Director Needles and members of the United States Parachute Association's Drop Zone Operators, thank you very much for inviting me here today and allowing me to speak to you about a subject we all care very deeply about -- safety.
First, let me express my deepest sympathy for the loss of your Director of Safety and Training, Chesley Judy, and the other sport parachutists on board the Beech Model 65 airplane that crashed September 10 at West Point, Virginia. I can assure you that the National Transportation Safety Board is diligently searching for both the cause of the crash and for the best ways to prevent future accidents of this kind. I am pleased that the USPA has been made a party to this investigation and know that through our mutual efforts we will resolve the issues of this accident and reduce the likelihood of a similar accident from occurring.
As early as 1984, the Safety Board acknowledged the vital role the USPA can play in promoting safety by recommending that the FAA maintain a close working relationship with you to foster appreciation and adherence to safety practices.
The sport parachuting industry has recently grown by leaps and bounds -- judging by your reaction, no pun intended. Last year, aircraft carried 3 million jumpers to their drop zones. Many of you run complex operations combining aviation, maintenance, personnel, and facilities. Most importantly, all phases of your operations are ruled by concerns for safety. That is why I am here today, to talk about our desire to work with the USPA in promoting safety.
Although the Safety Board is one of the federal government's smallest agencies, it has a big job. While we are sometimes confused with the FAA, we are not part of the FAA or any other Department of Transportation agency. Congress established us as an independent federal agency, and we are often required to investigate DOT's role in an accident scenario. We investigate about 2,600 accidents and incidents involving aviation, highway, marine, rail and pipeline annually; more than half of our resources are expended on aviation.
To do this job, the taxpayers have funded us to the tune of $38 million this year -- I know that all of you here are taxpayers, so we really work for you. Although we monitor the effectiveness of the safety programs of the Department of Transportation's modal agencies and of billion dollar transportation corporations, to give you an idea of our relative sizes, our annual budget would fund the DOT for just nine hours!
But $38 million is a lot of money from the American people, no matter how you look at it. As taxpayers, you're paying us to ensure safer transportation, and it's our job to deliver.
As many of you know, the Safety Board independently investigates aircraft accidents to determine probable cause and, more importantly, to make recommendations to the FAA, aircraft and engine manufacturers, to foreign airworthiness authorities, and to organizations like yours that can make a positive impact on safety and prevent accidents from recurring. The Board does not place blame, but rather attempts to resolve the accident issues in a way that would influence change in the industry, to promote safety and, in the case of the parachute associations, to make the sport safe. In other words, to save lives.
Our process is designed for the free flow of information between those individuals who have been involved in a mishap and the investigation team members. We ask for complete access to records and information so that we can have an accurate picture of those circumstances surrounding an accident. In that regard, we make certain individuals and groups parties to the investigation to ensure that appropriate expertise is brought to bear on the issues of the investigation. All of the parties have expertise or knowledge they impart to the investigation to help record the facts and findings of the accident. Only the FAA has a statutory right to be a party, all others are designated by the Board's Investigator-in-Charge, based on the expertise the party can provide us.
Another important purpose of the party system used by the NTSB during its investigations is to permit full access to the investigation findings for the individuals and organizations in the best position to make immediate corrective actions. In the West Point case, for example, I understand that immediate corrective actions were taken by the FAA before the NTSB issued safety recommendations.
I hope you won't be disappointed to learn that we do not allow lawyers or insurers to be parties to our investigations. We routinely exclude their participation to ensure that our investigations will not be unduly influenced by persons who have a self-interest in the litigation process.
Let me bring you up to date on the West Point accident. As you know, immediately after the accident, we dispatched a full Go-Team of investigators, with Vice Chairman Bob Francis accompanying the team to the site. In addition to the FAA and the USPA, parties to the investigation are Beech Aircraft and Lycoming Engines.
Since the investigation team completed its on-scene activities, work has been progressing on many fronts. Among the findings so far:
- The fuel in the storage tank was found not to be contaminated. However, because a hand pump was used to transfer the fuel to plastic jugs and then to the plane, fuel contamination cannot yet be ruled out.
