Thank you for that warm introduction.
It is fitting that I come before an organization dedicated to sharing solutions for preventing and mitigating the devastating loss of life and property caused by disasters, because the National Transportation Safety Board has just celebrated 30 years of doing just that. In those three decades, we've investigated more than 100,000 aviation accidents and tens of thousands of accidents in the surface modes of railroad, highway, marine and pipeline/hazardous materials.
Our investigations are aimed at preventing future accidents and mitigating the effects of those accidents that still occur by trying to make them more survivable. We do this by encouraging thorough and professional planning; planning in original vehicle design, in proper procedures, in training and in emergency response.
Eighty five years ago today, man's belief that good intentions were more important than mundane planning bore its terrible and inevitable result. The loss of the RMS TITANIC showed that failing to be prepared for any predictable eventuality can one day lead to tragedy.
- The finest ocean liner the world had ever seen was allowed to embark on its maiden voyage without binoculars for the crows nest watch; they were to be purchased in New York.
- The watertight compartments appeared to be more than adequate - in fact, rendering the ship "unsinkable" - unless the ship were to suffer a glancing blow that would breach more than 4 of them.
- It is only now that we are learning that the grade of steel used in the ship's construction was not of ideal quality.
- The captain had been warned about ice fields in his path, but refused to slow the ship's speed.
All of these factors combined to bring about one of the most shocking tragedies of the century. But one more factor ensured that the TITANIC disaster would forever be remembered for shortsighted planning. Although it took the ship almost 3 hours to sink, more than 1,500 persons perished in the freezing waters, most because there weren't enough lifeboats for them.
Although inconceivable today, such lack of foresight can still be seen in the failure of regulators to benefit from lessons learned through accidents or even because of close calls, the failure of companies to promote a corporate culture of safety, and the failures of individuals to make sure they are well rested and otherwise fit for duty. These are some of the problems we see in every accident we investigate.
As all of you know, transportation is one of the largest and most dynamic segments of our economy. According to the U.S. Department of Transportation, it accounts for about 11 percent of our annual gross domestic product - that's about $700 billion. All of us utilize our massive transportation infrastructure many times a day:
- We all drive our cars on some of the 4 million miles of roads, highways and bridges.
- Many of us fly often enough that 550 million passengers boarded commercial aircraft in this country last year, about twice our population. And in 10 years, domestic aviation operations will increase another 60 percent.
- We all depend on the 123,000 miles of railroads and 25,000 miles of waterways in the U.S. for most of the commodities we buy.
- The gas that heats our homes and the gasoline that fuels our cars come to our neighborhoods in some of the 1.4 million miles of pipeline. And,
- School buses alone carry about 9 percent of the U.S. population during a typical school day.
Unfortunately, when you have so much activity, it is inevitable that accidents occur in our transportation system. Most of you know the National Transportation Safety Board because of our high-profile aviation accident work - especially the ValuJet and TWA flight 800 accidents last year - but the Board also investigates highway, rail, pipeline and marine accidents. The NTSB was established as an independent agency 30 years ago by Congress to determine the "probable causes" of transportation accidents and issue recommendations to prevent future accidents.
And despite the inevitable scare stories that you read after a major accident, we actually have an extremely safe transportation system. Just a few years ago, the major airlines went an incredible 27 months without a single passenger fatality; that was 1 billion consecutive passengers carried safely to their destinations. Depending on the year, the major airlines suffer one fatal accident for every 2 to 5 million flights.
And, with as many highway crashes as we have, the accident rate continues to decline. In 1995, the highway fatality rate reached 1.70 per 100 million vehicle miles traveled, a 65 percent decrease since 1970.
This safety record is due in no small part to the efforts of the men and women of the NTSB, and the recommendations issued after every major accident to prevent future accidents. That is why I noted at the beginning how appropriate it is to be here; we have mitigated the effects of accidents in all modes of transportation. Let me give you a short list of aviation improvements you're probably familiar with that came out of NTSB recommendations:
- Floor exit lighting, smoke detectors in lavatories and fire-blocking cabin materials on airliners.
- Ground proximity warning systems on airliners. Since they were required on large transport category aircraft in the mid-1970s, accidents involving controlled impact into the ground by large airliners have virtually disappeared in this country.
- Windshear detection equipment and enhanced windshear training for pilots. There has been only one windshear-related accident involving a major airliner in this country in the last 10 years.
