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Remarks to the Aviation 2000 Conference and Exhibition, Washington, DC
Jim Hall
Aviation 2000 Conference and Exhibition, Washington, DC

Good morning. Thank you for inviting me to be your keynote speaker at this important gathering of individuals from throughout the aviation community. I appreciate the opportunity to be a part of the Aviation 2000 Conference to discuss an issue of concern to us all - maintaining the safety in our skies.

As you may know, the National Transportation 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 investigative 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.

The primary goal of every investigation is to prevent other accidents from occurring by conducting thorough, independent, and objective investigations. And, to then recommend ways to correct the problems we find. We involve all of the organizations with an interest in a particular accident -- the regulators, the airlines, the airports, the manufacturers, and the unions -- through our party system. No doubt some of you here today have assisted Board investigators during one of our investigations.

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.

In its 33-year history, the Board has issued almost 11,000 recommendations to more than 1,250 recipients. To date, more than 80 percent of them have been adopted.

Those recommendations have led to countless safety improvements in all transportation modes including aircraft collision 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 marking. I believe that the American people get a good return on their investment of 24 cents per person that it takes to run our agency each year.

  As you all know, the aviation community has had a very busy summer -- the number of flight delays and cancellations experienced so far this year are the highest since 1995 - caused, in part, by an increase in traffic. Over the past 10 years, aircraft operations (including commercial, commuter aircraft, general aviation, and military) have increased nationwide by nine percent and are projected to grow by another 25 percent over the next 10 years.

At the nation's 10 busiest airports, aircraft operations have increased by 44 percent, on average, in the last 10 years, and are projected to grow by another 27 percent in the next 10 years.

Between 1995 and 1999, passenger enplanements rose nearly 16 percent -- from 582 million to 674 million. During just the first six months of this year, the 10 major airlines reported a 3.7 percent increase in scheduled flights and a 5.8 percent increase in the number of passengers over last year.

That trend is going to continue. The RAND Corporation, a Washington D.C. think tank, is projecting tremendous growth in all areas of transportation. By 2010, domestic enplanements will grow from 561 million to over 850 million; the domestic commercial air carrier fleet will increase from just over 5,000 aircraft to more than 7,500 aircraft; the worldwide fleet double in size to 20,000 aircraft by 2010; and the number of our citizens travelling by air will increase from 126 million to 230 million.

We all know that aviation is one of the safest modes of transportation. But, we also know that we can't rely on the status quo to ensure its continued safety. In fact, Boeing has indicated that, based on the projected increases, if more isn't done to improve aviation safety worldwide, we could experience a major hull loss every week.

That is why you're all here - to help prevent that from happening by examining the challenges facing the aviation community and finding ways to improve its safety. And, in fact, the advances that have already been made in aircraft electronics, such as traffic alert and collision avoidance systems and real-time aircraft monitoring systems, have significantly improved aviation safety. But, more can - and must -- be done.

Aviation has long been a proving ground for many transportation-related safety improvements - including on-board recording devices - a fact that I continually point out to government and industry leaders in the other transportation modes. Recent advances in flight data and cockpit voice recorder (CVR) technology have made it possible to capture vast amounts of information that not only provide important data to accident investigators, but also allow operators to monitor and modify operational procedures so that they can prevent an accident and incident before it occurs.

That's what I want to focus on this morning - not only how flight recorders have benefited aviation safety, but also what needs to done to improve their effectiveness.

The Board's accident investigation experience over the years has shown that on-board recording devices can be one of the most useful tools available to us. They can help us quickly find out what happened by isolating the problem, and thus help prevent a similar accident from happening again.

To illustrate my point, let me tell you about a couple of our accident investigations and the effect that the information, or lack of information, recorded by the aircraft's flight data recorders (FDRs) had on them.