- Based on post-accident calculations, there appear to be weight and balance issues.
- Applicable federal rules did not allow the door to be removed from the aircraft. We are exploring who approved that action, and the potential effect that may have had on the airplane's performance. The maintenance logs are not complete.
- There has been no conclusive evidence that an engine failed in flight, although much of the evidence was destroyed in the post-crash fire.
- A helmet-mounted video tape has been recovered from the wreckage but its usefulness to the investigation is in doubt.
There is much work that has to be done, and your party representatives will be kept informed on developments. We hope to have a final report by early next spring.
Many casual observers might wonder what the Safety Board's interest is in sport parachuting aircraft. How much can you worry about the safety of people who routinely throw themselves out of airplanes thousands of feet off the ground?
Our response is an easy one -- skydiving might have its inherent dangers, but flying to the drop zone shouldn't be one of them.
There is a tendency to write off many of the accidents we've investigated as aviation crashes that just happened to have parachutists aboard. This is a trap we should avoid. There are elements in many of the accidents that are specific to the sport, most prominently the use of passenger restraints.
Our history of accident investigation involving sport parachutists shows that improvements can be and have been made.
On October 17, 1982, a military version of a Beech D-18 crashed during takeoff near Taft, California. The aircraft had 12 sport parachutists onboard; none survived. The Safety Board determined that the airplane had been overloaded with a center of gravity well aft of the prescribed limit.
We noted at the time our concern that the FAA was not sufficiently attentive to sport parachuting operations and that the safety of parachutists was jeopardized by airplane operators who didn't operate their airplanes safely. The Board urged the FAA to better define its oversight responsibilities regarding sport parachute aircraft. In early 1983, in response to the NTSB, the FAA issued an operations bulletin to help its field inspectors understand and properly inspect sport parachuting aircraft.
Less than a year later, on August 21, 1983, a Lockheed L-18 Learstar crashed after an uncontrolled descent from 12,500 feet. Of the 24 jumpers onboard, 15 were able to exit and safely parachute to a landing. The other nine perished. The Board determined that the airplane went out of control as the pilot slowed for jump operations and the jumpers maneuvered toward the exit for a group jump. The Safety Board believed that, had the pilot known the consequences of the shift in weight when all the jumpers moved to the rear but did not jump, he would have maneuvered the airplane differently.
As a result of our findings, we recommended that the FAA periodically inspect the jump airplanes and maintain close liaisons with the USPA and local DZs to foster appreciation for and adherence to good safety practices. The FAA responded to our recommendations with a General Notice to FAA field inspectors and a change in Advisory Circular 105-2 .
On April 22, 1992, a de Havilland Twin Otter crashed during takeoff at Perris Valley, California after an engine lost power. The Safety Board determined that the accident was caused by contaminated fuel obtained from the improper handling of the DZ's fuel tanks and the pilot's improper actions after the power loss, as well as other factors. Although the aircraft never rose above 50 feet, 14 jumpers and the two pilots were killed.
The Safety Board conducted an in depth study of drop zone operations following that accident. We found that sport parachute operations are complex and have unique procedures that are not found in any other aviation operation. Sport parachute flight operations do not have the pyramid of quality control personnel that the large airlines do and, as such, must control their own fuel handling, maintenance, and other procedures more directly than very large operations.
On September 7, 1992, a military variation of a Beech D-18 crashed near Hinckley, Illinois, killing all 12 aboard, after one of the engines malfunctioned. The pilot was maneuvering to land when the aircraft went out of control close to the ground.
In both of these 1992 accidents, the Safety Board found that the parachutists on the flight were not properly secured by seatbelts or restraints. This was extremely important because impact forces were not so great, particularly at Perris Valley, to cause the deaths and serious injuries that followed. Had the jumpers been wearing seatbelts, lives may have been saved. We are unaware of any restraints for floor-sitting passengers that have been approved by the FAA.
