Honorable Carol J. Carmody
Acting Chairman, National Transportation Safety Board
Remarks for Air Traffic Control Association 47th Annual Meeting
Glen A. Gilbert Memorial Award Banquet
November 7, 2002
Good evening. Thank you for inviting me to attend your annual Glen A Gilbert Memorial Award Banquet along with so many leaders of the aviation community. I also want to add my congratulations to your honoree this evening - Frank Frisbie - for receiving this prestigious award and for his dedicated service to the aviation community. I worked with Frank at the FAA so I know the high regard all held for him then, and his reputation and accomplishments have continued to grow in his post-FAA career.
Tonight is a pleasure for me also because I see so many friends and familiar faces among the ATCA membership. I have had contact with many of you during my days at FAA, on the Senate Commerce Committee; saw some of you in Montreal while I served at ICAO. Fortunately our paths have not crossed much since I have been at the NTSB.
All of us here share the same goal - ensuring the safety of the skies - and 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 or to improve transportation safety. There were a couple of things I didn't fully appreciate before I got to the NTSB, however. For one thing I am keenly aware of the difference between the role of a regulator like the FAA and that of the NTSB. In many ways ours is the easier task because we are insulated from many of the pressures brought to bear on the FAA. I am also keenly aware that the NTSB is an independent agency created by the Congress. It is a real novelty to send a budget to Congress without going through the agonies of clearance by the Department and the OMB. The NTSB has an enormous white hat, at least as far as the Congress and the press are concerned. 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 last week during our four-day hearing on last year's American Airlines flight 587 crash. It was lengthy, it was tiring but we got a tremendous amount of information from the witnesses and gained a better understanding of some of the issues relating to the vertical stabilizer and rudder, and the aircraft's performance. Our investigators believe, based on the information currently developed, that the tail fin separated because it was subjected to aerodynamic loads that exceeded its design limitations. The examinations to date indicate that the vertical stabilizer was actually stronger than its certification requirements. Aerodynamic calculations indicate that the loads on the vertical stabilizer were extremely high. Additionally, it appears that the rudder movements prior to the fin separation were the source of the large aerodynamic loads. Our job now is to determine why these rudder movements occurred.
Over the past year since September 11, much of the activity in aviation has been related to security. Although the NTSB's charter does not involve us directly in security issues, we are following closely the new security precautions that are being put in to place, and will evaluate the effects on the safety of aviation.
For instance, the airlines have taken action to reinforce the cockpit door. However, there are a number of safety issues that need to be considered as they under take that effort.
- Ease of communication. During some of our investigations, we have found that communication problems between the cockpit and the cabin crews, caused by damaged interphone systems, cockpit workload issues, or human error, could be resolved by face-to-face discussions between the crews. As security improvements are implemented, we must be sure that crew communications during emergency situations are not compromised.
- Emergency Access. Access to the cockpit can also be very important in an emergency. For example, in the DC-10 accident at Sioux City, Iowa in 1989, an off-duty DC-10 check airman seated in the cabin was taken to the cockpit by a flight attendant so that he could provide much needed assistance to the flight crew as they tried to land the plane.
- Emergency Escape and Rescue. We must consider how changes to the cockpit door would affect the crew's ability to escape or be rescued following an accident. Rescue personnel have had to use the cockpit door to free the trapped pilots, and crew and passengers have used the cockpit windows to escape when other exits were inoperable or blocked.
The Safety Board is being asked to assist in an increasing number of international accident investigations due to the widespread use of U.S. equipment. Over the past two years, we have assisted in more than 120 accident and incident investigations around the world. At times we have had three teams spread over China, the Middle East and South America. We have assisted with the China Air 747 which crashed in the sea, the Singapore Airlines accident on a mistaken runway in Taipei; the runway collision last year in Milan between an MD-83 and a Cessna Citation; the very recent mid-air collision in Germany between a DHL B-757 and a Bashkirian TU-154; two controlled flight into terrain (CFIT) events in the mountains of Colombia last year; a suspected CFIT in Tunis involving an Egypt Air B737-500; and another suspected CFIT in Korea involving an Air China B767-200. Our facilities here in Washington are also increasingly becoming a focal point for international aviation investigators. On just one day, we had representatives from five different countries working in our laboratory.
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 helped to bring countless safety improvements in all transportation modes -- including aircraft collision and ground proximity warning systems and airport wind shear warning systems to mention a few.
We know that we cannot be content with the industry's excellent record. We must always want more. To that end, I want to focus on two safety issues the Board is concerned about as they relate to ATC operations -- runway incursions and contract towers.
Runway incursions are a subject the Board has been engaged on since 1973. We have made over 100 recommendations and it is on our Most Wanted List for safety improvements. Although the aviation community has been working to reduce this safety hazard, the number of incursions is still too high. There were 383 runway incursions in the United States last year, almost double the 200 that occurred in 1994. Although that's 43 less incursions than in 2000, we must remember that air traffic was greatly reduced in the last quarter of the year. Through October of this year, 280 runway incursions have been reported. Runway incursions can be deadly. When two loaded aircraft are involved the loss of life is high. You may recall the collision between two aircraft at the airport in Milan last year, which killed more than one hundred people or the accident in Singapore in 2000, in which an aircraft hit an obstruction on the runway, killing 83 people. We don't want that to happen here.
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 visible efforts to address runway safety has been 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. AMASS has been in development for over 10 years, although the FAA says that AMASS is expected to be operational at 32 of the nation's busiest airports by 2003. Although it is a promising technology for some situations associated with runway incursions, 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:
- Requiring that all runway crossings be authorized only by specific air traffic control clearance;
- Requiring - for aircraft crossing multiple runways - an explicit crossing instruction for each runway after the previous runway has been crossed;
- Discontinuing 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;
- Adopting the landing clearance procedure recommended by ICAO; and
- Requiring the use of standard ICAO phraseology for airport surface operations and periodically emphasizing to controllers the need 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; nevertheless we believe it is critical to take action to retard the growth in incursions before we have a Milan accident in our backyard. Our recommendations build in redundancies to compensate for the inevitable lapses in human performance. 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. I don't believe these technologies have been implemented at our nation's airports either.
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 such as the controlled flight into terrain accident involving Korean Air flight 801 in Guam in August 1997, and the mid-air collisions at Meigs Field in Chicago in July 1997; Waukegan/Zion, Illinois in February 2000; and Stuart, Florida in March 2000, 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 and in the Florida accident for not providing adequate approach/departure control service, failing to advise the local tower controller of the change in approach procedure, and excessive and extraneous radio communications by the local controller.
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.
Aviation continues to be the safest mode of transportation available to the world's travelers. The Board's job - and yours -- is to ensure that it remains that way. The measures that I've discussed will help us do that. Thank you again for inviting me to be here with you tonight and share in the festivities.
Speeches & Testimony