Good morning Mr. Chairman and Members of the Committee. It is a pleasure to be here today to represent the National Transportation Safety Board.
It goes without saying that the past year was dominated by catastrophic transportation accidents that have required extraordinary efforts by the Safety Board and have strained the agency's resources more than any time in its history. It is well established that the TWA flight 800 Boeing 747 investigation has been the most costly and complex in the Safety Board's history, in terms of dollars spent for wreckage search and recovery, and the level of investigative staff work.
Moreover, as a multi-modal agency, the Safety Board has an important responsibility for the investigation of surface transportation accidents. Our workload in that area has also been unprecedented in the past year. Many of our laboratory specialists support our multi-modal mission. For example, the metallurgists working on TWA flight 800 are also working on surface accidents. Also, one of our key engineers responsible for surface transportation vehicle performance has been assigned full time for several weeks to supervise the 3-dimensional mockup of the TWA flight 800 wreckage.
Mr. Chairman, the TWA investigation provides dramatic testimony to the wisdom of Congress 30 years ago when it established a multi-discipline, independent accident investigation agency, initially affiliated with the Department of Transportation, to promote transportation safety by conducting independent accident investigations and by formulating safety improvement recommendations. However, because the Congress recognized the need to make it totally independent from the Department of Transportation, the Independent Safety Board Act of 1974 was passed.
The independence of the Safety Board and its clear mandate to conduct in depth objective investigation, draw conclusions from its findings, and to make recommendations to improve safety, without bias or undue influence from industry or other government agencies is essential to maintaining the safety of the American traveling public. It is not unusual for the Safety Board to address safety issues that are controversial or that may be critical of government or industry standards or operations.
The Safety Board is charged by Congress with investigating or causing to be investigated all civil aviation accidents in the U.S. In 1994, the Safety Board's authority was expanded to investigate government-operated aircraft as well, except those operating in military or intelligence missions. In addition, the Safety Board provides the U.S. Accredited Representatives to overseas investigations involving U.S.-registered, -certified, or -operated aircraft, and aircraft whose airframe, engines, and major components were manufactured in the U.S.
Since the Safety Board began investigating accidents, it has made more than 10,000 safety recommendations to prevent accidents, save lives, and reduce injuries. While every recommendation from the Board is developed to help improve safety and prevent accidents, some have a greater potential to save lives than others.
As you know, Mr. Chairman, it is the responsibility of the NTSB to formulate recommendations to those parties that can affect improvements in transportation safety, but it is the responsibility of agencies like the Federal Aviation Administration (FAA) to determine how best to implement those changes. In the last 5 years, the FAA has adopted 84 percent of our recommendations.
We harbor no illusions that the FAA should adopt ALL of our recommendations, nor do we seek to have our recommendations mandatory. Frankly, Mr. Chairman, if the FAA adopted all of our recommendations, then we would not be asking for enough. There are bound to be some areas where the regulatory agency honestly believes that a recommended change is not cost-effective - remember, the FAA must conduct cost-benefit analyses of any proposed changes - or that a better alternative can be found. This is not to say that we don't strongly disagree with some of their actions, or inaction, and that is what the Most Wanted list is designed to at least partially address.
In order to identify those recommendations with the greatest potential to improve transportation safety that have not yet been acted on, the Safety Board in 1990 adopted a Most Wanted program. Recommendations placed on the program list will receive more intensive follow-up activity in order to encourage government agencies and industry to act on the recommendations as quickly as possible.
To be considered for the Most Wanted list, a recommendation must affect transportation safety on a national level, concern a safety issue of high visibility, or be of great interest to the public. Also considered is the previous loss of life or property as well as the potential for future losses, and the extent of the exposure of the public to risk by the safety problem. Previous action taken by the recipient is also taken into consideration.
Currently on the Safety Board's Most Wanted list are five aviation related issues that include:
- The installation of expanded flight data recorders with an increased number of parameters.
- The installation of airport runaway incursion avoidance systems.
- The review of safe separation distances between larger and smaller following aircraft.
- The installation of mode C instrument alert systems for airport terminal areas.
- The sharing of pilot background information between airlines.
Last year the Congress acted on the issue of pilot record sharing and the Safety Board will consider removing this issue from the Most Wanted list. Unfortunately the remaining four issues will remain. I would like to address two of these issues in more detail.