With that in mind, the Safety Board made recommendations both to the FAA and to the USPA. The recommendations asked that the use of seatbelts be mandatory and enforced, that the results of our findings be made known to all sport parachutists, and that good, safe restraint systems and seating be developed by the FAA and industry that would better serve sport parachutists. Since then, there have been several meetings of the FAA and your organization for the development of good, safe restraint systems unique to parachutists. Our staff have also met with your representatives to better understand possible remedial actions.
Along those lines, the Board is concerned that because parachutists are frequently allowed to sit directly on the cabin floor, the crash loads, especially the vertical loads, are transferred directly from the airframe to the parachutists' bodies, instead of through the seat unit. The Board believes that even during a minor deceleration, an occupant sitting on the floor might receive serious injuries. Restraint systems and seating specific to the needs of parachutists and other occupants who sit directly on the floor of an airplane should be developed expeditiously.
I am very pleased that the USPA and local DZs have aggressively pursued these issues, particularly by changing the behavior of jumpers to insist that seatbelt usage be mandatory. Also, parachutists and DZs are paying much more attention to aircraft safety issues. Even though you are passengers and focused on the safe departure from an aircraft, you can do more to insure your own safety if you are alert to some of the best accepted practices of aircraft operation. For instance, the fuel for an aircraft should be tested before pumping, filtered at the pumps or the truck, then tested by the pilot before flight. You would be surprised at the number of accidents the Safety Board investigates each year that could have been prevented by such sound practices.
I would also like to acknowledge the FAA's role in taking more positive steps in giving sport parachute operations a higher priority in their national program for inspections. There has been marked improvement in recent years, although whether the FAA adequately oversaw the operation in West Point is still an open question. We hope that future FAA budgets will continue to allow proper funding of this important activity.
We at the Safety Board have discussed the need for increased involvement of the FAA in sport parachuting activities for the past few years. And, although some of you may think the FAA is not here to help you, we have found that the absence of adequate FAA oversight inevitably leads to degradations of safety. The FAA can help promote sport parachuting without undue hardships, the creation of hard feelings, or unjustly raising the cost of your sport.
The NTSB and the USPA are partners in search of the safe execution of sport parachuting. I have recently reviewed the USPA Skydivers Information Manual and was astonished at the scope of the information, not to mention the detail of each activity. I applaud the development and use of such a manual and would like to emphasize the importance of regular adherence to the operating rules in it. You are to be congratulated for your commitment to disseminate safety-related information to your members, both in the manual and in your magazine. I agree with you that the government cannot regulate common-sense safety. This is an area where the USPA has shown laudable leadership.
We've seen the genesis of some major accidents involving parachutists' planes, but I'd like to turn the issue around and ask, where does safety come from? At the Safety Board, we address most of our recommendations for aviation safety improvements to the FAA. We do that because the FAA has the responsibility and authority to take action -- regulating, issuing bulletins, and so on -- that can affect all of aviation at once. But the regulations are just a framework for safe operations. We cannot depend on safety coming only from the FAA -- it comes from you, the operators of all the DZs, the people who set policy and the skydivers themselves.
So rather than depend on outside forces, safety should come from the inside, because you have a tremendous investment in whom you carry. It is one thing for the FAA to set minimum safety standards, but you have to answer to a higher authority-- your jumpers.
I would like to encourage you to continue to set standards that come from within your organization. Experience has shown us that rules set by the participants are more likely to be followed and are vastly more effective than those set by the government. We at the Safety Board are very pleased with your commitment in ensuring the safety of your customers.
As we've seen, Safety Board investigations over the years have resulted in remarkable improvements in the safety of sport parachuting aircraft. The FAA now includes these operations in its inspection priority schedules, research has progressed on the development of appropriate passenger restraints, and the USPA has expanded its influence over the safety of parachuting itself to encompass the safety of the skyjumpers' aircraft.
As drop zone operators, you are on the front line of assuring the safety of your industry. You can provide us with valuable insights when participating in our investigations. We appreciate your role in our on-going West Point investigation. Please let us know how we can support your efforts to promote safety among your members.
Together, we can work for a safe 1996, and hope that we're always looking at...BLUE SKIES.
Thank you for inviting me.
Jim Hall's Speeches