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Remarks at the Leadership in Times of Crisis Seminar, Stony Brook, State University of New York
Carol Carmody
Leadership in Times of Crisis Seminar, Stony Brook, State University of New York

The NTSB was created by the Congress to investigate accidents, determine the probable cause and make recommendations to prevent recurrence. We have this authority across all modes of transportation, although aviation gets the most attention. We are the lead agency in aviation accidents unless there is credible evidence of criminal activity. In that case, the Attorney General and the Chairman must confer and the FBI would take the lead. This provision is contained in a statute because of the difficulties that arose between the NTSB and the FBI following the TWA 800 crash.

So on the morning of September 11, when I got the first call about a jet hitting a building in New York, I assumed I would be heading up there with a GO Team. Within minutes, the second plane hit and I realized this was not likely to be an NTSB investigation. The FBI Director called and I went immediately to their headquarters, arriving just as the building was being evacuated and the Pentagon was reported hit. We received minute-by-minute bulletins of the plane in Pennsylvania. Then we heard it was down and the rumor was that it had been shot down.

I left to return to headquarters and assured FBI Director Mueller that we would assist in any way we could, but that it was obvious the disasters were not accidents. No sooner had I reached my office than he called and said, "Could you send us some people to help find the black boxes and help identify aircraft parts." We dispatched teams immediately to Pennsylvania, New York and across the river to the Pentagon. We were able to recover cockpit voice recorders and flight data recorders from the Pentagon and Pennsylvania; not yet and maybe never from the Trade Center. Our experts read out the recorders and provided the information to the FBI for their use in the investigation. Our investigators stayed in New York for several months working both at Ground Zero as well as at the Freshkill site where large amounts of debris were taken to be sorted.

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.

In addition to the technical experts we sent on September 11, we also dispatched teams from our Family Affairs office. This office was established in 1996 as a result of the Aviation Disaster Family Assistance Act.

Family Affairs

Historically, the treatment of families of victims of major aviation accidents lacked organization, coordination, and compassion. Families told numerous horror stories -- constant busy signals from the airline's 800 accident information number; misidentified remains; personal effects being mishandled; unidentified remains not handled with dignity, including mass burials without informing families; news reports of accident details unknown to families; and the use of confidential information obtained during this grief process against families in court.

Many of these same concerns had been raised after Pan Am 103 yet the Pittsburgh crash in 1994 and the TWA crash in 1996 showed there had been no progress in the treatment of families. So the 1996 legislation designated the NTSB as the lead agency for coordinating this effort. The statute, along with the President's directive to six cabinet agencies, gave the Safety Board the authority it needed to bring together various state, federal, and local government agencies to serve the victims and families of transportation accidents.

The Family Assistance Act was extended in 1997 to require foreign carriers flying in or out of the United States to file with the Department of Transportation and the National Transportation Safety Board a family assistance plan to be used in case of an accident on U.S. soil.

The Office of Family Assistance fills the void - as a coordinator to integrate the major resources of the federal government and other organizations to support the efforts of the local and state government and the airline to meet the needs of aviation disaster victims and their families. Family counseling, victim identification and forensic services, communicating with foreign governments, and translation services, are just a few of the areas in which the federal government can help local authorities and the airlines deal more effectively with a major aviation disaster.

The Board has exercised its responsibilities at the site of all major aviation accidents since the passage of the law as well as several accidents in other modes. I have seen that office in action on several occasions, and let me tell you it is impressive. The office coordinates assistance, information, identification and recovery, and tries to assure that the families receive courteous and sensitive treatment and assistance with the various needs that accompany an accident.

The USG felt so strongly about the effectiveness of the program that the U.S. Delegation to the triennial Assembly of the International Civil Aviation Organization in 1998 offered a resolution urging countries to develop family assistance programs. The Resolution passed and a number of countries have developed similar programs to address the needs of families.

In light of our current concerns about terrorism or sabotage, it is important to note that the 1996 Act requires the NTSB to conduct family affairs activities after a crash, "regardless of its cause." Therefore, even in the case of an airliner crashing due to a criminal act as happened on September 11, 2001, the NTSB is still the family assistance coordinator at the scene.

Let me give you some specifics about the NTSB's family assistance. The office is comprised of seven individuals, all of whom have experience in some aspect of our response. One person is a forensic anthropologist, skilled in identifying individuals by extraordinary means. Another is former station manager with a major U.S. airline, familiar with the workings of the industry with which we must have close and mutual cooperation. Yet another is a certified mental health professional with years of experience in mass disasters. The Deputy Director of the operation is a former U.S. Army Colonel who operated the military's casualty notification and assistance system and who is responsible for creating our internal response plan.

Our family affairs operation is designed to harness the assets and abilities of the federal government. When we arrive on scene we are always careful to work in cooperation with the local medical examiner or coroner, whose responsibility it is to recover and identify victims. I focus on the recovery and identification of remains specifically because every family member will tell you that in the immediate aftermath of a crash there is no greater interest for those who have lost a loved one. NTSB fully recognizes that the family affairs efforts must be focused on the quick and accurate identification of remains.

We can bring to the scene a fully equipped mobile morgue and the staff required to operate it. The Department of Health and Human Services operates the National Disaster Medical System and their Disaster Mortuary or DMORT teams are fully partners with us in our response. If conventional means of identification are not adequate, the Board has access to the Armed Forces Institute of Pathology, the worlds' leading DNA laboratory. We have used DNA to identify hundreds of unidentified victims in a number of air crashes.

The families also want to know what caused the accident. The NTSB policy has long been to release factual information as soon as it has been confirmed; our commitment to the families is to brief them or their representatives before we release the information in a press conference. The family affairs staff organizes a meeting place for the families so that they may hear from the Board Member on scene and the lead investigators. We have found it to be very important for families to be able to ask questions, and to understand the NTSB's unique role and independent status.

So the NTSB's Office of Family Affairs is an effective coordinator on the accident scene that can integrate the major resources of the federal government and other organizations to support the efforts of local and state government agencies and the airlines to meet the needs of the victims and their families.

The Office also helps these entities be more proactive, so that they and we are better prepared in advance of an accident. For example, we have worked with:

  • Nearly all domestic and international major airlines and regional carriers to assist them in developing effective emergency response/family assistance plans. 

  • State and local medical examiners and coroners to ensure that they are aware of the resources that can be brought in to help them to recover and identify victims. 

  • Mental health agencies and the American Red Cross to coordinate the use of their resources. 

  • Federal, state, and local emergency management agencies so that their efforts are better coordinated with those of other agencies. 

  • Funeral directors across the country who can play a critical role in assisting in victim recovery and identification efforts. We have had to call upon the Disaster Mortuary (DMORT) teams, under the auspices of the Department of Health and Human Services, to assist local coroners with several accidents under difficult conditions. 

  • Airport authorities to ensure that they address family issues in their emergency plans. 

  • Representatives of many of the family advocacy groups to ensure that we address issues they believe are of greatest importance immediately following an accident. 

  • We are offering training programs in our new NTSB Academy starting this April.