  • In 1994, just outside Pittsburgh, USAir flight 427, a Boeing 737, crashed -- the second crash of the world's most popular aircraft in three years. The plane's FDR recorded only 11 parameters. As a result, the Safety Board's investigation into that extremely complex accident took more than four years to complete. Just last month - six years after the accident -- the FAA finally announced a plan to re-design the 737's rudder system.
  • 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 the Boeing 757.
  • All three accidents demonstrated how the availability of adequate data immediately following accidents can allow us to focus our investigative efforts, identify safety problems, and implement solutions in a relatively timely manner.
  • Because the ATR's FDR recorded 98 parameters, we were able to quickly focus on how the aircraft operated in icing conditions and we 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 of the coast of Peru.
  • The FDRs onboard both planes were capable of recording 350 parameters. Once they were recovered, they provided investigators with the data necessary to define the problem and to determine actions taken by the crews.
  • As a result, in the Birgen Air case, investigators did not 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, millions of dollars in investigative and recovery costs were saved by the countries involved, and the travelling public's confidence in the aircraft was maintained.

Based on our experience during the USAir flight 427 investigation as well as other investigations in which insufficient information was available, the Board issued safety recommendations to the Federal Aviation Administration (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 must 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. We also have to upgrade the CVR.

Following our investigations into ValuJet flight 592 in May 1996, and TWA flight 800 in July 1996, as well as foreign investigations involving SilkAir flight 185 in December 1997, and Swissair flight 111 in September 1998, the Safety Board issued recommendations to the FAA to address problems created when there's an interruption in the electrical power to the CVR - causing us to lose 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 cockpit, to significantly increase the likelihood of recovering valuable audio information. We also want to improve the crash survivability of all recorders. Unfortunately, the FAA has yet to take action to implement these critical requirements.

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

That brings me to an issue that has generated a great deal of controversy over the past few months - electronic cockpit imagery. I believe that cockpit image recorders are the natural next step in on-board recorders and we will see their implementation in the near future. The Board believes that we should not further delay the implementation of available technology that may help us more quickly determine the probable cause of accidents -- and, therefore, prevent future accidents.

Recording images of the cockpit is not a new idea. However, it has only recently become both technically and economically feasible. Technological advances in electronics make it possible for us to capture images of what is happening inside the cockpit so that questions regarding flight crew actions can be readily resolved. With the limits of current flight recorders and the implementation of fly by wire controls and glass cockpits, we need to take advantage of that technology. The idea is not to replace the CVR or FDR, or duplicate information already recorded, but to capture information that is not already recorded. That would enable us to more easily determine causes of accidents and implement solutions to improve safety.

Cockpit image recorders would provide key information that would allow us to determine if any human factors issues, such as non-verbal communication, information overload, distractions, and procedural problems exist.

For example, a cockpit video recorder could tell us which pilot was at the controls, what controls were being manipulated, pilot inputs to instruments (i.e., switches or circuit breakers), or what information was on the video displays (i.e., the display screens and weather radar). Video recorders would 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.

The Safety Board first discussed the need for video recording the cockpit environment in our report of a September 1989 incident involving USAir flight 105, a Boeing 737, at Kansas City, Missouri. In this incident, the airplane collided with four transmission cables during approach. The crew then executed a missed approach and landed uneventfully in Salina, Kansas.

The Board determined that the probable cause was the flightcrew's failure to adequately prepare for and execute a nonprecision approach and their subsequent premature descent below minimum descent altitude.

Our report pointed out the limitations of existing flight recorders to fully document the flight crew's actions and communications. An image recording of the cockpit environment would have established the availability and use of appropriate checklists and approach charts, the use of hand signals by the flight crew to communicate commands for airplane configuration changes, and what configuration changes were made. This data would have also provided investigators with insights into the nature of the crew's briefing and approach chart review as they prepared for the localizer back course approach.

The report also noted that the introduction of aircraft with electronic "glass" cockpits and the use of data link communications would enable the flight crew to make display and data retrieval selections that would not be detected by either the CVR and FDR -- but could be captured by a video recording. Because we recognized that video-recording devices weren't yet feasible, we didn't make a recommendation on the use of video recordings at that time.

However, in the 11 years since that incident, considerable progress has been made in both video and electronic recording storage technologies. Electronic recording of images in the cockpit is now both technologically and economically viable, and solid state memory devices can now capture vast amounts of audio, video and other electronic data.

