Just wanted to let those of you who don't already know, that families will NOT be given access to the draft report. They also say they will neither confirm or deny any leaks that come out.

I also want to take this opportunity to add that Beanspiller never said that his information came from the actual draft but from someone that participated in the investigation.

Also wanted to mention that we can confirm based on information we've received that the pilots' wives have seen copies of the drafts.

I do want to add that I think this decision is absolutely disgraceful though I certainly can't say that I am surprised. We have already suffered greatly as a result of this terrible tragedy and it is inexcusable that we would be left out of this process. What are we going to get- Some watered down version after all those responsible get to protest and change it around? It will just make me trust the results that we are able to see even less than I already do.

Barbara

Please read the following carefully and tell me when you are finished that you believe that:

1. The victims of this terrible atrocity are put first in priority.
2. That you believe you will be told the truth even if the real cause would possibly generate criminal charges. (ie. the IFEN)

Remarks by Beno�t Bouchard, Chairman
Transportation Safety Board of Canada

MAXIMIZING THE BENEFITS OF RECORDED DATA

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We are all here in Washington this week to review the state of knowledge with data recorders and to consider how we might better exploit data from on-board recordings the future. I am here partly because I share a belief in the importance of flight recorders with my friend and colleague- Chairman Jim Hall of the NTSB. I am also here because both Jim Hall and I are members of the International Transportation Safety Association, the body co-sponsoring this symposium with the NTSB.

Before I touch on the specifics of recorders I believe it is important to look first at where transportation accident investigation appears to be headed.

First: What should be the object of any transport accident or incident investigation? There is little doubt that in the minds of all, or at least most, of the people in this room that it must be accident prevention.
ICAO Annex 13 states, when referring to the investigation of aviation accidents and incidents: "It is not the purpose of this activity to apportion blame or liability." Most of us have these or similar words in our national legislation, at least for aviation accident investigation.

I mention this now because the interests of the legal and regulatory communities must be recognized in determining how we investigate with the object of preventing accidents. There is, therefore, good reason for us to go beyond simply stating the objective of "preventing accidents" and consider the means of achieving that objective. To fail to do so invites others to employ means that conflict with the non-blaming safety analysis that has served aviation for so many years and more recently has served all modes of transport.

Those of us in the government sponsored part of the accident investigation community and the operational people in the industry tend to look at transport accident investigation as being unrelated to disciplinary action, blame, and liability.
You will find many in the general public and some in regulatory organizations, who believe that if those at fault are caught and punished, that will make a major contribution to accident prevention. They are saying 'be careful because it can cost you money, your job, your reputation and possibly your freedom.' Can we say that they are entirely wrong?

More appropriately, can we say that punitive activities are likely to conflict with the efficient gathering of all relevant information necessary to the analysis of aircraft accidents and incidents? I think so.

Two recent accidents come to mind. We saw the intense interest of the FBI in the TWA 800 accident. In the SwissAir 111 accident near Peggy's Cove there has been, in Switzerland, an allegation of "manslaughter through negligence". An investigating judge has been assigned in Switzerland and the Canadian Department of Justice has been asked to obtain our files. While we like to cooperate, we will resist the use of our information for the purposes of prosecutions with extreme vigour. For the crews and the companies involved, this interest in criminal charges must be alarming. From the perspective of the accident investigation agency it is very worrisome.

The effect of bringing criminal charges against crews and companies can be very detrimental to the investigation and to safety. If crews and companies are fearful about speaking freely to investigators, the investigators must necessarily take longer and may not even succeed in identifying safety problems. So, what is required in the coming months?

The accident investigation authorities need to explain clearly the ground rules and the protections for information that are in place. The accident investigation organizations will need understanding and support from the industry to defend the protections that exist for important safety reasons. The investigation authorities must explain that some information that is wanted by the industry will not be available if we are to protect the principles that support getting complete safety information to the investigator by the quickest means available.

These quickest means are critical so that the investigator can make findings about safety problems and make them known, so that safety deficiencies can be eliminated as quickly as possible.

