Remarks of Jim Hall, Chairman
National Transportation Safety Board
at the Annual Cabin Safety Symposium
Costa Mesa, California
January 27, 1999


Good Morning Ladies and Gentlemen. I am always pleased to have the opportunity to speak to the International Aircraft Cabin Safety Symposium; this is, I think, my fifth opportunity to join you.

When I reviewed this year's program I noted that Ken Smart, the Chief Inspector for the AAIB in the United Kingdom and Benoit Bouchard, Chairman of the Transportation Safety Board of Canada, were also listed as speakers. I have worked closely with both of them. I'm sure you will agree that all of us who are committed to improving aviation safety owe them our appreciation for their excellent leadership.

The commercial aviation industry has much to be proud of, not the least of which is the consistent high level of safety in which it operates. It appears that 1998 will go down in history as the first year that no passenger died on a Part 121 or a Part 135 carrier in the United States. We must all continue our efforts leading us toward the day when years like 1998 are the norm, not something to be celebrated for their uniqueness.

As you are aware, there have been a series of highly visible, tragic accidents in the past several years in which there were no survivors. For example, TWA-800 and ValuJet at the Everglades are two accidents investigated by the NTSB in which the impact forces were so great as to preclude survivability. Unfortunately, our colleagues in Canada are currently investigating an MD-11 accident off the coast of Nova Scotia that, too, fits that description.

These type of accidents generate a lot of attention by the news media and may leave the public unaware of how many accidents actually are survivable. In preparation for this speech I asked my staff to review NTSB data and determine the survival rate for U.S. accidents. First, perhaps I should explain what I mean by the term "accident." According to U.S. Federal Regulations an accident occurs when there is a fatal or serious injury to a person or substantial damage to the airplane.

Between 1983 and 1996, there were 364 accidents involving U.S. air carriers. Sixty of those 364 accidents included at least one fatality. As you can see on the chart, of the 34,392 occupants involved in those 364 accidents, 32,221, or 94 percent, of them survived.

In order to look at the more severe accidents, staff reviewed accidents in which there was a fire, AND at least one serious injury, AND substantial or greater damage to the airplane. This reduced the list to 24, including 7 "non-survivable" accidents such as TWA flight 800. This subset of accidents involved 2,513 occupants. There were 1,377 survivors.

When the non-survivable accidents were removed from the previous subset, we looked at a group of 17 survivable or partially survivable accidents that involved fire, AND serious injury, AND substantial or greater airplane damage. These would comprise come of the most serious accidents passengers could encounter, yet 1,375 of the 1,759 occupants survived. Even in such life-threatening accidents, 78 percent of the occupants survived.

So why do we care about these numbers? I think that we have a responsibility to reduce the number of injuries to survivors and to ensure that the greatest numbers of occupants survive an accident. In survivable accidents, issues such as crashworthiness, occupant restraint, fire protection, crew communication and procedures, evacuation equipment, flotation devices, and passenger education are extremely important. But that is not news to you - those are subjects that are discussed every year at this symposium.

The Safety Board recently announced a Children and Youth Initiative. Earlier this month, I spoke to the National Safe Kids Leadership Conference. I asked them, and I will ask you, to make 1999 the Year of Child Transportation Safety. Many of the issues that our initiative addresses are related to highway safety. But since many of you in the audience travel with your children on the highway I hope you will indulge me and let be briefly talk about those issues. Among the improvements that the Safety Board would like to see in Highway Safety are ensuring that children sit in the back seat of passenger vehicles, simplifying the design of child safety seats, designing air bags that are as safe for children as they are for adults, reducing the number of teens who drink and drive and improving the protection inside school buses.

We must also ensure that all children in airplanes are buckled up in child safety seats or seat belts. It is astonishing that regulations require everything in an airplane to be secured during takeoff, landing and turbulence - except our smallest children. Our accident investigation experience has shown that it can be impossible for a parent to hold onto a child during an airline crash sequence or turbulence.

We all know the stories about injuries and fatalities to small children, but we recently had a case with an unexpected twist. While an airliner was cruising near Palm Beach, Florida, a mother lost control of her in-lap infant when the baby flew out of her arms during an in-flight loss of control. Fortunately the baby was caught by a passenger seated several rows away and was not injured. However, the frantic mother released her seatbelt to retrieve her baby and, because of the extreme motions of the airplane, became the only occupant to sustain serious injuries.

Let's work together this year, as we have so well in the past, to use the technology available, the resources at our disposal and our compassion to prevent the needless injury to or loss of more of our most precious resource - our children. It can be done. We need to make sure all children are properly restrained during takeoff and landing, and during times of turbulence.