In February of this year, as a result of an October 1997 accident involving a Cessna operated by the Department of Interior that was not required to have a CVR or FDR, the Board recommended that the FAA require crash-protected video recording systems on Part 135 aircraft not currently required to have a crashworthy flight recorder device.

In recent years, the Safety Board's investigations of other accidents involving Cessna 208s and similar turbine-powered aircraft had been hampered by a similar lack of FDR and CVR information. In addition, in this case, there were no recorded communications between the accident aircraft and air traffic control or other aircraft. A cockpit image recorder may have provided crucial information about conditions in the cockpit and the crew's actions. It would have also provided investigators with critical factual information such as altitude, airspeed, engine power, flight control inputs, aircraft configuration plus human factor and atmospheric conditions.

In April, the Safety Board recommended that the FAA require Part 121, 125, or 135 aircraft currently equipped with a CVR and a 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, including ValuJet flight 592 and EgyptAir flight 990 in October 1999, as well the SilkAir flight 185 and Swissair flight 111 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.

  • In the case of ValuJet flight 592, a cockpit image recorder may have provided critical information about the exact smoke and fire conditions present in the cockpit during the last few minutes of the flight.
  • A cockpit image recorder may have also shown the smoke and fire conditions and the status of the flight instrument displays in the cockpit of Swissair flight 111 that led to the crew's decision to descend from cruise flight and divert to Halifax.
  • Because there is no data on the CVR and FDR for the final minutes before the SilkAir flight 185 crash, the Indonesian investigation was hampered by a lack of information concerning what occurred in the cockpit. The availability of a cockpit image recording may have allowed them to focus their investigative efforts more effectively.
  • The need for a video recording of the cockpit environment was most evident in the EgyptAir investigation. The Safety Board's staff believes that electronic cockpit imagery would help resolve issues surrounding the flight crew's actions in the cockpit that resulted in the changes in the aircraft's controls as well as the circumstances that prompted those actions.

The use of a cockpit image recording system would also permit the recording of controller-pilot data link (CPDL) communications. Current analog CVRs cannot record CPDL messages. Therefore, they will need to be replaced by other systems on all aircraft using CPDL. In addition, the communication system architecture on many aircraft will make it difficult and expensive to record CPDL messages directly onto a flight recorder. In those instances, the video recording of the cockpit CPDL display would be an acceptable and cost effective means of complying with regulatory requirements.

The international aviation community is also aware of the safety benefits of crash-protected video recorders. ICAO's Flight Recorder Panel agreed, in November 1998, that the use of video recordings in aircraft cockpits would be very useful. The panel further noted that the European Organization for Civil Aviation Equipment (EUROCAE) was developing minimum operational performance specifications (MOPs) for such recorders.

As a result of the Montrose, Colorado, accident, the Safety Board recommended to the FAA that it incorporate EUROCAE's performance standards for a crash-protected video recording system into a technical standards order (TSO). The Safety Board believes the FAA should work with EUROCAE to help expedite the MOPS and to incorporate the performance standards defined in the MOPS into an FAA TSO for a crash-protected cockpit image recording system as soon as practicable.

The Safety Board is sensitive to the privacy concerns that have been expressed by pilot associations and others with respect to recording images of flight crews. In order to protect crew members' privacy, the Safety Board, in its request for reauthorization, asked Congress to apply the same protections that exist for CVRs to the use of image recorders in all modes of transportation. Under these provisions, a cockpit image recording would not be publicly released.

The Board is also aware of concerns regarding the treatment of video (as well as other types of recordings) in foreign accidents and we're working with ICAO to improve protections afforded to recorded information on an international level. However, given the history of complex accident investigations and the lack of crucial information regarding the cockpit environment, I believe that the safety of the flying public must take precedence over all other concerns.

In closing, you will be covering a number of important safety issues over the next two days including new flight recorder technologies, heads-up weather guidance systems, avionics maintenance issues, collision avoidance systems, databases, aging aircraft, and human/machine interface. I hope you'll all make the most of your time here by sharing experiences and finding new solutions to on-going problems. By working together, we can improve of what is undeniably an already safe aviation network.

Thank you, again, for inviting me to be here today.