Remarks by Jim Hall, Chairman
National Transportation Safety Board
at the International Recorder Symposium
Crystal City, Virginia, May 3, 1999
Good morning and welcome to the first International Recorder Symposium ever assembled. I am Jim Hall, Chairman of the National Transportation Safety Board, and I want to thank the International Transportation Safety Association for co-hosting this event.
We have a very full agenda during the next three days, and I want to compliment our staff for assembling such a distinguished schedule of participants. I'm particularly grateful to NASA Administrator Dan Goldin for presenting the keynote address at tonight's banquet, and to FAA Administrator Jane Garvey, who will address us during the conference. And, of course, I want to thank the DOT modal administrators and all the participants who will be joining us over the next three days.
As we begin today, I'd like to try to answer a fundamental question for you: Why are we holding this symposium? Although this symposium will deal with issues not directly tied to accident and incident investigation, it is through investigations that the Safety Board has developed its recorder expertise, and it is in that context that I wish to address you this morning.
The answer to why we are holding this symposium is really quite simple. Accurate data protects all of us.
For example, it protects the vehicle designer, because accurate data will help us find a problem with the design, if one exists, and lead to better designs in the future or even redesigns of existing vehicles. Or, the data will show that the design had nothing to do with the accident or incident, at all. Let me give you an example of this.
The fatal crash of an Airbus A320 aircraft during an early demonstration flight in 1988 brought the safety of its fly-by-wire technology into question. The pilot, who survived, claimed that the airplane failed to follow his command to climb and as a result crashed into a line of trees. However, the flight data recorder and cockpit voice recorder information painted a different picture. The recorded data indicated that the airplane operated as designed and that the flight crew did not take sufficient measures to avoid the crash. The A320 has enjoyed an exemplary safety record.
In similar fashion, accurate data protects the manufacturer, the operator, the regulator, and the owners and stockholders of companies.
But, most importantly, accurate data protects the American people - indeed, people all over the world - in three very significant ways.
First, it protects people emotionally. Information we've learned from recorders throughout the years has surely prevented an untold number of accidents and the loss of or serious injury to loved ones.
Second, it protects people economically. The prevention of accidents reduces insurance costs, and consequently the premiums that each of us pays, and has a profound affect on reducing medical costs and other government costs that often are borne by taxpayers. Accurate data can also preclude the need for long, expensive investigations like the one the Safety Board just concluded on USAir flight 427. That crash involved an airplane with a relatively primitive flight recorder. How much of that four and half years could have been saved had we had a more sophisticated recorder?
Third, and finally, by bringing surety to accident cause determination and, therefore, to remedial action, accurate data protects the confidence people have in their government and institutions, and in the integrity of their transportation system.
In addition, good recorded data can substantially reduce the time of an accident investigation, particularly when the wreckage is hard to retrieve. If we eliminate the need for wreckage recovery, we can save taxpayers millions of dollars. Two such cases overseas come to mind.
In 1996, two Boeing 757s crashed into the sea within months of each other, one near the Dominican Republic and the other near Peru. In both cases, the wreckage was at a depth that would have made recovery very difficult if not impossible and, of course, extremely expensive. These were two of the first fatal 757 accidents. Fortunately, the recorded data was sufficient to precisely define the problems and record the crews' actions or inaction to cope with the situations. As a result, in the one case the only wreckage recovered were the flight recorders; in the other case, a few selected parts identified as problem areas by the recorded information were also recovered. In both cases, millions of investigative and recovery dollars were saved - and confidence in the aircraft maintained - because of the information provided by the recorders.
Recorders have proved their worth over the decades as probably the single-most effective investigative tool we have. Look at how dramatically the airline accident rate has dropped over the last four decades. In 1960, there were 0.012 fatal accidents per million aircraft miles flown. In 1970, that number had dropped to 0.001, and it stayed in that range for many years. By last year, 1998, the rate had dropped to 0.0002. If my math is correct, that is one sixtieth the fatal accident rate of 1960.
