Address by Jim Hall, Chairman
National Transportation Safety Board
Rotary Club of Chattanooga
March 16, 1995
Thank you for inviting me to speak to you here in Chattanooga today. Its great to see so many familiar faces.
Most of you know the National Transportation Safety Board for its investigations of major aviation accidents, but the Board also investigates major highway, rail, pipeline and marine accidents. The NTSB, as it is commonly called, was established in 1967 by Congress to determine the probable causes of transportation accidents and issue recommendations to prevent future accidents. The NTSB is independent of the U.S. Department of Transportation, and is neither a law enforcement nor a regulatory agency. The Board does not establish legal fault or liability, nor do we levy fines or take adverse action against any company, individual or license. NTSB investigation reports are not admissible as evidence in courtroom proceedings and we do not get involved in matters of litigation.
Since its inception in 1967, the NTSB has investigated more than 100,000 aviation accidents, and almost 10,000 surface transportation accidents as the worlds premier transportation accident investigation agency.
On call 24 hours a day, 365 days a year, Safety Board investigators travel throughout the country and to every comer of the world to investigate significant accidents, developing a factual record that often leads to the issuance of safety recommendations aimed at ensuring that such accidents never happen again.
In its 28-year history, the Safety Board has issued almost 10,000 recommendations in all transportation modes to more than 1,250 recipients. Our recommendations serve, to a great extent, as a main area of government transportation safety oversight. The performanceor lack of performanceby transportation agencies in carrying out their safety responsibilities is fully analyzed in Safety Board reports.
Every time you or a member of your family boards an airplane, or a school bus, or a train, or a cruise ship, or even gets into an automobile, you are protected by safety features inspired by NTSB recommendations. At an annual cost of less than 15 cents a citizen, we believe we are one of the best buys in the government.
Our task is daunting. Transportation accidents kill almost as many Americans every year as died in the entire Vietnam war and cost our economy hundreds of billions of dollars annually. We oversee the safety responsibilities of all the DOT modal agencies, yet to give you an idea of our relative sizes, the Safety Boards annual budget would fund the Department of Transportation for just nine hours.
In my 18 months at the Board, Ive been to the scene of 10 accidents, five of them aviation. The initial impression we get at all of them is one of human tragedy. With the possible exception of those of you who may have experienced combat, you cannot imagine the feeling of walking through a field of small fragments of what was once a transport category aircraft, most of the pieces small enough to pick up. It is rare today that a U.S. airliner has a nonsurvivable accident, yet we had two of them last year in the space of two months. The USAir accident in Pittsburgh killed all 132 persons aboard, and the American Eagle accident in Roselawn, Indiana killed all 68 aboard.
In January, I chaired the Boards public hearing on the Pittsburgh accident. On the one hand, it was a showcase for the Boards marvelous abilities. We saw graphic computerized re-creations of the terrifying final seconds of that flight. We took testimony from some of the worlds experts on aircraft design, flight recorder capabilities and weather phenomena. I was proud of the technological accomplishments of my agency, even though we realize our limitations in attempting to solve this accident.
On the other hand, the hearing was a humbling reminder of what all of our work is about. In the audience, we had more than 100 members of the families of the victims of flight 427. I met with them the first night of the hearing and assured them that everything in our power was being done to find out what caused the deaths of their loved ones. I was able to arrange for them to be taken to a local hangar where the wreckage has been laid out for our investigation. Again, I was proud of what our investigators had been able to do. To see the lengths to which we have gone in order to get to the bottom of this mystery was gratifying to me, and I can say it was gratifying to the family members, who understood like never before the complexity of our task.
A widow had brought her teenage son to the hearing, and she told me afterward that she felt through our efforts her son was able to reach some closure about the death of his father in the accident.
The Safety Board provides the American public the best of what government has to offer, technological know-how and public service.
And one of the advantages of being small is that were nimble; we can act quickly when required. Just one week after the crash of the American Eagle ATR-72 in Indiana, we were able to recommend to the FAA that the aircraft be prohibited from flying into known icing conditions, based on information wed gathered in our investigation.
Ive told you already that the Safety Board is the premier accident investigation agency in the world, proved by the fact that States and foreign governments have modeled their agencies after us. One of the reasons Im so proud of the Board is the quality of our personnel.
Lets look at an example of what our laboratory engineers can do in giving movement to the thousands of bits of data they have to work with during an investigation. Im going to show you a brief video recreation put together on the Roselawn. Indiana ATR crash I just talked about.
Our laboratory was able to construct this because the flight data recorder recorded more than 100 elements constantly during the flight.