And in the surface modes:
- Close to 2 million carloads of hazardous materials move by rail each year. Head shields, shelf couplers and thermal protection on railroad tank cars have dramatically reduced catastrophic accidents during the last decade.
- Age-21 laws, which are again entering the national debate, have saved an estimated 15,000 lives since enactment in all the States in the 1980s. Safety Board recommendations sparked the national movement for such laws.
- Operation Lifesaver programs have helped cut crashes at highway-rail grade crossings in half.
- It was our safety study last fall that began the nationwide debate of the safety of passenger-side air bags for children. Since then, DOT has announced that it is reconsidering the method by which air bags are certificated and will consider allowing people to disconnect them under certain circumstances.
All this has been accomplished by a 350-person agency that has no regulatory or enforcement powers. Yet, despite this lack of direct regulatory authority, I'm proud of the fact that more than 80 percent of our safety recommendations have been adopted by government regulatory agencies. Although we oversee the safety programs of billion dollar corporations and federal agencies having tens of thousands of employees, to put our relative sizes into perspective, the Safety Board's entire yearly budget could fund the U.S. Department of Transportation for 9 hours of a single day.
A few years ago, most Americans didn't know what the NTSB was or what it did. Today, we routinely find ourselves on the front page or the top item of the nightly news. I may be prejudiced, but I think the 15 cents a year each citizen pays to fund us represents the best bargain in government.
It is truly a good feeling to know that what we do every day helps to save lives. The frustrations we encounter are when lessons learned from accidents are either forgotten or ignored, allowing history to repeat itself. Unfortunately, that might be our ultimate finding in a tragedy very close to home here, the crash last year of ValuJet flight 592 into the Everglades.
You are by now familiar with the circumstances of that accident. A fire broke out in the cargo hold shortly before or after takeoff. The plane crashed while attempting to return to Miami. The 110 fatalities represented a tragedy felt all over the country, but most keenly here. And many of us at the Safety Board were reminded of a similar circumstance, one that had a much happier ending, but nevertheless foreshadowed what occurred in the Everglades.
On February 3, 1988, American Airlines flight 132, a DC-9, departed Dallas/Fort Worth International Airport for Nashville with a midcargo compartment loaded with, among other things, a 104-pound fiber drum of undeclared and improperly packaged hazardous materials.
During the flight, a flight attendant and a "deadheading" first officer notified the pilots of smoke in the passenger cabin. The cabin floor above the cargo compartment was hot and soft, and the flight attendants had to move passengers from the affected area. Fortunately, the aircraft landed and a successful evacuation was conducted.
The airworthiness of the airplane was threatened by the fire. Excessive temperatures reached critical flight and engine control cables, floor beams and the passenger cabin floor. We believe that the cargo compartment did not meet the intent of the regulations designed to contain such a fire.
The passengers and crew of this particular aircraft were fortunate that day. While no one was seriously injured, the potential for a catastrophic accident was present. And even this incident wasn't the first of its kind. Less than 2 years earlier, an undeclared shipment of 35 percent hydrogen peroxide solution was shipped in drums with no outside markings to warn about the presence of hazardous materials. The shipment had travelled from Florida to Seattle on its way to the Philippines when cargo handlers found several packages had leaked. This was one of more than 2,000 hazardous materials incident reports involving air transportation filed with the DOT in the 17 years leading up to the American Airlines occurrence in 1988.
Despite Safety Board recommendations to the FAA to require fire detection systems, and fire extinguishing systems, and better fire blocking materials in cargo compartments, the sad fact is that the crew of ValuJet flight 592 had no more equipment available to warn them of a fire or to fight it than did the crew of that American Airlines flight 8 years earlier.
On May 31, 1996, the Safety Board issued urgent safety recommendations to the FAA to evaluate airline practices, including training, for detecting the shipment of hazardous materials, and to the FAA and another DOT agency to prohibit the transportation of oxidizers in cargo compartments that do not have fire or smoke detection systems.
In January, Boeing and the airline industry announced that they would voluntarily install smoke detectors in cargo compartments that did not currently have them. Although this is a step in the right direction, it still fails to address the issue of fire suppression, and the announced two-year installation timetable has not yet started to run.
The point of all this is that, as tragic as any fatal accident is, it is doubly so when we as a society have been granted a warning and we ignore it. It is now 9 years since the Nashville incident, and passenger airliners are still flying every day without a means for the flight crew to fight a cargo fire if it erupts, and even worse, without a means for the crew to even know that a fire has erupted. Although some airlines are ordering airplanes with smoke detection and fire suppression systems, no action has yet been taken that I know of to retrofit the existing fleet.