When there is a safety failure within the good and effective transport system that is overseen by the regulatory agencies, the accident investigators enter the picture to analyse the accident or incident. The part of the transportation system that is managed by regulators includes, among other things, the assessment of penalties to encourage operators back on the path to safety. Can we say that is entirely or even substantially wrong? Manufacturers use investigation information to verify the performance of their aircraft and to analyse performance anomalies. That's certainly in support of safety.

The TSB has made some assertions about the transportation industry and I suspect they are not far from what other accident investigation agencies have said or might say. Those assertions, or inferences, underlie the way that the Board operates.

The Board believes that almost everyone in the transportation community is objective and forthright. It presumes that people who work in the transportation community are generally competent, they like their work and they try to 'get things right'. That when there is a safety failure, it is likely because there was an absence of knowledge or training or understanding. Those inferences are reflected in the legislation and practices of the TSB.

In our work we have found much to validate their soundness.

When this is combined with the separation of accident investigation from the liability and discipline functions, it provides strong incentives to be forthcoming about safety problems. The presumption that the crews tried to get things right is behind us having human performance specialists trying, among other things, to determine whether the circumstances of the accident were beyond the limits of expected human behaviour.

I will now turn to those uses of accident investigation information that are for purposes other than the reduction of accidents or the advancement of transportation safety. Lawyers will use investigation information for the purposes of pressing, and defending against, civil claims. Media organizations will use accident investigation information as part of the news that sells their products. All those uses are legitimate but they are often in conflict with conducting the quickest possible investigation to identify safety problems and get them out of the system.

What does this all tell us about where aircraft accident investigation is headed? First, it tells us that safety investigators do not have an exclusive right to accident investigation information.

Often the accident investigators have the only information about many aspects of the circumstances of an accident and its analysis. Others claim access to that information for their own purposes - purposes that often conflict with efficient accident investigation and the earliest identification of safety deficiencies. It tells us that the others in competition for the information will press their point of view.

It tells us that we must put forth our own point of view clearly and with sound reasons. It tells us that we should do everything possible to separate our gathering of information from accidents and incidents for non- regulatory safety purposes from the activities of others who gather information for their own purposes which often conflict with safety. It tells us that we must explain the regime that includes incentives to provide information to accident investigators quickly and freely.

It tells us that in spite of our best efforts, that some information is so important to others that they will find means of obtaining it regardless of the law. (Swissair 111 some CVR excerpts leaked to US media and later picked up in Canada.)

The level of public attachment to aircraft accident stories has soared since the beginnings of CNN and the subsequent all news TV channels and radio stations.

The media interest in TWA 800 and SwissAir 111 represents a new reality. It is dragging along interest in smaller accidents and my belief is that media interest in aviation accidents will continue to grow. The present level of media interest puts great pressures on investigators. It puts pressure on the carriers, on the pilot's associations and on the regulators. We must accommodate and manage the change within this new reality.

We must manage our investigations in a way that respects the present state of society without compromising our ability to investigate as quickly and effectively as present day technology permits. I should add that this intense public interest is not all bad for the investigative process.

The intense interest almost guarantees the availability of adequate funding for large investigations and almost guarantees action to deal with the safety deficiencies identified in the investigation.

Aircraft are becoming ever more complex. Crews know and understand a smaller and smaller proportion of the aircraft systems and how they operate. Sophisticated training schemes for pilots and maintenance staff have been designed by manufacturers, largely on the basis of the need to know. More and more of the aircraft is being operated by software that may contain deficiencies that can remain hidden for years. The pilot's knowledge of all the systems is becoming less than it was and this is threatening his ability to reason his way out of problems. On the happy side, the reliability of the components and systems is increasing at a very satisfying rate.

What does this tell us of the future of accident investigation? Certainly, that we can get much quicker analysis of many of the failures because the electronic theory that permitted the development of the complex systems can be used to analyse their failures very quickly - provided that we can preserve the data. It tells us that we need ever more highly educated and qualified investigators.