Flight Data Recorders
Although not a new issue on the Most Wanted list, I would like to discuss the importance of enhanced flight data recorders (FDR). Almost two years have passed since the Safety Board issued its recommendations for enhanced FDRs, and the FAA has failed to enact any rulemaking on this important safety issue.
On July 16, 1996, the FAA issued the NPRM on enhanced FDRs, with a 30-day comment period. NTSB comments on the rule were generally favorable. However, the NPRM would not require FDR retrofits to begin for at least another two years. Further, no action was taken on the Board's urgent recommendation to expedite the retrofit of Boeing 737 airplanes.
We are aware that a rulemaking package was forwarded to the Office of the Secretary of Transportation on February 7, 1997. However, the DOT and Office of Management and Budget review process has been lengthy. How much longer must we wait before action is taken?
We believe that expanded flight data recorders are critical to accident and incident investigations. United Flight 585, which crashed in 1991 in Colorado Springs, Colorado, had a 5-parameter recorder and USAir 427, which crashed in 1994, had only 11 parameters. Vital information for investigators was simply unavailable and that is unacceptable.
On March 25, 1997, a Gulfstream G-2 corporate airplane was cleared to land on runway 31 at LaGuardia Airport. About the time the G-2 was touching down on the runway, the tower controller advised its pilot to go-around. The G-2 was unable to execute a missed approach and it collided with an airport maintenance truck. The same tower controller had cleared a vehicle operator onto runway 31 about 40 minutes before the G-2 was cleared to land. The truck driver, his assistant, and the two G-2 pilots were not injured although the airplane and vehicle were substantially damaged.
Mr. Chairman, the circumstances of this accident could very easily have involved a commercial air carrier resulting in multiple fatalities. Although our investigation continues, we have learned that the controller, who cleared the maintenance truck and the incoming airplane, simply forgot about the truck he had approved out onto the runway.
Forgetting is a human factor routinely found in operational errors by air traffic controllers that cause incidents virtually every day in our nation's air traffic system. This type of human error has also been identified in past accidents. For example, on February 1, 1991, a USAir Boeing 737 collided with a Skywest Metroliner at the Los Angeles International Airport, killing 34 passengers and crew. This accident occurred, in part, because the air traffic controller cleared the USAir airplane to land about 3 minutes after she had cleared the Skywest airplane onto the same runway to hold for departure. She forgot the Skywest flight.
And I regret to say that operational errors and runway incursions have been increasing. Operational errors in the terminal environment have increased 14 percent from 1995 to 1996. Similarly, runway incursions have increased 19 percent from 1995 to 1996. These trends raise concerns about the progress being made by the FAA in addressing the risks associated with the potential for ground collisions.
Following several accidents and Safety Board recommendations, in 1991, the FAA established a Runway Incursion Action Plan to reduce surface errors at the nation's more than 570 airports. This plan was revised in 1995. The action plan focuses on reducing human error, improving ground communications, and developing and implementing technologies to increase airport surface guidance and surveillance, as well as improved ground traffic management procedures and equipment. One of the more important components of the FAA's efforts is the Airport Movement Area Safety System (AMASS).
AMASS, which is a system integrated into the new ASDE-3 ground radar system, automatically tracks all operations, compares each vehicle and aircraft movement, and provides visual and audio alerts of potential conflicts. This is a real-time system for preventing runway accidents in a dynamic airport environment. AMASS would have provided the means to prevent accidents similar to the ground collisions that occurred February 1, 1991, at Los Angeles, November 22, 1994, at Bridgeton, Missouri, and March 25, 1997, at LaGuardia. Unfortunately, except for a prototype at San Francisco International Airport that is operating with a limited capability, AMASS installations are not yet in place.
In a February 28, 1995, safety recommendation letter to the FAA, the Safety Board expressed its concerns about delays in AMASS installations. In that letter we cited FAA testimony before Congress on March 6, 1990, in which the FAA stated that it had entered a contract for design and manufacture of AMASS that would be fast tracked with the project operational in 1992. In the February 28, 1995, letter, the Safety Board expressed its concerns that "this important project [AMASS] has been effectively paralyzed as a result of a succession of changes."
