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Remarks to the Global Airline Industry Program, Massachusetts Institute of Technology
Jim Hall
Global Airline Industry Program, Massachusetts Institute of Technology

Thank you. I appreciate being invited to be here today to speak to you about global safety issues in civil aviation.

As many of 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 (DOT) modal administrations.

The primary goal of every investigation is to prevent other accidents from occurring by conducting thorough, independent, and objective investigations. And, 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.

This system has served us well and has helped give the American people confidence in their transportation system. But, maintaining that confidence requires constant vigilance by everyone within the 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 - and probably experienced first hand -- the aviation community has had a very busy year -- 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.-based international 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.

The Board's job is to investigate all commercial and general aviation accidents in the United States, and to lead the United States' team that assists other nations investigate accidents involving U.S. airlines and U.S.-manufactured aircraft.

Over the past two years, we have assisted other nations around the world with their investigations of more than 124 accidents and incidents. In just the last few months, we have sent investigators to Paris, Bahrain, and Taiwan to assist. On just one day, earlier this year, we had representatives from five different countries working in our laboratories.

It's important to note that we don't investigate accidents and serious incidents in isolation. All of the organizations with expertise to assist in an investigation -- the regulators, the airlines, the manufacturers, and the unions -- actively work with us. These same groups participate, as appropriate, when we assist other investigative organizations. Of course, these investigations are conducted in accordance with the cooperative framework established by the International Civil Aviation Organization (ICAO), specifically Annex 13.

The primary goal of every investigation is to prevent another similar accident from occurring by conducting thorough, independent, and objective investigations of accidents and incidents. And, then recommend ways to correct the problems found.

To accomplish that goal, the investigative organization must be truly independent from any other governmental body. No entity should be expected to investigate or oversee itself -- it can't and doesn't work. It is for that reason that I have long advocated that all countries should have an investigative organization separate from other governmental agencies that oversee the regulation and operation of the aviation system.

In 1994, the European Civil Aviation Conference, which represents nearly 40 European States, adopted a directive that aviation accidents and serious incidents will be investigated by an authority that is independent of the organizations responsible for regulation and safety oversight of the aviation system.

As a result, many European states have formed independent aviation investigation bodies. Currently, we have nine such independent boards in place around the world. Collectively, we have formed an organization, International Transportation Safety Association (ITSA), to share ideas and discuss issues of mutual concern.

The importance of an independent and objective organization to conduct impartial aircraft accident investigations cannot be overstated. I believe the travelling public has benefited from the work of professional air safety investigators and accident investigation agencies throughout the world.

Their work has led to direct improvement in the way aircraft are built, maintained and operated.

For example, all aircraft operated in the United States and many other countries will soon have enhanced ground proximity warning systems to help prevent controlled flight into terrain accidents and the cargo compartments of all aircraft will be equipped with fire detection and suppression systems so that pilots will be informed of cargo fires, and the cargo fires will be extinguished, before the safety of flight is threatened.

British investigators found the potential for a reversal of the elevator operation in a 747-400, which led to a redesign of the hydraulic system on those airplanes. Dutch investigators uncovered mechanical design and maintenance defects in Boeing 747 engine pylons that led to redesign and enhanced maintenance procedures for all Boeing 747 airplanes. And, a Canadian investigation into a MD-11 accident resulted in a change to the certification standards for thermal insulation blankets.

Another means to enhance our ability to fulfill our obligations is to develop bilateral and multi-lateral cooperative agreements to ensure that investigations in all countries, including developing ones, are conducted in a thorough and objective manner. For example, many states may not have the resources to fully staff and fund an independent investigation authority, especially in view of the rarity of such events. In such cases, those states should develop agreements with other states that can provide the necessary expertise to assist with the investigations. I don't believe that ICAO should necessarily be the lead organization to provide those resources; but I do believe that ICAO plays a vital role in providing guidance for countries in setting up such agreements.

Considerable progress has been made in the international arena under the leadership of ICAO. The Global Aviation Safety Action Plan and the Safety Oversight Program being implemented by ICAO are impressive and positive steps toward improving airline safety on a worldwide basis. Bilateral and regional partnerships and cooperative action plans are being put in place around the world to ensure adequate communication of safety information and timely notifications and reporting of accidents and incidents. I believe that the partnerships and cooperation exemplified by those agreements should be expanded to include accident/incident investigations.