It tells us that the independent investigation agencies will need more and more outside help. Some of the help will come from sister agencies, some will come from independent experts, some from cooperative associations such as ITSA, and some will necessarily come from manufacturers and operators. This will bring with it the necessity of learning how to manage the conflicts of interest that are inevitable in these sorts of relationships. It also tells us that in those accidents where we lose the electronically stored data we will face an almost impossible task.

The demands of the legal community and the size of the claims tell us that the work of the investigators will be challenged as never before.

That means that the investigation methodology will have to become more rigorous and align its self more clearly with the principles of scientific inquiry. It means that the management of the investigations has become a sophisticated task. In the early stages of the SwissAir 111 accident there were about 5,000 people whose work was being coordinated and directed by the investigator-in- charge.

Now I would like to say a few words about the applicability of the aircraft's 'Black Box' to other modes of transport and what we might consider in the exploitation of the data.

An FDR/CVR on a modern aircraft is often essential to the analysis of an accident. In modern aircraft with glass cockpits (i.e. computer generated electronic displays instead of mechanical or electro-mechanical instruments) the lack of a flight data recorder can seriously compromise the ability of investigators to understand the sequence of events. In several investigations where most of the wreckage has been inaccessible - in the ocean, on mountains or where there is severe fragmentation - the accidents have been analysed almost entirely on the basis of FDR/CVR information. On the other hand, accidents like TWA 800 demonstrate that even sophisticated recording systems cannot always yield the answers. Recorders are most useful in identifying operational problems and human factors, which are elements in the majority of accidents. The recorders increase the efficiency and objectivity of investigations and provide reliable information about what happened. To understand the 'why' of an accident it is first necessary to understand the 'what'. Recorders can often effectively allow the investigators to develop the 'what' in great detail.

There are accidents where the recorders are undamaged in the accident but are not serviceable because they have shut down days or weeks earlier as a result of some internal failure.

Marine Voyage Data Recorders (VDRs) which will record both voice and operating data were introduced in the last five years. Recent activity within the International Maritime Organization (IMO) has gained momentum to set standards for the devices internationally for safety purposes. It is interesting to see the marine mode come into the picture with a much longer voice-recording requirement. They also will record radar data. Two points for the established aviation community to think about.

In Canada, Rail Event Recorders (no voice) were introduced in the 1980s. No related regulations or significant changes have been made since then, however the TSB believes that voice recorders should be introduced. In the U.S., there is current activity to develop crash survivable voice and data recorder standards for trains. NTSB and TSB officials are exchanging information with a view to proposing some North American standards.

TSB (Canada) developed a multi-modal Statement of Requirements (SOR), placing emphasis on the importance of recorded information for investigative purposes in aviation, marine, rail, and pipeline transportation. The intent is to provide investigators with enough information that the reliability, comprehensiveness and timeliness of the analysis can be roughly equivalent regardless of the mode of transport. The SOR is still in draft form and requires further consultation prior to forming the basis of a formal recommendation to regulatory authorities. The SOR is expected to evolve as the TSB gains experience from its investigations and technologies develop.

There is a void in the TSB SOR in that it does not address highway transportation issues. That deficiency is being addressed through ITSA. There is also a concern that those with interests other than safety will use selected recorded information to support whatever theories suit their ends. It seems very important to apply state's accident investigation data to analysis based on scientific method. If others use some of the data for other purposes it is important to insist that they so not present it as the accident investigator's information.

To close, here is what I see as some issues by transport mode.

Air - it will be necessary to agree on what parameters should be recorded and whether to retrofit existing aircraft. It will also be important to determine the extent to which we record data link messages.
Marine - a key consideration is to determine whether the recorders should be designed to float free or remain fixed to the vessel. The rate of recording radar data is another important marine issue.
Rail - whether there is justification to introduce voice recordings.

For the future, I urge you to:

Recognize that the operational environment increasing in complexity in all modes
Accept that there is increasing need for reliable recording systems in all modes
That the necessary technology is readily available
Continue to exploit the successful experience and progress made to date.

http://www.ntsb.gov/events/symp%5Frec/proceedings/May_4/transcript_bouchard.htm