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Remarks at the Air Line Pilots Association's Air Safety Forum, Washington, DC
Carol Carmody
Air Line Pilots Association's Air Safety Forum, Washington, DC

Good morning. Thank you, Duane, for inviting me to participate in the celebration of ALPA's 70th anniversary and the Air Safety Forum. The sessions I have attended have been outstanding, and I want to compliment John Cox for his excellent work in organizing this event. Congratulations to all of you on your 70th anniversary. The National Transportation Safety Board and ALPA have been working together for more than 30 of those years to ensure the safety of our Nation's aviation system.

Everyone at the Board appreciates the assistance provided by ALPA members to increase aviation safety through training, dissemination of information, participation in accident investigations, and support of the Board's safety recommendations. During those 70 years, you have all worked tirelessly for the cause of safety - but we all know that more remains to be done - by both our organizations.

The Safety Board has been the eyes and ears of the American people at accident sites for over three decades. Congress believed, when it established the Board in 1967, that an independent 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.

Our reason for existence is to prevent accidents from occurring by conducting thorough, independent, and objective investigations and by then recommending ways to correct the problems found. We involve all of the organizations that can provide technical expertise in a particular investigation -- the regulators, the airlines, the airports, the manufacturers, and the labor organizations -- through our party system.

This system has worked well and has helped give the American people confidence in their transportation system. But, maintaining that confidence requires constant vigilance by everyone within that system -- regulators must properly regulate the industry; owners and operators must ensure the safety of their operations; manufacturers must design and build safe vehicles; and the NTSB must reassure the public that there is an independent review of how well those entities are fulfilling their responsibilities. This interrelationship creates a healthy tension between the participants -- by design -- and it works.

We all know about the growth of the commercial aviation industry in the last decade: eight consecutive years of air traffic growth, with significant increases in the general aviation fleet. The Federal Aviation Administration predicts by the year 2011 the number of air travelers will increase from 664.5 million to more than one billion: aircraft operations at FAA air route traffic control centers will increase from 45.7 million in 2000 to 59.4 million in 2011, growing 2.4 percent each year. The number of passengers on foreign flag air carriers traveling to or from the United States is expected to increase from approximately 137.6 million in 2000 to 239.4 million in 2011; a 5.1 percent rate of growth each year.

Along with the increase in air travelers will come an increase in transport category aircraft. According to the Boeing Aircraft Company, in 1995 there were 11,066 transport category aircraft operating around the world. That same year, there were 21 hull losses. Boeing projects that, if those trends continue by the year 2015, there will be 23,081 aircraft, about 44 hull losses -- more than double the 1995 figure. I agree with David Hinson in his comments yesterday when he said anything less than a goal of zero accidents is unacceptable. It's hard to imagine a hull loss accident nearly every week, but accidents are a real possibility - unless we take the necessary steps now to safeguard the system - both here and around the world.

Because more of our citizens are flying internationally and more of our U.S. manufactured equipment is being used by foreign airlines, the Safety Board is being asked to assist in an increasing number of international accident investigations. Over the past two years, we have assisted in more than 120 accident and incident investigations around the world. Our facilities here in D.C. are also increasingly becoming a focal point for international aviation investigators. On just one day recently, we had representatives from five different countries working in our laboratory.

A few years ago, the Board asked the RAND Corporation to review our operations and procedures to ensure that we were ready to take on the challenges of the 21st century. Rand told us to expect that accident investigations will be even more complex in the future. Accident investigations like those of USAir flight 427 and TWA flight 800 will be the norm -- not the exception.

If Rand is correct, we'll need not only better trained investigators, we'll need more -- and better -- data to help us determine the cause of those accidents. In addition, the success of other initiatives such as Flight Operations Quality Assurance also depends on the collection and analysis of more complete and accurate data.

There can be no better argument for improving both flight and cockpit data recorders. At a minimum, we need more parameters recorded, longer recording time, backup electrical power, and improved crash survivability. The Board has been asking for these enhancements for years, but to date, there's been little progress. As a result, we've had long, arduous investigations and extensive and exhaustive search and recovery efforts that have proven to be very expensive, and would not have been necessary if more information had been available to investigators.

For example, in 1994, just outside Pittsburgh, USAir flight 427, a Boeing 737, crashed - the second crash of a 737 in three years. The plane's FDR recorded only 11 parameters. As a result, the Safety Board's investigation into that accident took more than four years to complete.