The latest information published by the FAA on the status of AMASS is not encouraging. The prototype testing in San Francisco has been on-going since May 1996. Under a contract awarded in June 1996, three full-scale AMASS systems are due to be installed in Detroit (September 1997), St. Louis (November 1997), and Atlanta (February 1998). Another 20 systems that are currently in initial production are scheduled to be delivered for installation between July 1998 and July 1999. There are options for 16 more AMASS systems; however, the funding is not available at present. We believe these are two important safety issues that must be addressed by the FAA.
TWA Flight 800 Investigation
On July 17, 1996, TWA flight 800 tragically crashed into the Atlantic Ocean near East Moriches, New York, killing all 230 people on board. The aircraft wreckage in this accident was ten miles off the coast at a depth of 120 feet, making this investigation anything but typical.
To ensure the safety of the divers and to identify the location of the wreckage, the area had to be thoroughly mapped before the full scale underwater recovery effort could begin. Heavy wreckage was not lifted from the ocean floor until early August. By the end of October, the divers had cleared the debris fields of all large pieces of wreckage. On November 3, scallop trawlers were brought in to drag the ocean floor. To date, an area of over 28 square miles has been trawled, with some areas having been gone over in excess of 20 times. A second pass is being made over the entire area: trawling will continue until substantial amounts of wreckage are no longer being recovered.
Based on the condition of the wreckage from the center forward section of the airplane and that surrounding the center wing tank, the investigators were particularly interested in this area and have created 3-dimensional mock-ups of this section. Three sets of scaffolding were erected on which this section of airplane was reassembled in order to give the investigators a better picture of what occurred. The fuselage surrounding the center wing tank was on one, the top and sides of the center wing tank on another, and the floor center wing tank was on the third. Following these initial efforts, it was decided to construct a full scale 3-dimensional mockup of a major portion of the airplane, including the fuselage skin. The mockup being constructed with the assistance of contractors to the Safety Board will be about 92 feet long, the largest in the world ever constructed. That work has been essentially completed.
It is apparent that an explosion occurred in the center wing tank, but the origin of the explosion is not yet known. To date, with over 90 percent of the airplane recovered, there is no physical evidence of a bomb or missile strike.
Based on the examination of the wreckage and other evidence, on December 13, 1996, the Safety Board issued four safety recommendations to the FAA aimed at reducing the flammability of the ullage in airliner center wing tanks, with specific emphasis on the Boeing 747 center wing tank. The recommendations urged the FAA to:
- Require the development of and implementation of design or operational changes that will preclude the operation of transport-category airplanes with explosive fuel-air mixtures in the fuel tanks. Significant consideration should be given to the development of airplane design modifications, such as nitrogen-inerting systems and the addition of insulation between heat-generating equipment and fuel tanks. Appropriate modifications should apply to newly certificate airplanes and, where feasible, to existing airplanes. (A-96-174)
- Pending implementation of design modifications, require modifications in operational procedures to reduce the potential for explosive fuel-air moisture in the fuel tanks of transport-category aircraft. In the B-747, consideration should be given to refueling the center wing fuel tank (CWT) before flight whenever possible from cooler ground fuel tanks, proper monitoring and management of the CWT fuel temperature, and maintaining an appropriate minimum fuel quantity in the CWT. (A-96-175)
- Require that the B-747 Flight Handbooks of TWA and other operators of B-747s and other aircraft in which fuel tank temperature cannot be determined by flight crews be immediately revised to reflect the increases in CWT fuel temperatures found by flight tests, including operational procedures to reduce the potential for exceeding CWT temperature limitations. (A-96-176)
- Require modification of the CWT of B-747 airplanes and the fuel tanks of other airplanes that are located near heat sources to incorporate temperature probes and cockpit fuel tank temperature displays to permit determination of fuel tank temperatures. (A-96-177)
The FAA responded to these recommendations on February 18, 1997. In general, the FAA's response stated that the recommendations propose major changes in the requirements for fuel tank design and fuel management of transport category airplanes. The FAA stated, the airworthiness standards of 14 CFR Part 25 assume that fuel vapor is flammable, and the design requirements dictate the elimination of ignition sources within the fuel tanks.
Because the FAA considered the control of flammability characteristics of fuel vapor in airplane fuel tanks as a major change in design concept, it elected to evaluate the safety recommendations by means of soliciting information about the effectiveness and practicality of implementing the recommendations. The FAA stated that it would publish a public notice in the Federal Register within 30 days.
