Remarks of Mark V. Rosenker, Chairman
National Transportation Safety Board
For the Cargo Airline Association
October 17, 2007
Good evening. Thank you for inviting me to join you to discuss issues related to aviation safety in general, and cargo transportation specifically. I would also like to thank Yvette Rose for inviting me to speak to you tonight.
As many of you may know, the Safety Board has served as the transportation safety advocates of the American people for 40 years. During those 40 years, we have investigated more than 128,000 aviation accidents and thousands of highway, railroad, hazardous materials, pipeline and marine accidents. We have issued more than 12,600 recommendations to improve transportation safety in all modes. Of those recommendations, over 4,700 have been issued to the FAA with an overall acceptance rate of 81.6%. Presently there are just over 375 open recommendations to the FAA. Unfortunately 97 of those are classified with an open unacceptable response, which means that the Safety Board is unhappy with FAA’s progress in implementing our recommendation.
Being in the air cargo industry, you are probably more familiar with the NTSB’s role in aviation investigations within the United States. However, our responsibility to aviation safety does not stop at the U.S. borders. We provide accredited representatives, under Annex 13 of the ICAO treaty, who represent the United States, in foreign countries where an aviation accident has occurred. We do this if the accident involved a U.S.-manufactured aircraft, the aircraft was carrying American citizens, the accident involved a U.S. carrier, or if there were U.S.-manufactured engines or parts on the aircraft.
With all the foreign carrier accidents that have been in the news lately, I thought it would be interesting to take a look at how well U.S. Part 121 cargo and passenger operations have faired over the past 10 years. Since 1997, there have been 66 Part 121 cargo accidents, with only 3 of those accidents resulting in fatalities. Part 121 passenger operations had 347 accidents, of which 23 resulted in fatalities.
I was pleasantly surprised to see how low the numbers were for the cargo industry, considering the thousands of operations. You can be proud of the record of THREE fatal accidents in 10 years. The three fatal accidents involved one in which the cargo was misloaded and the pilots improperly set the trim; the second was attributed to poor maintenance and an improperly installed elevator control tab; and the third involved fuel starvation and poor piloting techniques.
The Safety Board is deeply committed to making the entire cargo industry even safer, including Part 135 operators. We held an air cargo forum three years ago that was attended by representatives from both the industry and government. Your president, at the time, Mr. Stephen Alterman, gave a presentation. While the forum highlighted some of the safety issues that the air cargo industry deals with daily, I believe that the greatest impact the Safety Board can have is when our recommendations are adopted by the FAA and the operators. I would like to highlight a few of the recommendations that the NTSB has made regarding the air cargo industry. Most of the recommendations that have been made are from the fatal accidents I just mentioned and were specific to those accidents. However, I will highlight some recommendations from other accidents that can have broad implications to the general cargo industry.
In 1998, we issued several recommendations stemming from a 1996 accident in Newburgh, New York. The Safety Board concluded that the transportation of undeclared hazardous materials on airplanes was a significant problem and more aggressive measures were needed. We recommended that the DOT require that persons offering any shipment for air transportation provide written responses, on shipping papers, to inquiries about hazardous characteristics of the shipment. We further recommended that DOT develop other procedures and technologies to improve the detection of undeclared hazardous materials. Unfortunately, this recommendation was closed – unacceptable action in June 2006, because the DOT concluded that it would not be cost beneficial to issue the regulations that were recommended. Although there is no requirement from DOT, I would like to challenge you to individually implement this recommendation at your carrier if you have not already done so. The same applies to this next recommendation from the Newburgh accident.
The Safety Board issued a recommendation to the Research and Special Programs Administration, who, at the time, was responsible for hazardous materials regulations. We recommended that air carriers transporting hazardous materials have the means, 24 hours a day, to quickly retrieve and provide consolidated, specific information about the identity, hazard class, quantity, and location of all hazardous materials to emergency responders. Although RSPA did issue a rule requiring that all hazardous materials be identified, they did not include a requirement for a consolidated list. The lack of a consolidated list was a significant safety problem identified during the investigation of this accident, thus, the recommendation was closed—unacceptable action in August 2003.
If you are thinking that none of our recommendations from the Newburgh accident were adopted, let me give you an example of one that was accomplished. We asked FAA to review the aircraft cabin interior firefighting policies, tactics, and procedures currently in use, and to develop and implement improvements in firefighter training and equipment to enable firefighters to extinguish aircraft interior fire more rapidly. As a result of FAA research and development, an elevated boom with a skin-penetrating nozzle was developed (this is also referred to as a snozzle). The FAA also funded 12 large firefighting training facilities throughout the country, each with an aircraft simulator that can be used for interior attack. In addition, the FAA developed mobile simulators which can be moved from airport to airport and offer interior simulation options. This recommendation was closed—acceptable action in 1999. It has not only benefited the cargo community, but all airplanes flying today.