Contrast that accident with the Board's investigations into the crash of an American Eagle ATR-72 in Roselawn, Indiana, in 1994, and two 1996 accidents involving Boeing 757s. Because the ATR's FDR recorded 98 parameters, we were able to focus quickly on how the aircraft operated in icing conditions and issued urgent safety recommendations just eight days after the accident.

Both of the Boeing 757 accidents required underwater recoveries under extremely difficult conditions. A Birgen Air flight crashed off the coast of the Dominican Republic in 7,200 feet of water. And, an Aeroperu flight crashed in more than 600 feet of water off the coast of Peru. The FDRs onboard both planes were capable of recording 150 parameters. Once they were recovered, they provided investigators with data necessary to define the problem and to determine the crews' actions.

As a result, in the Birgen Air case, investigators did not need to recover the remainder of the aircraft. In the Aeroperu accident, only a few additional parts had to be recovered. Because of the information provided by the recorders, the countries involved saved millions of dollars in investigative and recovery costs, and the travelling public's confidence in the aircraft was maintained.

Based on the Board's experience during the USAir flight 427 investigation and others, in which insufficient information was available, the Board asked the FAA to increase the number of FDR parameters. By 2002, all newly manufactured aircraft will be required to record a minimum of 88 parameters and older aircraft will have to be retrofitted. But, just increasing the number of parameters on FDRs won't solve all of the problems encountered because of gaps in recorded information. Therefore, we have also recommended that the cockpit voice recorder (CVR) be upgraded.

Following our investigations into ValuJet flight 592, TWA flight 800, and the foreign investigations into SilkAir flight 185 and Swissair flight 111, the Safety Board asked the FAA to address problems created when there's an interruption in the electrical power to the CVR -- causing the loss of the last critical moments of an accident flight.

In 1999, we recommended that the FAA require a CVR that records two hours of data, rather than the current 30 minutes; 10 minutes of backup power in case of a power loss; and a redundant CVR near the front of the aircraft - all of which would significantly increase the likelihood of recovering valuable audio information. We have also asked that the crash survivability of all recorders be improved.

Recent innovations in recorder and power supply technologies make it possible to provide an independent power source that would operate a solid state voice recorder for 10 minutes. And, with the advent of these recorders, combination recorders may soon be available that will store audio, data, and even images.

That possibility leads me to an issue that has generated a great deal of controversy -- electronic cockpit imagery. Recording images of the cockpit is not a new idea. However, it has only recently become both technically and economically feasible, and we need to take advantage of that technology. It is now possible to capture images of what is happening inside the cockpit so that questions regarding flight crew actions can be readily resolved. The idea is not to replace the CVR or FDR, or to duplicate information already recorded, but to capture information that is not being recorded - information that would allow us to determine causes of accidents and implement solutions.

For example, a cockpit image recorder could tell us which pilot was at the controls, what controls were being manipulated, what the pilot inputs were to various instruments, or what was shown on the visual displays. Image recorders could also provide crucial information about the circumstances and physical conditions in the cockpit that are simply not available to investigators, despite the availability of modern CVRs and 100-parameter digital FDRs.

In April 2000, the Safety Board recommended that the FAA require Part 121, 125, or 135 aircraft currently equipped with a CVR and a FDR to be equipped with a crash-protected cockpit image recording system. We made this recommendation based on a series of investigations in which the Board had inadequate information about the cockpit environment, including ValuJet flight 592, EgyptAir flight 990, SilkAir flight 185, and Swissair flight 111. For example a cockpit image recorder on Swissair flight 111 may have shown the smoke and fire conditions and the status of the flight instrument displays that led to the crew's decision to descend from cruise flight and divert to Halifax.

There is no data on the CVR and FDR for the final minutes before the SilkAir flight 185 crash, and the Indonesian investigation was hampered by a lack of information concerning what happened in the cockpit. The need for a video recording of the cockpit environment has been most evident in the EgyptAir investigation. The Safety Board's staff believes that electronic cockpit imagery could help resolve issues surrounding the flight crew's actions and the circumstances that prompted those actions.