The September 8, 1994, accident involving USAir flight 427 near Pittsburgh, Pennsylvania, which killed all 132 people on board, continues to be on of our most complex investigations. It has been one of the most far-reaching investigations in the history of the Safety Board, with NTSB investigators and party participants working continually over 2 years to try to understand the very complex circumstances of this tragic event. The investigation has involved tens of thousands of staff hours and numerous flight tests, resulting in 20 safety recommendations.
The Safety Board is aware that Boeing is actively engaged in a redesign of the main rudder power control unit for the existing Boeing 737 series at an estimated cost to Boeing of $120 million to $140 million.
In January 1997, Boeing and the FAA announced that the primary and secondary slides of the PCU servo control valve would be redesigned to preclude the potential for reverse rudder operation. The FAA plans to issue an airworthiness directive (AD) that would require the Boeing 737 fleet to be retrofitted with the new valve within two years.
We are encouraged by Boeing's commitment to move forward. We are concerned, however, that there may be a delay by the Federal Aviation Administration in issuing a final rule, or that the final rule might allow more than 2 years for operators to complete the installation of the new servo control valve. On February 20, 1997, the Safety Board issued three additional safety recommendations to the FAA regarding the Boeing 737 aircraft. Those recommendations state:
- Require the expeditions installation of a redesigned main rudder power control unit on Boeing 737 airplanes to preclude reverse operation of the rudder and to ensure that the airplanes comply with the intent of the certification requirements. (A-97-16)
- Advise Boeing 737 pilots of the potential hazard for a jammed secondary servo control valve slide in the main rudder power control unit to cause a reverse rudder response when a full or high-rate input is applied to the rudder pedals. (A-97-17)
- Require the Boeing Commercial Airplane Group to develop operational procedures for Boeing 737 flight crews that effectively deal with a sudden uncommanded movement of the rudder to the limit of its travel for any given flight condition in the airplane's operational envelope, including specific initial and periodic training in the recognition of and recovery from unusual attitudes and upsets caused by reverse rudder response. Once the procedures are developed, require Boeing 737 operators to provide this training to their pilots. (A-97-18)
This investigation continues, and I am proud of the dedication of the investigative team. I believe these recommendations reflect, in part, the progress we are making. Safety Board staff hopes to have a final report regarding this accident before the Board for consideration this year. We will, of course, keep the Committee advised of developments.
I want to turn now to what has become a new responsibility for the Safety Board, assistance to family members of victims of air disasters.
Since the dawn of commercial aviation, the unpleasant duty of notifying next of kin after airline accidents has fallen upon the airline involved in 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 modus operandi 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, expanded and aggressive 24-hour news coverage, and perhaps a mistrust of authority all have contributed to this new environment.
In September 1996, President Clinton issued a directive naming the Safety Board as the coordinator of federal services to the families of victims of transportation accidents, and in October he signed legislation that gives us that responsibility for aviation disasters. The Safety Board did not seek this responsibility; in fact, I had hoped that it could be handled without federal intervention. But the families, the President and the Congress have entrusted us with these responsibilities and we will do the job.
Under this new authority the Safety Board:
- Will coordinate the provisions of federal services to the families of victims. These could include, but are not limited to, providing speedy and accurate information about the accident and recovery efforts, ensuring the families who wish to travel to the accident site receive all necessary assistance, and arranging opportunities for counseling and other support.
- Will work with State and local authorities and with private relief organizations to ensure appropriate coordination of the services they provide with those of the federal government.
The following federal agencies will cooperate fully with the Safety Board in these efforts: the Department of State, Defense, Justice, Health and Human Services, Transportation, and FEMA.
Another provision of the Act calls on the Secretary of Transportation to appoint a task force composed of family members and representatives of government and private relief agencies. This task force will have quite a full plate before it. It is charged with developing a model plan to assist airlines in responding to aircraft accidents. The first meeting of the task force is scheduled for the end of this month.
Let me describe two recent experiences since passage of the Family Assistance Act. On November 19, 1996, a United Express Beech 1900C collided with a King Air at intersecting runways in Quincy, Illinois. All 14 persons on both aircraft died in the accident.
Although this was a relatively low-fatality accident as major airline disasters go, it still had a significant impact on local resources and facilities. The coroner had no medical expertise, and no facilities or staff at his disposal. Under an agreement with the Department of Health and Human Services, we arranged for a mobile morgue that was fully equipped, supplied, and staffed. This service was set up inside the airport's vacant firehouse, and served as the mortuary.