What youre going to see is an animation based on the information off the recorder. On the right side and along the bottom of the screen will be some of the major pieces of information displayed on a hypothetical instrument panel, including airspeed, altitude and attitude. Remember, unlike what you can see on the screen, the pilots were flying in instrument conditions and could not see the horizon.
The flight had been in a holding pattern for more than 30 minutes in what is believed to have been some form of freezing precipitation. The aircraft is making a turn and beginning to descend as directed by air traffic controllers. The plane has accumulated a dangerous level of ice by this time.
As it makes its turn, a flap overspeed warning is heard on the cockpit voice recorder, prompting the crew to retract the flaps. The autopilot commands the planes nose up to adjust to the changed configuration of the wing.
We believe at this point the combination of the new angle of attack and the ice accumulation began to separate the air flow over the wing. The autopilot could no longer compensate for changed air flow and therefore disconnected, allowing the right aileron to suddenly deflect in the right wing down position. This caused the sharp roll to the right you see and the subsequent loss of control.
This animation ends four seconds before the aircraft impacted the ground, although some incomplete data have been recovered after that period from the flight data recorder. The last speed recorded for the aircraft was 373 knots.
These graphic presentations can sometimes be horrific, but they are an indispensable tool for our investigators as they reconstruct the final moments of an accident sequence.
Despite the many alarming headlines in recent months about airline safety, and the stories Ive passed along to you today, it should not be forgotten that airline travel is safe by anyones measure. Before the recent string of accidents, the major scheduled airlines had gone 27 months without a passenger fatalitythats an uninterrupted string of almost 1 billion passengers carried safely. In the 15 years between 1978 and 1993, the major U.S. airlines averaged one fatal accident for every 1.4 million flights.
This laudable record has come about in no small measure through the efforts of my agency, which issues safety recommendations after every investigation to ensure that such an accident never happens again. Let me give you a short list of aviation improvements youre probably familiar with that came out of our recommendations:
And its not just in aviation. We have had a hand in improving safety in all modes
of transportation. Heres a short list:
Many of our investigations affect you because of their impact on the national transportation system. We had such an accident right here in Chattanooga last year.
On June 6, 1994, 3,079 gallons of arsenic acid leaked from a tank car parked at the Harry deButts train yard. Some contaminated water from the rail yard discharged into Citico Creek, and the water from the creek drained into the Tennessee River where Chattanoogas water intake pipes are located.
Cleanup, containment and disposal costs were estimated at almost $9 million as of the end of January. We got into this investigation six weeks later because, initially, neither the railroad nor the city realized the enormity of the leak. Last month, we completed our investigation and determined that the probable cause of the accident was the tank car companys failure to detect and correct a misaligned cargo discharge pipe system on the car, which led to the leak. Contributing to the severity of the environmental impact was the lack of a means to contain the release within the yard and the delay in calling in an environmental contractor.
We found four other tank cars that had similar misalignment problems and theyve been removed from service. Were concerned that tank cars built to a similar design could have the same kind of failure we saw in Chattanooga, especially after we found a problem on a tank car in New Jersey last December. We think the FRA and the industry should evaluate the failure rate of these cars and require the necessary repairs. This can benefit all Americans, including those of us from Chattanooga, since the yard here handles thousands of hazardous materials cars a year.
As a result of our investigation, we issued 12 safety recommendations to the U.S. Department of Transportation and the companies involved in the incident. A thirteenth recommendation urged the Hamilton County Emergency Services and the City of Chattanooga to conduct emergency response drills and exercises with transporters of hazardous materials.
The lack of proper drills is not a problem unique to Chattanooga. We see this in many instances. In fact, we recommended to none other than the Port Authority of New York that they perform unannounced disaster drills after our involvement in the investigation of the Trade Center bombing.
The fact of the matter is there is no substitute for hands-on emergency drills. Im happy to report that Mayor Roberts and Don Allen wrote to me last week to assure us that the City and Hamilton County are proceeding with plans to assure coordination with regional and local transporters of hazardous materials in emergency response drills.
In closing, let me say that there is no way to quantify how many accidents didnt happen because of the work of the NTSB, how many lives were not lost, how many families were not forever torn asunder by tragedies that were prevented. I told you that the age-21 laws alone have saved 14,000 lives, but who are they? Could any of those 14,000 people be sitting here in the room with us today? Could one be waiting for you at home?
Please, when any of you come to Washington, drop by our office in LEnfant Plaza. Id love to have you meet our people and tour our laboratories. Im sure youll agree with me that the National Transportation Safety Board is the kind of government agency of which we can all be proud.