Another area the Board is very interested in, for all modes of transportation, is human fatigue. The cargo industry is no exception. In 1995, after a cargo accident in Kansas City, Missouri, the Safety Board issued a recommendation to the FAA to finalize the review of current flight and duty time regulations and revise the regulations, as necessary, to ensure that flight and duty time limitations take into consideration research findings in fatigue and sleep studies. The recommendation went on to say that the new regulations should prohibit air carriers from assigning flightcrews to flights conducted under part 91 unless the flightcrews meet the flight and duty time limitations of part 121 or other appropriate regulations. Subsequently, the FAA issued a notice of proposed rulemaking in 1995, but encountered a number of technical and operational issues and withdrew the NPRM. In 2000 the FAA stated its intentions to release a supplemental NPRM (SNPRM) to address this issue. To date, the FAA has not issued this SNPRM or taken any other action to address this issue. So, the recommendation is currently open – unacceptable response.
With the time I have left, I’d like to discuss an air cargo accident that the Board is currently investigating. In July 2006, the Safety Board held a Public Hearing on an accident in which an airplane caught fire in flight and landed at Philadelphia on February 7th, 2006. Some of you may have attended the Public Hearing and remember the proceedings but for those who were unable to be there, I’d like to give you a brief recap and point out some of the significant issues that came out of that Hearing.
First a little background. About 25 minutes before landing, the first officer smelled something burning. The flight engineer stated he also smelled something. He then went back to look for smoke and, even though he could smell smoke, he could not see any. During post-accident interviews, he stated he pulled the smoke curtain back and used a flashlight to look along the upper wall of the cargo deck. He stated that there was no room to walk into or around the cargo containers. Approximately 3 and a half minutes before landing, the odor became stronger and the main deck smoke warning light came on. The captain reported the smoke indication to ATC and the flight engineer noted that the lower aft cargo fire warning light had come on. The captain instructed the flight crew to don their oxygen masks. During the final approach, there was a loss of some of the captain’s electrical instruments. At that point, the flight crewmembers indicated that smoke began streaming into the cockpit just before touchdown and became much thicker as the airplane decelerated after landing.
After landing, the captain and first officer opened their windows to get fresh air but the smoke concentration continued to increase. The smoke became so heavy the first officer said “he couldn’t see his hands in front of him.” Both the captain and the first officer looked for the NOTOC, or Notice to Captain, but they were unable to locate it. It was found 30 minutes later by firefighters.
The flight crew exited the burning airplane by the L1 slide. Airport Rescue and Fire Fighting or ARFF was able to use a thermal imaging camera to help identify the hot spots within the airplane and the fire was put out about four hours after touch down. There were about 80 ARFF and mutual aid firefighters who responded to this accident.
Problems that the firefighters experienced were: 1. The NOTOC was not immediately available (so they were not sure what hazardous materials were on board the airplane), 2. The “snozzle” was incorrectly placed during initial attempts, 3. ARFF did not have a diagram of the aircraft, and 4. The firefighters tried to unload the cargo but could not open the cargo door because they had not been trained on cargo airplanes (10 firefighters and 1 mechanic were tied up trying to accomplish this task). The airplane and cargo were lost, but the flight crew sustained only minor injuries.
Currently, cargo airplanes are only required to have a fire detection system and not a fire suppression system, for in-flight cargo fire protection. After the Newburgh investigation, the Safety Board issued a recommendation to the FAA to examine the possibility of on-board fire suppression systems and to require them if they were feasible. The FAA stated that a suppression system would add significant additional weight to an aircraft and determined they should not be required. Yet fire suppression systems offer a significant improvement in fire safety and the Safety Board continues to encourage the FAA to evaluate currently available systems and promote new technology to reduce weight, increase reliability and create a system whose cost will encourage operators to install them. As a matter of fact, FedEx has introduced a fire suppression system into its aircraft that meets all these criteria.
The Safety Board will be holding a Board meeting on the UPS accident investigation at the beginning of December. It will be open to the public and I invite you to attend, so you can see first hand how the Board deliberates on an accident report. For those of you who can’t attend in person, the meeting will also be web cast live on our website; www.ntsb.gov. You can also visit our website if you want to find out more about the UPS accident or any other cargo accident investigation.I thank you for inviting me to speak this evening, and I would be pleased to answer any questions you might have about the Board’s work and hear what safety concerns you in the cargo industry have.