When I spoke to you last year I told you about the NTSB's safety study on emergency evacuation of commercial aircraft. I would like to update you on that study.

Data collection for the evacuation study began on September 24, 1997, with the evacuation of a Boeing 727 operated by Frontier Airlines after the aircraft ran off the runway in Salt Lake City. Since then, staff has collected information about 34 evacuations for the study. Of these 34 evacuations, 21 involved use of evacuation slides or suspected fire and are receiving a more detailed level of investigation. The study plan requires 25 detailed investigations and at the rate of evacuations experienced since September 1997, we anticipate reaching that number before the end of next month.

The predominant cause for evacuation appears to be fire or suspected fire. Engine fire occurred in 14 cases, cargo fires occurred in 7 cases, cabin or cockpit fire occurred in 3 cases. Other causes for evacuation include gear collapse, auxiliary power unit (APU) "torching," landing short, running off runway, and collision with ground power unit (GPU). A mix of air carriers is included in the evacuations. Of the 34, 16 involve major U.S. carriers.

For the evacuations receiving detailed investigations, we are working with the airlines to collect safety briefing cards, cockpit crew materials, such as evacuation related checklists, portions of flight manual, and training, and similar materials for cabin crew.

Overall, 1,994 passengers were evacuated from the 34 aircraft in the study; the 21 detailed investigations encompass 1,334 of the evacuees. To date, questionnaires have been mailed to 641 of the evacuees in the detailed study cases; 217 questionnaires have been returned for a 34-percent response rate. Cockpit crews have returned 14 of 30 cockpit crew questionnaires, cabin crews have returned 15 of 26 cabin crew questionnaires, and aircraft rescue and fire fighting (ARFF) representatives have returned 6 of 11 ARFF questionnaires.

Preliminary review of the materials collected to date indicate five safety issue areas that will be examined in the safety study: crew resource management (CRM) for cockpit-cabin communication, slide malfunctions, cargo smoke detectors, safety briefing content, and an evacuation resulting from an APU torching. Let me touch on each of these.

Cockpit-Cabin CRM. Comments on several crew questionnaires indicate that better communication between crews would have improved the evacuation. NTSB staff plan to visit several training sites to examine CRM training coordination between cockpit and cabin crews.

Slide Malfunctions. Nine of the ten aircraft equipped with slides deployed their slides for the evacuation. In three of those evacuations, however, at least one slide failed to deploy.

Cargo Smoke Detectors. Cargo fire was the reported cause of the evacuation in seven of the 21 detailed cases involving regional carriers. In each of the cases, however, the cargo compartments examined by ARFF personnel indicated no evidence of fire. In questionnaires, one captain indicated that he believed the alarm was false but chose to evacuate to be safe.

APU Torching. The one passenger-initiated evacuation in the study occurred as a result of an APU torching. This evacuation resulted in the most serious injury of the study when a 10-year-old boy broke his arm jumping from a wing. The Board has previously addressed this issue with Safety Recommendation A-92-135 that asked the FAA to assure that airlines informed passengers prior to an APU start of the potential for torching. Although the FAA, in response to this recommendation, asked its Principal Operations Inspectors (POI) to assure that airlines informed passengers, the passengers were not informed in this case. Staff will examine ways to increase the effectiveness of the FAA's action taken in response to the Board's previous recommendation.

Safety Briefing Content. Passengers have indicated several things that could have made the evacuation more successful. Passengers who used slides indicated being unprepared on how to use the slide. Many passengers had little idea what to do once outside of the aircraft. Numerous comments were received about people who attempted to evacuate with their belongings, and several passengers suggested the need for briefings on the airline's luggage policy with regard to emergencies.

If the current pace of data collection and passenger response remains on schedule, the draft report could be submitted to the Safety Board by the end of this year or early the next.

Last year I also spoke to you about the NTSB Web Site. Some of you may have already obtained information from the site. In the past year we have added several new features that you may find useful. We have made available all major accident reports and publications since 1996, expanded the aviation accident synopses to include a full narrative, added an e-mail subscription list for safety recommendations and press releases, added pages for family disaster assistance, and implemented a search engine to improve accessibility of our documents. We've doubled the average number of hits per day in the past year.

We hope you will visit the site at www.ntsb.gov and will sign up for our e-mail subscription list. We believe that the information gathered from accident investigations should be used to improve all aspects of aviation safety.

Again, I want to thank you for inviting me to join you, and I want to thank you for your untiring efforts to keep the issue of cabin safety before the public and industry. Nineteen ninety eight was a good year for aviation safety in the United States. I hope we can say the same thing when we meet again next year.

 

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