Remarks of Mark V. Rosenker
Vice Chairman, National Transportation Safety Board
at the Government Services Administration's
Federal Aviation Awards Ceremony
September 28, 2004
Thank you for inviting me to be here with you today at this important ceremony recognizing the exceptional individuals involved in the safest and most effective aviation programs in the federal government, and also to discuss aviation safety issues of concern to General Services Administration (GSA), the Interagency Committee for Aviation Policy (ICAP), and the National Transportation Safety Board (NTSB).
The Safety Board was created in 1967 to conduct independent accident investigations in all modes of transportation, and to make recommendations to prevent the recurrence of similar accidents. As an independent investigating board, our role is very different from that of the regulators, such as the FAA. In some ways, ours is the easier task because we are insulated from many of the pressures brought to bear on the modal administrations. The NTSB is also the one that wears an enormous white hat -- at least as far as the Congress, the public, and the press are concerned. In 1996, the investigation of accidents and incidents involving public use aircraft was placed under the jurisdiction of the Safety Board. As a result, the NTSB and ICAP share mutual goals and are partners in ensuring the safe operation of aircraft in our national transportation system.
When the Board investigates an accident, we don't do it in isolation. In the case of an aircraft accident, regulators, operators, and manufacturers of that particular aircraft, as well as various professional associations and unions participate. We call this process "the party system." This system has worked extremely well and has helped give the American people confidence in their transportation system. Maintaining that confidence requires constant vigilance by everyone within the system -- regulators must properly regulate the industry; owners and operators must ensure the safety of their operations; manufacturers must design and build safe products; and the NTSB must continuously reassure the public that there is an independent review of how well those entities are fulfilling their responsibilities. Some of you or your colleagues may have participated as a party in an NTSB investigation. The recent investigations of air tanker accidents are good examples of how the Board, and ultimately the public, benefit from the expertise that the members of ICAP provide.
Since coming to the Board in March of last year, I have had the opportunity to vote on the probable cause and safety recommendations resulting from a myriad of aviation accidents, some of which were of great national interest. Two examples are last year's Air Midwest beech 1900 that killed all 21 persons on board in Charlotte, North Carolina, and the accident that killed Senator Paul Wellstone in Minnesota on October 25, 2002.
In the Wellstone accident, an intense post crash fire destroyed most of the aircraft. The aircraft was a King Air 100 and was not required to be equipped with a cockpit voice recorder (CVR) or a flight data recorder (FDR). Without these devices, it was extremely difficult for our investigators to determine exactly what happened during the final moments of the flight. Despite that difficult challenge, however, the Board did determine the probable cause and made a number of recommendations dealing with mandatory training inspections, proficiency checks, and potential installation of low air speed alert systems.
An additional issue that the Board is considering as a result of this accident, is the use of cockpit imaging recorders, or simply, cameras in the cockpit. As you can imagine, this has generated a great deal of controversy. Recording images of the cockpit is both technically and economically feasible, and we feel make it possible for investigators to better understand what is happening in the cockpit prior to and during an emergency. For example, a cockpit video recorder could tell us which pilot was at the controls, what controls were being manipulated, what information the crew was receiving from the instruments. The installation of such a device could be a critical investigative tool in aircraft that presently do not have CVR and FDR capabilities.
However, we are also sensitive to privacy concerns expressed by pilots and others with respect to recording images of flight crews. In order to protect crewmembers' privacy, the Safety Board has asked Congress to apply the same protections that currently exist for CVRs to the use of image recorders in all modes of transportation. In addition we are looking at the possibility of encrypting this data to prevent entities outside the control of the U.S. Government from releasing the sensitive material.
As a result of our work on the Charlotte Beech 1900 accident, 21 safety recommendations were made to the FAA. These included improved surveillance of air carrier maintenance programs, upgrading the information on maintenance work cards and repair manual instructions, establishing new standards for more effective weight and balance procedures, and reinforcing air carrier accountability for all contract maintenance work performed.
So what are we looking at next? At the end of October, the Board will be meeting to consider a final report concerning American Airlines Flight 587, which crashed in Belle Harbor, New York, shortly after takeoff from JFK. This accident was the second worst in U.S. aviation history, the first catastrophic loss of an Airbus product in the United States, and the first we have investigated that involved an in-flight separation of a major structural component made of composite materials -- in this case, the vertical stabilizer and its attached rudder. I can assure you, this has been a comprehensive investigation, which has lasted almost three years and covered a number of critical issues.
In addition to aviation, we investigate accidents in all other modes of transportation; this includes railroad, pipeline, highway and marine. We have been particularly busy in the marine division, investigating major catastrophes, such as the boiler explosion of the cruise liner Norway that killed 7 crewman, the capsizing of the commercial fishing boat Taki Too, killing eleven, the Staten Island Ferry also killing 11, and most recently, the capsizing of the Baltimore Harbor water taxi, which killed 8 people.
With nearly 2,000 investigations a year, you can clearly see that the NTSB is an extremely busy federal agency. In its 37-year history, the Board has issued more than 12,000 recommendations to more than 1,250 recipients. Most of our recommendations go to government agencies, but, when appropriate, they are sent to state and local governments and industry. To date, I'm proud to state that 82 percent of them have been adopted, resulting in countless safety improvements in all modes of transportation. For example, aircraft collision and ground proximity warning systems; airport wind shear warning systems; passenger vehicle next generation air bags; improved school bus construction standards; pipeline excess flow valves; and better commuter train emergency exit markings -- just to mention a few.
Before closing, I want to tell you about the NTSB Academy, which is a major Safety Board initiative to improve the training and skills of its own employees, and to make its safety expertise widely available to the global transportation community.
This state-of-the-art facility is not only providing the training necessary to keep our accident investigators on the cutting edge of investigative technology and performance - but it is also advancing transportation safety worldwide.
I understand that members of ICAP have attended courses at the Academy and that they have contributed significantly to the classroom discussions, and provided experience and expertise that has been well received by both students and instructors. I hope that those of you who haven't attended a course will take the opportunity to do so. Information on all of our courses is available on our website - www.ntsb.gov.
Finally, I want to commend the GSA and ICAP with the operation and collection of information for the Federal Aviation Interactive Reporting System (FAIRS) and the Aircraft Incident Reporting System (AAIRS). These systems have been beneficial to the NTSB in ensuring the accuracy of the operational hours of the Federal fleet of aircraft, and enhancing the information that we compile on accidents and incidents involving public use aircraft. I also want to commend the ICAP Safety Standards and Training subcommittee for establishing the Federal Aviation Officer Program and the "Safety Standards Guidelines for Federal Flight Programs." I believe these programs will contribute significantly to the reduction of accidents and incidents and to the overall aviation safety of federal government aircraft.
Aviation continues to be the safest mode of transportation available to the world's travelers. The Board's job -- and all of yours -- is to ensure that it remains that way.
Thank you for inviting me to be here today.