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Remarks at the 7th Annual Central European/US Airport Management and Infrastructure Workshop and Trade Mission, Salzburg, Austria
Carol Carmody
7th Annual Central European/US Airport Management and Infrastructure Workshop and Trade Mission, Salzburg, Austria

Thank you for inviting me to your seventh annual Airport Management and Infrastructure Workshop to discuss aviation safety issues of concern to your organizations, your airports, and the National Transportation Safety Board (NTSB).

The Board has been investigating accidents in all transportation modes for over three decades, and has developed a deserved reputation as experts. Our statute requires us to investigate all aviation accidents and we do about 2000 a year. We have the lead in aviation investigations unless there is credible evidence of criminal activity; then the Chairman and the Attorney General are supposed to confer and decide that the FBI would take the lead. Such was the case following the September 11th terrorist attacks in New York, Washington, and Pennsylvania. When the first plane hit the trade center, we started to assembly a go-team; when the second plane hit we knew that this was NOT an aviation accident. I spent that morning at the FBI, and pledged the Board's support to the FBI Director. That very afternoon, we sent staff to all three sites - New York, the Pentagon, and Pennsylvania, to identify aircraft parts, to look for the CVRs and FDRs. We also sent family assistance personnel to work with the airlines in providing assistance to the families of the accident victims. We were successful in locating the recorders at the Pentagon and in Pennsylvania, although one was not useful. We still have staff members Board working on scene in New York, and at our headquarters - providing technical expertise to read out the recorders.

I recently visited Ground Zero. Although I had seen hundreds of photos of the site, none of them prepared me for the magnitude of the devastation. It reminded me of pictures I have seen of cities in war-torn Europe following WWII. I was impressed anew by the courage and determination of members of New York's police and fire departments and the other government agencies who began work minutes after the attack, and continue to work 24 hours a day. Seeing the destruction, the buildings gone, the buildings damaged but remaining - those sights leave me with the sense I get from any horrible disaster - the randomness of death, and the resilience of people in the face of the most appalling tragedies.

I was very proud of our NTSB people who were looking and are looking for recorders both by sifting through wreckage, and by manning a high-powered camera six floors up trained on the rubble. I saw part of an engine that had sheared off when the jet hit the south tower, and landed on a building over a block away. When we went out to the land dump where all the material was being transported and sifted, I asked to see the aircraft parts that had been retrieved thus far. I was shown a pile about the size of a small conference table. Very little had been found, although the work continues.

Congress established the Board in 1967because it believed that an independent investigative agency was needed to investigate accidents in all modes of transportation -- aviation, highway, marine, rail, pipeline, and hazardous materials; to make recommendations to improve transportation safety and prevent future accidents; and to provide oversight to the Department of Transportation modal administrations.

To do that, we involve all of the organizations with an interest in a particular accident -- the regulators, the airlines, the airports, the manufacturers, and the various professional associations and unions -- through what is known as the party system. The primary goal of every investigation is to prevent other accidents from occurring by conducting thorough, independent, and objective investigations; and, then to recommend ways to correct the problems found.

This system has worked well and has helped give the American people confidence in their transportation system - a confidence that has been shaken by recent events. Regaining and maintaining that confidence will require the constant vigilance of everyone in the aviation community. The NTSB's charter does not involve us directly in security issues, but we are following closely the new security precautions which are being put in to place, and will evaluate the effects on the safety of aviation.

In its 34-year history, the Board has issued almost 12,000 recommendations to more than 1,250 recipients. To date, 80 percent of them have been adopted - slightly higher in aviation. Those recommendations have led to countless safety improvements in all transportation modes - including 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.

Before September 11th, the FAA predicted considerable growth in the industry; both in operations, numbers of passengers and transport category aircraft. I usually make the point that growth is likely to lead to more accidents if we don't increase our vigilance. We don't know what the long-term effects of the attacks will be, but the point of this is that we cannot be content even with the industry's excellent record. We always want more.

Today I want to talk about a few of the safety issues the Board is concerned about as they relate to airport operations - runway incursions and overruns, contract towers, airport firefighting, and family assistance. Most of my remarks are about the situation in the United States, but I believe that they are relevant to the entire aviation community.