The Board is very sensitive to the privacy concerns that have been expressed by your association and others with respect to recording images of flight crews. To protect crewmembers' privacy, we asked Congress to apply the same protections that exist for CVRs to the use of image recorders. Under these provisions, a cockpit image recording would not be publicly released. We know there are concerns about the treatment of video and other types of recordings in foreign accidents and we're working with the International Civil Aviation Organization (ICAO) to improve protections afforded to recorded information on an international level. I know something about ICAO since I spent five years there representing the United States, and that is where we need to concentrate our efforts. I was interested in Captain Murphy's remarks yesterday about this issue. IFALPA has representation at ICAO and sits as an observer on the Air Navigation Commission - the chief technical body at ICAO. I hope IFALPA will continue and intensify its efforts to work with colleagues from other countries to convince them of the need for confidential treatment of recorded information.

Let me turn to another issue of concern to both our organizations - runway incursions. There were 429 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 August 8 of this year, 250 runway incursions have been reported. There were 258 for this same period last year. Although the FAA and the aviation community have been diligently working to reduce this safety hazard, the numbers are not encouraging. Fortunately, there have been few actual collisions and the number of fatalities has been small, but the possibility for a catastrophe increases with time if the error rate is not reduced.

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.

Since 1973, the Safety Board has issued more than 100 recommendations regarding runway incursions. In 1990, we placed runway incursions on our list of Most Wanted Safety Improvements. Last year, we 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 which would provide a direct warning to flight crews. The FAA is implementing AMASS, although we understand with some delays, but AMASS alerts only the tower - not the cockpit. The other five recommendations we made last summer were of an operational nature which we believed necessary since the technology is not mature. These are:

    · 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. We believe that awareness and education are important, but in a system as complex as airport traffic control, human mistakes are unavoidable. That is why 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.
Finally, I want to briefly discuss another issue of concern to the Board - and to ALPA - fatigue. The National Transportation Safety Board has worried about fatigue for more than 25 years. Recommendations on operator fatigue in all modes of transportation have been on the Safety Board's "Most Wanted List" of safety improvements since the list's inception in 1990. In May, we reaffirmed its importance by retaining the issue on the list for another year.

Over the years, we have made about 100 recommendations on this issue to operators and regulators asking for additional education and research as well as specific regulatory changes. Our first recommendation on pilot rest and duty limitations was made to the FAA in 1972. We became more concerned in the 1980s after fatigue was cited or suspected of being a factor in at least two aviation accidents -- the in-flight upset of China Airlines flight 006 in February 1985, and the crash of an Arrow Air charter flight in December 1985, that killed 248 American soldiers.

In 1989, the Safety Board issued three safety recommendations to the DOT, calling for an aggressive federal program to address the fatigue problem in all sectors of the transportation industry. These recommendations asked for:

    · a coordinated research effort on the effects of fatigue, sleepiness, sleep disorders, and circadian factors on transportation system safety;

    · an extensive educational program for all segments of the transportation industry regarding shift work, work and rest schedules, and proper regimens of health, diet, and rest; and

    · a systematic review and improvement of regulations governing the hours of service in all modes to assure that they were consistent and that they incorporated the results of the latest research on fatigue and sleep issues.

In 1999, the Board reviewed the status of those recommendations. Our report examined the progress, or rather the lack of progress, in each mode. We again asked the DOT to require the modal administrations to modify their regulations to establish scientifically based hours-of-service regulations, to provide predictable work and rest schedules, and to consider circadian rhythms and human sleep and rest requirements. We asked that this be done within two years. We recently passed the two-year mark and, once again, little progress has been made.

The FAA has announced that, within the next few months, it intends to begin enforcing the existing regulations concerning flight time limitations and rest requirements -- regulations that date back to 1985. These rules require airlines to provide reserve pilots with a pre-scheduled and protected eight-hour rest period sometime during the 24-hour period prior to completion of a flight assignment. Because these regulations haven't been enforced, airlines could require their reserve pilots to be "on call" 24 hours a day for several consecutive days without giving them the legally mandated crew rest. Although we're pleased that the FAA intends to enforce its existing regulations, the Board is still concerned that no further rulemaking has been undertaken to resolve the overall issue of hours of service or to equalize the duty and rest requirements for Part 121 and Part 135 operations.

The three issues I discussed today - data recorders, runway incursions, and fatigue - are all on the Board's Most Wanted List of Safety Improvements. I hope you will continue to be vocal advocates for the recommendations that have made to address each of those areas and that - if implemented - will improve the safety of every flight crew and every passenger. Thank you, again, for inviting me to be here with you today.