Despite the fact that all 14 victims were badly burned, they all were identified and returned to their families within four days. This would not have been possible had local resources not been augmented.
Although most families did not come to the scene, those who did were taken to the accident site on the second full day. The city provided us with police escorted transportation for the family members. The families who were on scene were briefed by Safety Board and our Investigator In-Charge. Those family members who did not travel to Quincy were briefed by staff members by phone.
On January 9, 1997, a Comair EMB-120, a Brasilia, crashed on approach to Detroit, killing all 29 persons aboard. In this instance, nearly all families came to the scene. The Michigan State Police took care of security at the accident site, at the morgue, and at the hotel where the family members were staying.
The identification of victims began on the second full day following the accident, Saturday, and continued through Wednesday. All 29 victims were identified. This was an extremely difficult task because of the severe fragmentation of the remains and the extreme cold temperatures in the days following the accident (wind chills for many days after the accident were well below zero). A team of 125 people worked in the ad hoc morgue set up in a hangar for 20 hours a day. The mobile morgue was flown in the morning after the accident. Personal effects were recovered by teams of volunteers. The local Mental Health office provided counseling for family members and for rescue personnel.
What we have seen in these two accidents has been evident in many accidents in the past. Local jurisdictions are not prepared for the consequences of a once-in-a-lifetime event like a major airliner crash. This is no criticism of them. You cannot build an infrastructure to be prepared for such a rare event; it would deprive communities of resources needed elsewhere for more pressing community needs.
The Monroe County crash of the Comair commuter in January brought that county its highest death toll in a single event in more than 150 years. Any individual airline might go decades between fatal accidents; it is difficult for them, too, to be completely prepared for such an event.
The Safety Board deals with many major accidents every year. And we've been doing this for 30 years. That is why we were placed in charge of coordinating government services to the families, and that is why we are optimistic that once we have agreements in place with the many government and private agencies that can provide needed services, and once we have this program funded, we can fulfill the obligations given us by the American people though legislative directive.
I can say that both of the recent accidents taught us lessons, but they also demonstrated the benefits of our involvement; many who have participated in previous incidents commented on how far things had come and how much better off families were under this more-organized on-scene effort.
I would like to point out that we have structured our family assistance program to ensure that our new responsibilities and authorities do not interfere with or adversely affect the well-established process of managing major investigations.
Mr. Chairman, let me now address some financial issues that are important to the Safety Board. As you know, the 1997 enacted appropriation level for the Safety Board is $42.4 million and 370 FTES. Not included in this amount is the $6 million 1996 supplemental earmarked primarily for reimbursement to the U.S. Navy for TWA Flight 800 recovery costs. In 1997 we requested approval for an additional TWA 800 related supplemental of $23.2 million. This would have covered investigative expenditures through the end of the fiscal year, as well as allowing us to start our family assistance efforts. OMB approved $20.2 million for inclusion in the President's Budget. I realize, Mr. Chairman, this is not a budget hearing but I did not want to miss a chance to make our case.
Our emergency fund, which has been funded at a $1 million level, is used to pay for extraordinary recovery and investigative tasks. OMB has approved expanding the fund next year to $2 million. The simple truth is that this fund does not begin to cover the extraordinary costs of our investigations. Aircraft tragedy investigative costs are usually born by both the Federal Government and by the carrier through its insurance underwriters. If the aircraft crashes on land, the carrier is generally responsible for wreckage recovery and removal. If we deem that the wreckage is vital to our investigation, we see that the critical parts, or all of the wreckage, are removed to a secure location for examination. In general, payments for this is made by the insurance underwriters.
In accidents occurring over water, or where the probable cause may be criminal in nature, the responsibilities are not so clear. For example, in the TWA Flight 800 investigation, I asked for the early financial participation of the carrier, manufacturers, and engine supplier and all declined. The federal government has in fact borne all of the extraordinary costs in this investigation outside of the party's participation.
I would also be remiss if I did not mention the outstanding support of the state, and local authorities and agencies at the accident scenes. In New York, Florida, and in Michigan, costs have been incurred on behalf of the accident that are currently being borne by the states and localities. They are not insignificant and I believe that a system or process needs to be in place to address the legitimate local costs associated with aircraft disasters.
Mr. Chairman, this concludes my testimony and I will be happy to answer any questions.
Jim Hall's Speeches