There were 431 runway incursions in the United States last year, more than double the 200 incursions that occurred in 1994, and a significant increase from the 322 incursions in 1999. Through October 24th of this year, 329 runway incursions have been reported. Since 1990, there have been six fatal runway incursion accidents that killed 64 people. Of course that doesn't include the crashes at Tenerife and recently Milan that killed almost 700 people. Although the aviation community has been diligently working to reduce this safety hazard, the number of incursions is going in the wrong direction.

Since 1973, the Safety Board has issued more than 100 recommendations regarding runway incursions. In 1990, we placed the issue on our list of Most Wanted Safety Improvements. We all know that there isn't any one solution that will eliminate the problem of runway incursions. It will take a combination of approaches. Over the years, the Safety Board has issued recommendations for a broad range of actions -- including procedural changes, educational efforts, and technology improvements.

So far, technological solutions have been long on promise, but short on performance -- even though the Board has been recommending a collision avoidance system for aircraft ground operations since 1991. The FAA has been attempting to implement the Airport Movement Area Safety System (AMASS), which would give controllers at the busiest airports valuable information on potential collisions. Even though the system has been delivered to 33 airports, it's only operational at three (San Francisco, Detroit, and Los Angeles) despite an enormous investment in time and money. The system will not prevent runway incursions in all situations because current AMASS parameters may not provide controllers sufficient time to intervene and react to maintain safe separation in all circumstances. Further AMASS does NOT alert flight crews. Improper or misunderstood clearances continue to place aircraft, vehicles, and their passengers in danger -- despite ongoing safety briefings and seminars, improved signage, painted runway markings, and informational brochures. The reason is simple -- human error. Pilots may misunderstand a clearance or read it back incorrectly and controllers fail to catch the error. Or, they turn at the wrong point. Or, controllers clear an aircraft onto a runway already occupied by a vehicle or another aircraft.

Last year, the Board held a special runway incursion meeting, and issued six more safety recommendations on the issue. Foremost among these was the recommendation that the FAA require a ground movement safety system which would prevent runway incursions and provide a direct warning to flight crews. We believe this is crucial to allow time to react not only for the controllers, but also for those operating the aircraft. The other five recommendations asked the FAA to:

  • Require that all runway crossings be authorized only by specific air traffic control clearance;
  • Require that when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed;
  • Discontinue the practice of allowing departing aircraft to hold on active runways at nighttime or any time when ceiling and visibility conditions preclude arriving aircraft from seeing traffic on the runway in time to initiate a safe go-around maneuver;
  • Adopt the landing clearance procedure recommended by ICAO; and
  • Require the use of standard ICAO phraseology for airport surface operations and periodically emphasize to controllers the need to use this phraseology and to speak at reasonable rates when communicating with all flight crews, especially those whose primary language is not English.

To date, the FAA has not implemented any of these recommendations. I don't doubt that the FAA is hesitating because of the implications of these proposals on the capacity of the system. Up until September 11 at least, FAA's biggest headache was air traffic delays. So I know this is not easy for the FAA to adopt; nevertheless we believe it is critical to take action to retard the growth in incursions before we have a Milan accident in our backyard. The FAA Runway Incursion program addresses awareness and education, and these are certainly important; but in a system as complex as airport traffic control, human mistakes are unavoidable. Our recommendations build in redundancies to compensate for the inevitable lapses in human performance. And, the FAA, together with the rest of the aviation community, must continue to explore innovative ways to ensure that the air traffic environment minimizes the impact of human mistakes before they result in an accident.

For that reason, the Board has also supported other, more cost-effective solutions for lower activity airports, including ground loop technology, runway stop-bars, in-pavement lighting, and airport surface sensors using Global Positioning System technology. However, none of these technologies have been implemented at our nation's airports either.

The Board has also been concerned about the issue of runway overruns for a number of years and several recent accidents have shown that our concerns are justified. In June 1999, an American Airlines' McDonnell Douglas MD-82 overran the runway at the Little Rock National Airport in Arkansas. The captain and 10 passengers were killed and the other 134 passengers and crewmembers were injured. Last month, the Board adopted the final report on this accident. We examined a number of airport-related issues including the difficulties in locating downed aircraft in and around airports during periods of low visibility, as well as runway safety areas. The Board also made a recommendation to the FAA asking that it conduct research activities to determine if recent technological advances would enable submerged low-impact structures and other nonfrangible structures at airports to be converted to frangible ones.