As the result of decisions reached at the September 1999 AIG99 meeting in Montreal, ICAO is developing model agreements for countries to use in order to meet their treaty obligations to conduct investigations of accidents and serious incidents. Many states already have formal agreements for aircraft certification and safety oversight.

I believe that investigation authorities need to do the same. The NTSB, as well as the investigation authorities from other countries, including Australia, France, the United Kingdom, is in the process of developing such agreements with several states. Two weeks ago, I signed just such a memorandum of understanding with the Director of the French accident investigative organization.

The Swissair flight 111 crash, in September 1998, near Halifax, Nova Scotia demonstrated the need for such plans. Between 1993 and 1995, the FAA had conducted flammability tests of aircraft insulation following fires on five airliners. Despite findings that suggested airworthiness concerns, the FAA took no corrective actions. The fires had occurred in three countries, Italy, Denmark, and China, but the NTSB only participated in the Italian and Danish investigations.

Although the Chinese did an excellent job of investigating the three fire events in their country and forwarded their findings and concerns to the manufacturers and the FAA, the NTSB was never informed of the events.

The Canadian Transportation Safety Board will ultimately determine whether those accidents are relevant to the Swissair accident. However, they certainly illustrate the need for notification and reporting of incidents and accidents by an independent investigation authority, and the need for cooperation among states during the investigations, in accordance with ICAO guidance.

The RAND Corporation, in its recent report on the NTSB, indicated that although future major accidents in the United States will probably be fewer in number, they will also be more complex.

In other words, accident investigations such as USAir flight 427,TWA flight 800, and Swissair flight 111 will more likely be the norm rather than the exception.

If RAND is correct, I believe they are, that accidents will only become more complex, we'll not only need to share information more effectively, we'll also need more -- and better -- data to determine the cause of those accidents. In addition, the success of other initiatives such as Flight Operations Quality Assurance (FOQA) will depend on the collection and analysis of accurate data.

Let me tell you about just a few 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. ยท 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 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 cockpit voice recorder (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, 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.

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 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.

Before I close, I would like to touch on one more subject. In 1996, the President and the Congress gave the Safety Board the additional responsibility of coordinating the Federal effort to the families of the victims of major aviation accidents.

Since the legislation was enacted in October 1996, the Board has

  • hired a family affairs staff;
  • developed, in concert with family advocacy groups and the aviation industry, a Safety Board family assistance plan;
  • received assurances from foreign and domestic air carriers regarding their plans to assist family members following an aviation disaster;
  • co-chaired, with the Secretary of Transportation, a task force on assistance to families of aviation disasters; hosted an international symposium on family affairs;
  • completed memoranda of understanding with seven Federal organizations and the American National Red Cross;
  • met with dozens of industry and local organizations regarding the importance of family assistance; and
  • entered into an agreement with the Air Transport Association regarding extraordinary accident investigation costs, particularly in relation to identification and recovery of accident victims.

In 1997, legislation was enacted to extend the Family Assistance Act to foreign carriers flying into and out of the United States.

Together, the 1996 and 1997 acts ensure that all victims and their families will be treated fairly and equally regardless of the carrier they use. And, they also have required many carriers that may not have previously thought about family assistance issues to actively consider them in their planning.

We may soon see similar requirements for other modes of transportation as well. Currently, there is legislation pending in Congress to require passenger railroad in the United States to establish family assistance plans.

The crash of Swissair flight 111 validated why the Foreign Air Carrier Act was necessary. Because Swissair and its code-share partner, Delta, had a plan in place, they were able to quickly and effectively respond to the family members' needs. Next-of-kin notification was efficient and family members received up-to-date information as soon as it was available.

The airline also tried to anticipate the families' needs - including offering them $20,000, with no strings attached, to cover their immediate expenses. Last year, we saw similar results following the EgyptAir flight 990 crash. And, if you read the press accounts following the Concorde crash, you saw that Air France received numerous laudatory comments from the victims' families for their compassionate response.

The response from these carriers shows how much improvement there has been in how families are treated following aviation disasters. However, there is still more work to be done. Family assistance is no longer just an U.S. initiative. It is a global issue. It is an endeavor in which every country, every service agency, and every transportation-related industry around the world should be involved.

As we all know, aviation is the safest mode of transportation available to the world's travelers. Our job is to ensure that it remains that way. The measures that I've discussed today will help us do that. Thank you, again, for inviting me to be here today.