Imagine the safety impact of such a change on our highways, where we still see about 40,000 deaths a year.
Much of the safety improvement we've experienced in aviation can be attributed to the development of safety devices like ground proximity warning systems and anti-collision systems, both in the air and on the ground, and to changes in operating practices in icing and convective weather - all brought about in large measure by information learned through voice and data recorders.
What better example do we have then the 1994 crash of the ATR-72 in Roselawn, Indiana, which killed all 68 persons aboard? Within a week of that accident, the 98-parameter data recorder had given us sufficient information to prompt recommendations about operations of that aircraft in icing conditions. Contrast that with the difficulty in determining what happened to USAir flight 427, which had an 11-parameter recorder.
Recorder data has led to tangible improvements in other modes of transportation, as well. For example, after a half a million gallons of gasoline spilled into marshland in Gramercy, Louisiana, recorded data was able to confirm testimony from the operator working in the control center. There were so many alarms sounding that he missed the very important alarm that should have prompted him to shut down the system. Based on the recorded data, the company modified its control system to remove distractions that could cause a repetition of that accident, and used the data to program simulators to train operators on how to deal with abnormal conditions.
In the rail industry, recorders helped investigators piece together the last few minutes leading up to a deadly collision between an Amtrak train and a commuter train in 1996. The three crewmembers of the commuter train were killed, along with eight of their passengers, but the recorded data showed that, even though they were under a restricted signal that they should have seen just before entering the last station before the accident, they departed the station as if they were operating under a clear signal. As the stop signal at Silver Spring became visible, the engineer applied emergency brakes, but it was already too late to avoid the collision. The commuter railroad changed its procedures based on that data so that crewmembers will always leave a station as if they are under a restricted signal until they see a clear signal.
In the marine mode, while recorded data has helped us to determine the probable cause of some accidents, recorders in use at this time are still very rudimentary. The technology is there for advanced voyage recorders, but it is not being utilized. Because of the absence of adequate data recording, millions of dollars were spent to try to reconstruct what happened to the Estonia, which took about 800 people with it when it sank in the Baltic Sea in 1994. The International Maritime Organization is considering requiring voyage recorders on some passenger vessels.
Ironically, even though we have seen the safety benefits of recorded data in almost all modes of transportation, the one mode where recorders have not yet had any impact is in highway accident investigation, where more than 90 percent of transportation fatalities in the United States occur each year. I hope this symposium helps spur a much greater use of data recorders in the investigations of highway accidents and incidents, as well as in the other modes of transportation.
Generally, recorded information has been used retrospectively; that is, following an accident or incident, and during routine data monitoring, but rarely in real time. The digital transmission of key vehicle performance parameters such as GPS location, speed, direction of travel, and other parameters to dispatcher or controller facilities whether they be rail yards, truck depots, airports or harbor facilities could significantly improve the safe movement of passengers and goods.
Well, that brings us to this symposium. Where is this technology going and how can it be used in other ways? That is what we are here to find out. The intelligent use of recorder information can improve equipment reliability and help a company's bottom line, in addition to the obvious safety benefits. As we explore ways to expand the use of recorded data for safety and economic reasons, we must also be cognizant of the sensitivity and any legal implications associated with those data.
It is time for all modes of transportation, both in the United States and worldwide, to realize the unlimited potential that recorder technology has to offer both in terms of economics and safety. I believe this symposium will lay the groundwork for that to happen. But it will happen only if you take the initiative to broaden the use of data recorders in your modes of transportation. You are the leaders who can get this done, but you must start doing this now, not next year, or the year after. I ask you to follow the admonition of Woodrow Wilson, who said, "If you are to be a leader, you must lead your generation, not the next." It is time for you to bring this generation's transportation system up to date with the best recorder technology available. While the economic benefits are great, the benefits to the safety of our fellow citizens is immense.
Your work over the next few days can truly protect us all. Thank you for being here, and I look forward to hearing from all of you over the next few days.