In March 2000, a Southwest Airlines B-737, with 142 people on board, ran off the end of a runway, traveled through a blast fence, and came to rest on a highway outside the airport perimeter. The airplane almost crashed into a gas station in Burbank, California. The runway did not have a 1,000-foot runway safety area. We were fortunate that there were no fatalities in that accident, but we came very close to another major aviation disaster. We are nearing completion of the investigation of the accident.

In 1994, the Board recommended that the FAA inspect all Part 139 certificated airports for adequate runway safety areas and nonfrangible objects, such as blast fences, and that it require substandard runway safety areas to be upgraded to minimum standards wherever it is feasible. When the FAA surveyed the areas, it found that about 40 percent of them were substandard. Rather than immediately correct the problem, the FAA is requiring runway safety area improvements as part of an airport's overall runway improvement projects. The Board believes this is inadequate. There are technologies currently available that could help prevent overruns and they should be put in place now. New York's JFK International Airport has resurfaced one of its overrun areas with an arresting material designed to slow an overrunning aircraft - the Engineered Materials Arresting System (EMAS). The Little Rock airport installed an EMAS system on the accident runway last fall.

We know the system works. In February 1984, a Scandinavian Airlines DC-10 ran off the end of a runway at JFK into a tidal waterway. Twelve passengers were injured and the airplane was substantially damaged. In May 1999, an American Eagle Saab 340B ran off the end of the same runway. However, its wheels sank about 30 inches into the arresting material, which brought the airplane to a stop in 248 feet. There were no injuries to the 30 onboard.

According to a Safety Board performance study, had the EMAS not been there, the airplane could have traveled 500 to 1,000 feet beyond the end of the runway, with similar results as the Scandinavian DC-10. The Board believes that the arresting system should be installed wherever full 1,000-foot runway safety areas are not feasible.

The Safety Board has also been examining service at contract tower facilities to a greater extent as the program has matured. Air Traffic Control (ATC) performance in our accidents at contract-towered airports -- the controlled flight into terrain accident involving Korean Air flight 801 in Guam and the mid-air collisions at Meigs Field in Chicago; Waukegan/Zion, Illinois; and Stuart, Florida have been investigated by the Board in recent years. The Board concluded that controller performance did not cause or contribute to either the Korean Air flight 801 or the Meigs Field accidents; however ATC was cited as a factor in the Waukegan/Zion accident for failing to properly sequence the two airplanes. The Florida accident is still under investigation.

To date, Board investigators have found no appreciable difference in the level of service provided by contract towers versus that provided by FAA-staffed towers. As air traffic in the United States continues to grow and activity at smaller community airports increases, the probability of incidents and accidents occurring at airports with contract towers also increases. As a result of our investigations at Zion and Stuart, the Board recommended that the FAA install radar display equipment in all towers at airports with adequate existing radar coverage, whether the facility is contract or federally staffed. Providing ATC tower facilities with such a tool will raise the level of safety at such airports. The FAA has responded favorably to this recommendation and indicates that all FAA-operated towers meeting its validation criteria will have tower radar displays installed.

Following a number of accident investigations in the last decade that involved emergency evacuations of aircraft, the Board conducted a safety study on the issue and published the results in June 2000. We investigated 46 evacuations involving 2,651 passengers between September 1997 and June 1999. We found that, on average, an evacuation occurred once every 11 days.

One of the issues examined was the adequacy of aircraft rescue and firefighting (ARFF) guidance and procedures related to evacuations. We sent questionnaires to ARFF personnel involved in the evacuations. They indicated that they needed more hands-on familiarization training to prepare them to assist in airplane evacuations. Many ARFF personnel, especially those at smaller airports, believe that they don't receive adequate training on the airplane types that frequent their airports because aircraft aren't readily available from air carriers.

Our report recommends that the FAA establish a task force to address the issue of periodic hands-on aircraft familiarization training for ARFF personnel at all Part 139 certified airports for each airplane type that serves the airport on a scheduled basis. The FAA reports that it is forming a task group and has invited representatives from the American Association of Airport Executives, the Airports Council International-North America, the Regional Airline Association, the Air Transport Association, the Association of Flight Attendants, the Association of Professional Flight Attendants, the Air Line Pilots Association, the Aircraft Rescue and Fire Fighting Working Group, and the International Association of Fire Fighters, to participate.