The loss of TWA flight 800 two months after the ValuJet tragedy not only plunged the nation into mourning, it plunged the aviation industry into a period of self-evaluation. As you know, President Clinton formed the White House Commission on Aviation Safety and Security shortly after the TWA accident, and I was honored to have been asked to serve as a Commissioner. In February, we concluded our work by issuing more than 50 recommendations addressing security and safety issues. But these recommendations won't be worth anything unless they are enacted as expeditiously as practicable. The President and Vice President Gore have expressed their commitment to getting our recommendations implemented.
The TWA investigation has been unprecedented in its human scope and in its expense. We have been on-scene for 9 months - a record. Our latest estimates are that this investigation will cost $27 million, not counting salaries of government employees that would have been paid anyway - that is, representatives from the NTSB, the FBI, the Coast Guard, the Navy, FEMA and others. Consider that the entire yearly budget of the NTSB is just over $40 million.
As far as the investigation itself, we are completing a three-dimensional mock-up of a major portion of the aircraft's wreckage, the largest effort of its kind in the world. Although we have most of the wreckage, we are continuing trawling operations off the Long Island coast to find every bit of debris possible. We have retained the California Institute of Technology to determine the explosive characteristics of the fuel that was aboard flight 800. Explosives tests are being conducted in Great Britain. We have had assistance from experts from all around the world, including France, the Netherlands and Russia. We will continue to work closely with the FBI and all other parties until we are convinced we have pursued every possible credible scenario that could have led to the explosion in the center wing fuel tank.
We at the NTSB deal with the hardware of an accident - the structure of the plane, the engines, the pilot and maintenance records. But we also deal with the human element, be it the role of the crew in the accident, or the survival aspects for the passengers.
There is one group of people, however, who have been overlooked in the past by government and industry, alike - the victims' families. Four times in the last two and a half years, I have been to the scene of a non-survivable major airline disaster. These accidents - in Pittsburgh, Pennsylvania; Roselawn, Indiana; the Everglades and Long Island - have claimed the lives of 540 people. Two other recent non-survivable accidents in Illinois and Michigan have claimed another 43 lives.
Historically, while we could never forget the human tragedy that the accidents represented, the Safety Board has maintained a professional distance from the families of accident victims, giving them all the factual information we have, but leaving other responsibilities to the airlines. Basically, since the dawn of commercial aviation, the unpleasant duty of notifying next of kin after airline accidents has fallen upon the airline that had the accident, and that carrier often made arrangements for the transportation of family members to a location near the accident site, and for the return of victims' remains.
Whether or not this way of doing business was ever adequate to address the needs of victims' family members, it is clear that the way things used to be done is not adequate today. The world has changed and all of us involved in the events following major airline accidents have to change with it. The combination of a litigious society, aggressive 24-hour news coverage, and perhaps a mistrust of authority, all contribute to this very challenging environment.
Family members are demanding more accountability and more services from those of us involved in the various aspects of an accident. I believe that most of these demands are just common sense. Late last year, Congress gave the Safety Board the authority to provide liaison services between these family members and government agencies. We have now had the experience of two accidents since the passage of that law, and are developing agreements with public and private agencies to provide services to these people in the weeks following the accident. We know we can't really alleviate the grief they are going through, but we want to make sure no government actions add to their burden.
I want to talk to you about our family assistance responsibilities, because I think it can be helpful to many of you in other industries. It is just a fact of life that our nation's institutions, and that includes the public and private sectors, have to sensitize themselves to the needs of individuals who have suffered loss. With the heightened emotions that accompany these tragedies, it can be difficult to avoid offending people in the performance of your duties. Officials in San Diego might very well have been surprised by the criticism they encountered from the families of the deceased after releasing video tape of the scene of the mass suicide there last month. All of us have to decide how far we can and should go to alter our procedures in light of the nation's heightened awareness of victims' rights.
In a way, even though our family assistance responsibilities are new, they have not forced the Safety Board to radically change its procedures, probably because we have always maintained some contact with family members.
Under the new law, the role of the NTSB can generally be described as a coordinator to integrate the resources of the federal government and other organizations to support the efforts of the local and state government and the airline. 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 with a major aviation disaster.
