecting pilots who may need more evaluation or treatment.
That completes my testimony, and I will be happy to respond to any questions you may have.