Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
National Transportation Safety Board
International Mass Fatality Management Conference
New York, New York - April 27, 2012
Remarks Prepared for Delivery


Thank you, Paul (Sledzik), for that warm introduction. And, thank you, Dr. (Charles) Hirsch, Barbara Butcher, and Frank DePaolo for your gracious invitation to speak at this conference.

It is an honor to be here with you-attendees from 38 states, 19 countries, and several government agencies. I appreciate your interest in mass fatality management and your dedication and commitment to improvement.

Before I begin my formal remarks, I want to acknowledge the leadership role, both nationally and internationally, that the New York City Office of Chief Medical Examiner has played in its leadership in technical advancements and also in coordinating the Regional Mass Fatality Management Response System, which includes several major urban and suburban jurisdictions. The System is a model for increasing capacity and sharing resources following a major mass fatality event.

At the NTSB we truly appreciate the outstanding work of Dr. Hirsch and his staff in supporting Safety Board investigations over the years. Every one of the forensic and support staff I have met during my trips to New York City brings a professional and compassionate approach to their work. Thank you, too, for providing us with the information we need to our jobs.

In my eight years at the Safety Board, I have had the opportunity to participate in briefings with family members. These briefings are quite powerful and full of emotion. But, in nearly all cases, a family member's deepest concern is the status of their loved one. Has the victim been recovered? When will the remains be released? Why is this process taking so long?

Yes, victim recovery and identification is a fundamental concern for family members. It is integral to the grieving process. And, this basic human need is one that is shared across all cultures. Add to that, the many religious personal, cultural, and philosophical perspectives; these all combine to make your work even more challenging.

The U.S. Congress recognized the needs of family members impacted by major aviation accidents when it tasked the NTSB with coordinating the assistance to family members after major accidents. Congress gave the NTSB the responsibility to facilitate victim recovery and identification-but it did not give the Board the legal responsibility to conduct those processes. That responsibility remains with the local medical examiner or coroner. Fortunately, many of these offices in the United States-your offices-have not had to deal with a major transportation accident. Yet, if you do experience such an event, know that you can rely on our Transportation and Disaster Assistance team, or TDA, to work closely with your jurisdiction to ensure that you get the resources and advice to effectively manage the event.

Much like piloting an aircraft or cruise ship, mass fatality management must be a zero defect process. The medicolegal investigation, the recovery of victims, and the identifications must be done right.

To achieve that zero-defect goal, it is essential to develop and validate standard operating procedures and for practitioners to be competent in their work. This is important to us at the Board. To further this goal, we have partnered with the FBI to lead a Scientific Working Group with national and international experts on Disaster Victim Identification (DVI) to develop guidelines and best practices in the recovery and identification of disaster victims.

You'll hear more about this group, and about the excellent work of the Interpol DVI teams, later today. As we've experienced, mass fatality incidents are international in scope, and the needs of family members, regardless of nationality, race, or religion, are universal-which requires a truly international approach.

And, it's equally important to remember that family members play key roles in the victim identification process. They are the primary source for antemortem information that is integral to the identification process. They provide DNA reference samples, and they become involved in decisions regarding the disposition of remains.

Additionally, you must interact with them, provide them information, and allow them to ask questions. Everything can be done correctly from a technical perspective, but if you don't effectively and compassionately address the needs and concerns of family members regarding victim recovery and identification, the response will fall short. Interactions with family members are essential-and equally essential is that they be conducted with professionalism, understanding, and compassion.

This is not an easy task. There is a constant and often delicate balance to maintain between the medicolegal responsibilities associated with any mass fatality event and the concerns and needs of the bereaved. Careful consideration of the issues and discussing options with experienced responders can help untangle many complicating issues.

Sudden and unexpected death affects not only individual families, but it can have profound effects on communities and societies-not only in recovering from the event but, in a positive way, by generating long-lasting improvements to ensure safety.

For example, here in New York City early in the last century there was a significant mass fatality disaster that led to safety improvements that still benefit all of us.

In June 1904, a fire erupted aboard the steamboat General Slocum in the East River-upriver from where we are today. That steamboat fire caused more than 1,000 fatalities and left more than 300 survivors.

The ensuing investigation resulted in significant improvements to steamboat safety regulations. President Theodore Roosevelt appointed a five-person commission to investigate the accident and make recommendations to prevent a similar event from happening in the future. Many safety violations were uncovered, including too few lifejackets, unusable lifejackets, as well as non-functioning fire hoses. Among the commission's safety recommendations: improved firefighting equipment and training for crew members, evacuation drills for crew and passengers, a sufficient number of life preservers (one for each passenger and crew), and accessible lifeboats.

The fact that major disasters lead to improvements in safety is still relevant more than 100 years after the fire on the General Slocum-as our five-member board saw after the crash of Continental Connection Flight 3407, which occurred near Buffalo, New York, on February 12, 2009. This tragedy took the lives of 50 people: 49 on the airplane and one on the ground.

Our investigation highlighted a number of broad-ranging aviation safety issues, including pilot professionalism, human fatigue, remedial training for flight-crew members, pilot training records, and regulatory oversight. In the days following the accident, many of the family members who lost loved ones came together with the resolve to make sure that the various factors that contributed to the accident would never lead to a future accident.

These family members became highly effective safety advocates, developing a strategy to promote changes in aviation safety based largely on the safety issues uncovered as a result of the NTSB investigation of this accident. In more than 40 trips to Washington, DC, they met with Members of Congress, staff of Congressional committees, administration officials, and the President. They testified at Congressional hearings, conducted media interviews, sent press releases, and started a website. Ultimately, their efforts were influential in the passage of the Airline Safety and Federal Aviation Administration Extension Act of 2010. That legislation included many of the safety recommendations the NTSB made following our investigation of the accident.

These are just two examples of the positive results that mass fatality events can have on society. Yes, many times family members become advocates for improved safety. But, the way they were treated during the initial response stays with them forever. This is why it's important to do the work correctly and always with an understanding of the importance of the families in the process.

In closing, I commend your commitment to examine ways to improve the processes involved in mass fatality management. Poet-undertaker Thomas Lynch perfectly captured the spirit and the importance of your work in his poem, "Local Heroes" about the forensic response to the 2001 World Trade Center disaster.

Lynch wrote:

"...here, brave men and women pick the pieces up.
They serve the living, caring for the dead."

You, too, serve the living as you care for the dead. Thank you-all-for all that you do.