Remarks by Honorable Jim Hall
Chairman, National Transportation Safety Board
Conference of Directors General of Civil Aviation
Singapore
February 23, 2000


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Thank you, Mr. Wong and our other hosts from the Civil Aviation Administration of Singapore for your kind introduction and for inviting me to participate in this important meeting of the Directors General of Civil Aviation of the Asia-Pacific Region. I also wish to thank the officials from ICAO for sponsoring this conference. My staff and I appreciate the opportunity to be here among so many distinguished members of the civil aviation community.

I've been asked to speak on the rather broad and generic topic of "Safety Issues in Civil Aviation" today. I'd like to discuss what we - as a global aviation community - can do to improve aviation safety for all of our citizens. As we all know, aviation is one of the safest modes of transportation available to the world's travelers. In fact, an ever-increasing number of our citizens are travelling by air. In 1998, 126 million people traveled by commercial air carrier. In 2010, that number will increase to 230 million. A significant amount of that growth is occurring, and will continue to occur, in the Asia-Pacific region.

Many of you in this room share in the responsibility for maintaining the system's and the public's safety. And, undoubtedly, each of us has our own ideas about how to best fulfill our responsibilities. But, I believe we can all agree that it takes everyone's efforts - and everyone's willingness to work together - to ensure the continued safety of the aviation system.

Today, I want to focus on three specific areas that will improve safety: independent safety boards in every country, better data and information, and better investigative training. However, the general theme of my remarks will address the need for expanded cooperation by the means of bilateral and multi-lateral cooperation among States. Certainly, ICAO plays an important role in facilitating such cooperation and providing a standardized framework for it.

I'm sure many of you are aware of the National Transportation Safety Board's (NTSB) work. 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 you in your investigations of accidents involving U.S. airlines and U.S.-manufactured aircraft. In fact, over the years, we have worked - and are currently working - with many of you and your countries on accident investigations - either by sending investigators, as designated representatives, or by making our laboratory facilities available to you to readout recorders or examine materials. Over the past two years, we have assisted other nations around the world with their investigations of more than 124 accidents and incidents; 27 of them in the Asia-Pacific region.

However, at the Board, 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 you with your investigations. Of course, these investigations are conducted in accordance with the cooperative framework established by 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 if the manufacturers, airlines, or regulators do not take appropriate actions first.

To accomplish that goal, the Safety Board uncovers and reports on the safety deficiencies it finds - whether they're in pilot training or performance; aircraft design and manufacture; air traffic control services; airline management oversight; or Federal Aviation Administration (FAA) certification, surveillance, and oversight.

The U.S. Congress, more than 30 years ago, established the Safety Board as an independent agency - separate from the Department of Transportation (DOT). In addition to investigating accidents, we were given the responsibility of providing oversight for the transportation industry and DOT's modal administrations. This system has served us well. And, it has helped give the American people confidence in their transportation system.

To maintain that confidence, everyone in the United States aviation community must remain continually vigilant - the FAA to properly regulate the industry; the airlines to ensure the safety of their operations; the manufacturers to design and build safe aircraft; and the NTSB to assure the traveling public that there is an independent review of how well those entities fulfill their responsibilities. Obviously, this interrelationship creates a healthy tension between all of the participants. It's meant to be that way - by design - and it works. The United States Government is built on checks and balances.

I believe that independent accident investigative bodies are a necessity - not a luxury. 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 (ECAC), representing nearly 40 European States, adopted a directive that aviation accidents and serious incidents shall be investigated by an authority that is independent of the organizations responsible for regulation and safety oversight of the aviation system. Many European States have formed independent aviation investigation bodies. Currently, we have nine such independent boards in place around the world.

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, the 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 be the lead organization to provide those resources; I must emphasize that ICAO plays a vital role in providing guidance for countries in setting up such agreements.

I understand that as the result of decisions reached at the September 1999 AIG99 meeting in Montreal, ICAO is in the process of developing model agreements for countries to use in order to meet their treaty obligations to conduct investigations of accidents and serious incidents. Many states 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.