Currently, airports which serve scheduled air carrier aircraft with less than 30 seats are not required to be certified, and therefore do not meet Part 139 requirements. In our 1994 safety study on commuter airline safety, the Board recommended that the FAA enhance the safety of airports served by commuter airlines by including all airports with scheduled passenger service in its Airport Certification Program. The FAA responded with a Notice of Proposed Rulemaking to revise the current airport certification regulation to include certification requirements for airports with scheduled air carrier aircraft with 10 to 30 seats; however, the final rule has not yet been issued.

Following our investigation of a 1996 accident involving a United Express Beech 1900 and a King Air B90, in Quincy, Illinois, the Board also recommended that the FAA develop ways to fund ARFF protection for airports with scheduled passenger operations by aircraft having 10 or more passenger seats and that it require trained ARFF units, capable of timely response, are available during commuter flight operations.

Last February, the Board adopted a safety report on the survivability of U.S air carrier accidents. The study examined accidents that occurred between 1983 through 2000. It showed that 51,207 (95.7 percent) of the passengers survived those crashes. This information is truly significant - it indicates that many occupants may survive a crash and may be in need of assistance from airport and ARFF personnel - and that your prompt response can save lives.

We made some recommendations arising from the Little Rock accident. These are directed to the FAA:

  • require a minimum ARFF staffing level that would allow exterior firefighting and rapid entry into airplanes to perform interior firefighting and rescue of passengers and crewmembers;
  • evaluate crash detection and location technologies and select the most promising technology to ensure that emergency responders could expeditiously arrive at an accident scene; and
  • require airport operators to conduct an interagency critique within 60 days of an air carrier accident.

Before I close, I want to discuss one other issue of special concern to the Board - assisting the families of victims of aviation accidents. Several years ago, during our public hearing on the crash of US Air flight 427, a number of family members shared their experiences with the Board. They told stories of continuous busy signals from the airline's 800 accident information number, the lack of information, untimely notification, misidentified remains, personal effects being mishandled, unidentified remains not handled with dignity, and the use of confidential information in the litigation that inevitably followed. In short, when they needed guidance, assistance, and compassion, they felt abandoned and abused. Their feelings were not unique; family members from almost every other accident shared them.

In October 1996, Congress passed the Aviation Disaster Family Assistance Act, making the Board the lead federal agency for coordinating federal assets at accident scenes. And, it gave the Board the authority it needed to bring together federal, state, and local government agencies to better serve the victims of transportation accidents and their families. The Act also required the U.S. airline industry to take specific steps to mitigate the effects of an airline disaster on the victims' family members, including requiring all domestic airlines to have a plan in place, and on file with the U.S. Department of Transportation (DOT), to efficiently respond to such tragedies.

Following the crash of Korean Air flight 801, we learned that foreign air carriers flying in and out of the United States were not covered by the 1996 legislation. As a result, Congress passed the Foreign Air Carrier Family Support Act of 1997 that requires foreign carriers to develop family assistance plans and fulfill the same requirements as U.S. domestic airlines.

The 1996 and 1997 acts ensure that all victims and their families will be treated fairly and equally regardless of the carrier they use. And, they also have required many carriers that may not have previously thought about family assistance issues to actively consider them in their planning.

The legislation does not require airports to take any specific actions to assist victims' families following an accident, but many airport managers and ARFF commanders have told us that they are developing family assistance response plans to deal with family members who might come to the airport following a crash.

The Safety Board established our Office of Family Affairs to help ensure that the necessary federal resources are made available to assist families, the affected airline and the community in which the disaster occurs. Many airports have been working with the Family Affairs staff to develop plans that incorporate airport and airline emergency plans with local community emergency plans so that they will be able to provide services until airline and federal resources arrive on scene.

Following the crash of American Airlines flight 1420 at the Little Rock airport, it became even more apparent that airports needed to be better prepared to assist survivors and family members. In September 1999, the FAA issued an Airport Emergency Plan Advisory Circular listing seven areas for airports to consider in order to enhance their ability to assist family members. These areas include:

  • mutual aid agreements among the airlines at the airport;
  • additional coordination with local emergency services;
  • pre-determined location for a "Friends and Family" reception area in the terminal;
  • improved information flow between the affected airline and the airport;
  • terminal access for airline employees during an emergency; and
  • plan to assist non-tenant airlines involved in a disaster.

Although airports are not required to enact any of these measures -- it is not only the prudent thing to do -- it is the right thing to do.

Thank you for inviting me to be here today.