Under our draft plan, which should be finalized in a few weeks, local officials will maintain the same jurisdictional authority they have always had, such as accident response, recovery, security, cleanup and medical examiner operations. The Safety Board will, of course, still lead the aviation accident investigation.
The airline continues to have a fundamental responsibility to the victims and their families. The airline is still primarily responsible for family notification and all aspects of victim and family logistical support.
We believe it is imperative that all personnel involved in providing services to assist the victims and their families must demonstrate compassion, sympathy, technical expertise and professionalism. Information provided by family members and victims through discussions, interviews, counseling and other exchanges of personal information must remain confidential and be used only for the intended purpose.
There are many family assistance mission tasks following a major accident, and they are similar to those that will confront you in any industry:
- Assisting the local medical examiner in the identification of fatalities and the notification of their families.
- Providing psychological and logistical support and services to victims and their families.
- Providing daily briefings to families on the progress of recovery efforts, identification of victims, the investigation, and other areas of concern.
- Conducting a memorial service for victims and their families.
- Providing for the return of personal effects.
You will have to decide the best way to respond to the needs of family members. Specific tasks that have been assumed by the Safety Board's Director of Family Assistance after an accident are:
- Coordinating federal assistance and serving as liaison between the airline and family members.
- Providing an NTSB toll-free number to family members to obtain information on the recovery and identification effort, accident investigation and other concerns.
- Requesting a copy of the passenger manifest from the airline.
- Coordinating with the Department of Transportation for marine search and rescue.
- Reviewing with the airline family support logistics with special consideration toward security, quality of facilities, and privacy for family members.
- Providing and coordinating family briefings to those at the site and those who decide not to travel to the site.
- If possible, arranging an appropriate time and means for family members to visit the crash site.
Our draft plan also spells out the responsibilities of the airline and each of the federal agencies that would mobilize after a major aviation disaster: the Department of Health and Human Services, the Department of Defense, the Department of State, FEMA, and the Department of Justice.
The American Red Cross has been designated as the organization responsible for providing mental health support.
Through common sense and good organization, this plan can work. We have had two accidents since passage of the law that have caused us to institute our plans - the November runway collision in Quincy, Illinois that killed 14 people, and the January commuter crash in Monroe, Michigan that killed 29. The victim identification went relatively quickly in both cases, and we have received compliments from family members for how the painful post-accident events were handled.
Improvements in how victims and their families are treated after accidents since passage of the Family Assistance Act can be demonstrated:
- Last year, before passage of the Act, there was a lack of coordination between local, state and federal government agencies along with the airline itself. Responsibilities were not clearly differentiated. Although the airline was responsible for providing information to the families, they wanted to know about recovery and identification of victims, return of personal effects and the progress of the investigation, areas about which the airline had no first hand knowledge.
- Before the Act, the local medical examiner was very much on his or her own. Today, the Safety Board has made arrangements with the Department of Health and Human Services to immediately activate a National Disaster Mortuary Team (DMORT).
- In the past, mental health support was arranged in a somewhat haphazard fashion. Conflicts between well-meaning organizations and individual volunteers were often the norm.
- Airline accidents might be a once-in-a-lifetime event for many local jurisdictions and even airlines; any lessons learned were not applied to future disasters. With the development of an experienced cadre of individuals, the post-accident traumas might be mitigated somewhat.
I urge all of you to consider in your post-disaster plans how victims and their families will be accommodated. Whether one's loved one dies in an airplane crash, a hotel fire or a dam break, many of the lessons we are applying can be instructive to you. Please let us know if we can help you.
Of course, our most important accomplishment would be making sure the accident doesn't happen in the first place. That will be possible only with the commitment of the governmental regulatory agencies, the operating companies, the vehicle and component manufacturers, the appropriate labor unions, and the individuals into whose hands we entrust our lives every day.
When I spoke about the TITANIC at the outset, I said that even today there exist corporate cultures that, far from promoting safety, actually invite disaster. Is it that far from an ocean line's management not providing enough lifeboats to an airline that doesn't oversee its own maintenance? Is there much of a difference between not providing watchmen binoculars to not training tow boat operators in the use of the radar that sits before them?
To that end, I have directed my agency to convene a symposium in Washington next week on the effects of corporate culture on safety. I hope some of you can join us in exploring this fascinating and emerging topic.
Thank you for allowing me to be a part of this valuable conference. I hope we can do this again.
Jim Hall's Speeches