Considerable progress has been made in the international arena under the leadership of the International Civil Aviation Organization (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.

Let me illustrate why I believe such cooperation is essential. 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 these events.

The Canadian Transportation Safety Board will 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 amongst States during the investigations, in accordance with ICAO guidance.

The Rand Corporation, an international "think tank", in a 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 all 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 also depend on the collection and analysis of accurate data. In fact, no accident prevention program can be successful unless investigators have better data available to them.

There is no better argument for improving both flight and cockpit data recorders. At a minimum, we need more parameters recorded, longer recording time, backup electrical power, and improved crash survivability. As you may know, the Board has been asking for these enhancements for years. Yet, progress has been glacial. The result has been extensive and exhaustive search and recovery efforts that have proven to be very expensive - efforts that may not have been necessary if more information had been available to investigators.

If we all agree that only the most difficult problems remain and that we need improved data to solve them, one must wonder why we aren't all doing everything possible to gather as much accurate data as possible. Recent accidents, being investigated by the NTSB, such as EgyptAir flight 990 and Alaska Airlines flight 261, have also indicated a need for video recorders on board aircraft. I have asked the NTSB staff to examine the possibility of recommending that they be placed on commercial air carriers in the near future.

In its report on an accident involving a public use aircraft in Montrose, Colorado, the Board asked the FAA to require video recorders on single engine, turboprop aircraft operating under Part 135. Board staff is also examining the technical feasibility of cockpit video recording requirements for Part 121 operations, so that the characteristics of the cockpit environment and the actions of the flight crew can be clearly documented.

However, as we increase the amount and use of data, we also have the responsibility to respect the privacy of pilots, dispatchers, air traffic controllers and others whose actions and words may have been captured by a recording. In the United States and elsewhere in the world the importance of protecting the rights of the pilots and others engaged in safety-related tasks must be balanced against the protection of those who entrust their lives to them. To help us understand these issues, the NTSB will be conducting a symposium on this subject on April 25 and 26 in Washington, DC. Many leading members of the legal and aviation communities will participate in this symposium. I invite you to attend and share your concerns with others from the United States and around the world. More information on this important international symposium can be obtained on the NTSB's website, www.ntsb.gov.
As we all know, independent investigative entities and better data are not sufficient to assure quality investigations. Organizations involved in aviation safety need to be staffed with individuals who have the best training and skills available. The Safety Board has not only urged such training, we have actively participated in helping other nations train their investigators. In fact, NTSB staff has just participated in a one-week course at the Singapore Aviation Academy. And, several investigators arrived in Taiwan today to begin teaching an advanced accident investigation training course. We've also conducted workshops in Mainland China and Indonesia. These training sessions are in addition to our in-house two-week accident investigation courses conducted in Washington, D.C.

In the next year, the NTSB will significantly expand its training program when we open our own training academy dedicated to enhancing the skills of investigators in all facets of transportation safety. The academy's courses will be developed and taught by experienced accident investigators, who also have the necessary expertise and formal training in educational methodology, to make our programs the best available training in accident investigation techniques in the world. In addition to training courses, we will offer conferences and seminars designed to maintain and advance the state of the art.

Soon, we will be reaching out to everyone may have an interest in our program, particularly other governments, to seek their assistance in charting a course for the academy. I hope I can count on you to share your ideas and experiences to help us address the needs of the transportation safety community worldwide. We believe that by providing an environment, in which investigators can share their experiences and skills with one another, we can all learn from each other and enhance the safety of civil aviation.

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. As a result, we have seen a marked difference in how family members are being treated following accidents compared to how they were treated following previous aviation disasters. Many other countries are beginning to establish their own policies and procedures for improving how families will be treated following a transportation accident. It is the right thing to do and I hope that all countries will follow suit. We should treat all of the families of victims of aviation accidents, as we would want our families treated. We are all one family.

Thank you, again, for inviting me to be here today. I look forward to working with all of you as we continue to improve our aviation system for the world's travelers.

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