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Remarks before the IATA World Air Transport Summit, Washington, DC
Carol Carmody
IATA World Air Transport Summit, Washington, DC

Good morning. Thank you for inviting me to participate in this summit and this briefing session along with this distinguished panel. I appreciate being asked to discuss aviation safety issues of concern to your organizations and the National Transportation Safety Board (NTSB).

I believe everyone here knows that the Safety Board was created in 1967 to conduct independent accident investigation in all modes of transportation, and make recommendations to prevent recurrence and to improve transportation safety. As an independent board our role is very different from that of the regulator, the Federal Aviation Administration (FAA). In many ways, ours is the easier task because we are insulated from many of the pressures brought to bear on the FAA. The NTSB has an enormous white hat, at least as far as the Congress and the press are concerned. The NTSB is not subject to departmental politics. The NTSB submits its budget to the Office of Management and Budget at the same time we submit it to the Congress. It is wonderful, but believe me it is very different from other government experiences I have had.

When we conduct an investigation at the NTSB, we involve all of the organizations that can provide technical expertise -- the regulators, the airlines, the airports, the manufacturers, and the labor organizations -- through our party system. You may have seen that system at work a few weeks ago during our hearing on the Air Midwest crash that occurred shortly after takeoff from Charlotte, North Carolina on January 8, 2003. Two areas of focus in that investigation have been the weight and balance of the aircraft, and recent maintenance on the elevator system. Of course, that is only one of our ongoing investigations - others that are still open are American Airlines flight 587 and the Wellstone accidents, plus we continue to assist NASA with the space shuttle Columbia accident.

The public hearing is only one part of our investigative process. The end result of our investigations is the finding of probable cause and the issuance of recommendations to prevent another similar accident from occurring. In our 36-year history, the Board has issued almost 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 organizations and associations. To date, 80 percent of them have been adopted and they have led to countless safety improvements in all transportation modes -- 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.

We put those recommendations that haven't yet been implemented which we believe would save the most lives on our Most Wanted List. Currently, there are six on the list related to aviation:

  • Airport Runway Incursions
  • Airframe Structural Icing
  • Explosive Mixtures in Fuel Tanks on Transport Category Aircraft
  • Human Fatigue in Transportation Operations
  • Automatic Information Recording Devices
  • Child Occupant Protection


We believe that implementation of recommendations in these areas is crucial to improving aviation safety. These critical safety issues in the industry have been highlighted in a number of NTSB investigations over the years. Yet, we still haven't resolved them. I don't have time to talk about all of them, but want to briefly discuss a few of them - runway incursions, structural icing, explosive mixtures in fuel tanks, and recorders.

There were 339 runway incursions in the United States last year, more than 1½ times the 200 that occurred in 1994. In just the first four months of this year, there were 104 runway incursions reported, compared to 90 during the same period last year. There have been 1,333 incursions reported since 2000. Runway incursions can be deadly. Although the aviation community has been working to reduce this safety hazard, the number of incursions is still too high.

Since 1973, the Safety Board has issued more than 100 recommendations regarding runway incursions. The issue has been on our list of Most Wanted Safety Improvements for 13 years. 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 including procedural changes, educational efforts, and technology improvements.

One of the most touted technology improvements to deal with runway incursions is the implementation of AMASS -- Airport Movement Area Safety System. AMASS generates an audible and visual alert to controllers when an aircraft or vehicle is occupying a runway and when arriving or departing aircraft cross a certain threshold or attain a certain speed. After ten years in development, AMASS finally will be operational at 34 of the nation's busiest airports by the end of 2003, according to the FAA. It is a promising technology for some situations associated with runway incursions, but AMASS parameters may not provide controllers and flight crews sufficient time to intervene and react to maintain safe separation in all circumstances. We believe that the system is missing a key element -- a direct warning to flight crews or vehicle operators. This warning is crucial because it would give both controllers and those operating the aircraft time to react.

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. We have recommended to the FAA that since the technology isn't complete, some operational measures be considered to minimize the possibilities of runway incursions, such as:

  • adopt procedures to specific clearances for each runway crossing;
  • stop allowing departing aircraft to be held on active runways at night;
  • use standard ICAO phraseology to reduce confusion in pilots whose native language is not English.


To date, the FAA has not implemented any of these recommendations. The FAA's runway incursion program does address awareness and education, which 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. We believe it is critical to take action to retard the growth in incursions before we have an accident on US soil like the one in Milan in 2001 that killed more than 100 people.

The 1994 crash of a commuter airliner in Roselawn, Indiana, which took 68 lives, prompted the Safety Board to examine the issue of airframe structural icing and conclude that the icing certification process has been inadequate. Since then, we have investigated a number of other accidents and incidents in which icing was involved.

We found that manufacturers have not been required to demonstrate an airplane's flight handling and stall characteristics under a realistic range of adverse ice accretion/flight-handling conditions and the FAA has not adopted a systematic and proactive approach to the certification and operational issues of turbine-engine driven transport category airplane icing. As a result, the NTSB made a series of recommendations for expedited research into the effects of all types of structural icing. We also recommended that the certification standards be upgraded, improved detection and protection systems be developed and implemented, and operational procedures be improved.

Much of the work being done to address our recommendations has been through Aviation Regulatory Advisory Committees formed by the FAA. They are developing new advisory material and certification standards that are expected to ensure that all aircraft are properly tested for the various types of icing conditions they may encounter. A lot of work has been done, but our recommendations were issued almost five years ago, and there will be further delays before FAA will enact rulemaking. Until then, icing will continue to be a major threat to aviation safety.

As a result of the TWA flight 800 investigation, we issued two safety recommendations on fuel tank explosions soon after the crash in 1996. One asked the FAA to eliminate the explosive fuel/air mixtures in the tank - a long-term solution -- and the other asked them to mitigate the problem with a number of near-term actions until they could eliminate the problem.

Center wing fuel tank explosions have resulted in 346 fatalities over the years. Operating transport-category airplanes with flammable fuel/air mixtures in fuel tanks presents an avoidable risk of explosion and the Board believes that a fuel tank design and certification philosophy that relies solely on the elimination of all ignition sources, while accepting the existence of fuel tank flammability, is fundamentally flawed. We have seen that possible ignition sources cannot predictably and reliably be eliminated.

Recently we've seen progress on our two recommendations. In November, the FAA issued an emergency order requiring operators of Boeing 737, 747, and 757 aircraft to keep enough fuel in the center wing tank to keep the fuel pumps submerged. And, the FAA publicized promising research results that demonstrated that a fuel tank inerting system for new and existing aircraft was practical and effective. The Board is continuing to urge the FAA to require fuel tank inerting in all new and existing transport category aircraft as a long-term solution.

Following our investigations into ValuJet flight 592, and TWA flight 800, as well as foreign investigations involving SilkAir flight 185, and Swissair flight 111, the Safety Board issued recommendations to the FAA to address an interruption in the electrical power to the cockpit voice recorder (CVR) -- causing a loss of 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 cockpit, to significantly increase the likelihood of recovering valuable audio information. We also want to improve the crash survivability of all recorders. The FAA recently advised the Board that the NPRM concerning the two-hour CVR with an independent 10-minute power supply was returned from the Department of Transportation because it was going to be too expensive and burdensome for the industry to implement.

In April 2000, the Safety Board also recommended that the FAA require commercial aircraft currently equipped with a CVR and a flight data recorder (FDR) to also be equipped with a crash-protected cockpit image recording system. We made this recommendation because we didn't have adequate information about the cockpit environment in several recent major investigations, such as the ValuJet flight 592 and EgyptAir flight 990 investigations. In each of these investigations, crucial information about the circumstances and physical conditions in the cockpit was simply not available to investigators, despite the availability of good data from the FDRs and CVRs. The FAA submitted the recommendation to the RTCA Future Flight Data Collection Committee for consideration. The committee's final report, issued earlier this year, was favorable to the concept of using video technology in the cockpit. Consequently, we have again urged the FAA to promptly initiate rulemaking activity for the recording requirements outlined in these recommendations.

Overall, this system works well and helps give American people confidence in their transportation system. Maintaining that confidence requires constant vigilance -- 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 responsibilities are being fulfilled.

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.

Scheduled to open in the fall, this state-of-the-art facility will not only provide the training necessary to keep our accident investigators on the cutting edge of investigative technology and performance -- but it will also advance transportation safety worldwide. With our increasingly global transportation systems, we have an obligation to insure that high standards and effective techniques are employed no matter where transportation disasters occur around the world.

The Academy provides an excellent platform for sharing our knowledge, providing training for accident investigators, first responders, law enforcement, firefighters and others worldwide who we need to work with us at an accident site, and for advocating safety improvements on a global scale.

Currently, we are offering courses such as:

  • a two-and-a-half-week course in basic aircraft accident investigation for newly hired investigators from the NTSB, industry, and other government agencies from the U.S. and other nations.
  • a comprehensive family assistance course for those who assist friends and families of major transportation accident victims.
  • a course of airline industry training to familiarize industry representatives with their duties and responsibilities during NTSB accident investigations.
  • a newly developed course designed for law enforcement officers who initially respond to transportation disasters.
Some of you have already taken advantage of some of these courses. I hope others of you will -- so that your staffs can be better prepared and will know our procedures better. It will also allow all of us to get to know each other better - before a disaster strikes and we need to call upon one another.


Thanks again for inviting me here today. We know that we cannot be content with the industry's excellent safety record to date. We must always want to do more. I look forward to discussing this topic with you further.