Remarks for Carol J. Carmody
Acting Chairman, National Transportation Safety Board
21st Century Challenges for Commercial Aviation Operations:
Capacity, Safety, and Environment Global Air & Space 2001
Arlington, VA
May 8, 2001

I appreciate the opportunity to participate with the other distinguished members on the panel to discuss challenges facing commercial aviation operations in the 21st century. I am glad to see that safety is featured in the title of the forum. The Congress, the public, the press and the industry are exerting enormous pressure on the FAA to address system capacity. The subject receives a lot of ink, and a lot of attention. I want to be sure the voices for safety are as loud as the clamor for addressing delays. On that point, I want to talk a bit about an issue that is directly related to today's topic and one of continuing concern to the Safety Board - runway incursions.

There were 429 runway incursions in the United States last year, more than double the 200 incursions that occurred in 1994, and a significant increase from the 322 incursions in 1999. In just the first quarter of this year, 97 reported runway incursions have been reported - 12 more than during the same time period last year. Although the FAA and the aviation community have been diligently working to reduce this safety hazard, incidences are still occurring in increasing numbers. Fortunately, there have been few actual collisions and the number of fatalities has been small, but the possibility for a catastrophe increases with time if the error rate is not reduced.

Despite ongoing safety briefings and seminars, improved signage, painted runway markings, and informational brochures, improper or misunderstood clearances continue to place aircraft, vehicles, and their passengers in danger. The reason is simple - human error. Pilots misunderstand a clearance or read it back incorrectly and controllers fail to catch the error. Or, controllers clear an aircraft onto a runway already occupied by a vehicle or another aircraft.

On January 22, 2001, TWA flight 24, an MD-80, flew over American Airlines flight 1991, another MD-80, on runway 16 left at Seattle-Tacoma International Airport. The two aircraft, carrying 176 people, missed one another by about 60 feet. At the time of the incident, visibility was less than ¼ mile with fog.

American Airlines flight 1991 had landed on the parallel runway and was instructed by the tower controller to hold short of runway 16 left. The flight crew responded "cleared to cross one six left American 1991." The tower controller did not correct the flight crew's erroneous read back. American 1991 then crossed the active runway as TWA 24 was departing on it. If SEA-TAC had been equipped with a ground movement safety system, as the Board has recommended, the system might have prevented this incident.

Since 1973, the Safety Board has issued more than 100 recommendations regarding runway incursions. In 1990, we placed runway incursions on our list of Most Wanted Safety Improvements. Last July, we issued six more safety recommendations on the issue. In addition to our recommendation to require a ground movement safety system that would prevent runway incursions and provide a direct warning to flight crews, we recommended that the FAA:

• Require that all runway crossings be authorized only by specific air traffic control clearance;
• Require that when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed;
• Discontinue the practice of allowing departing aircraft to hold on active runways at nighttime or any time when ceiling and visibility conditions preclude arriving aircraft from seeing traffic on the runway in time to initiate a safe go-around maneuver;
• Adopt the landing clearance procedure recommended by International Civil Aviation Organization (ICAO) and
• Require the use of standard ICAO phraseology for airport surface operations and periodically emphasize to controllers the need to use this phraseology and to speak at reasonable rates when communicating with all flight crews, especially those whose primary language is not English.

Now I think that if any of these operational recommendations were to be implemented, they would not increase capacity. Indeed they might well contribute to further delays. Therein lies the dilemma of the FAA. The FAA has taken numerous actions, but the number of runway incursions is not decreasing. Increased awareness and education are important, but in a system as complex as airport traffic control, human mistakes are unavoidable. We must build in redundancies to compensate for the inevitable lapses in human performance. And, the FAA, together with the rest of the aviation community, must continue to explore innovative ways to ensure that the air traffic environment minimizes the impact of human mistakes before they result in an accident.

Since this is a global forum, I want to mention briefly some other measures which could improve safety around the word.

• Create an accident investigation organization in every country that is separate from the governmental agency that oversees the regulation and operation of the aviation system. Over the years, the travelling public has benefited significantly from the work of professional air safety investigators and accident investigation agencies around the world which has led to improvements in the ways in which aircraft are built, maintained and operated. Many European states have already formed independent aviation investigation bodies similar to the NTSB and the Canadian Safety Board. Other countries should follow suit.
• Develop bilateral and multi-lateral cooperative agreements to ensure that investigations in all countries are conducted thoroughly and objectively. Many states may not have the resources to fully staff and fund an independent investigation authority, especially because of the rarity of the events. In such cases, those countries should develop agreements with other states that can provide the necessary expertise to assist with the investigations. ICAO can play a vital role in providing guidance to countries in setting up such agreements.
• Enhance the availability, accessibility, and quality of data to help determine the cause of accidents and incidents. The success of other initiatives such as Flight Operations Quality Assurance (FOQA) will also depend on the collection and analysis of accurate data.

The Board has 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. We've also 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.

Last year, 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 did not have adequate information about the cockpit environment in several recent major investigations, including ValuJet flight 592 and EgyptAir flight 990, as well the SilkAir flight 185 and Swissair flight 111 investigations. In 1998, ICAO's Flight Recorder Panel stated that the use of video recordings in aircraft cockpits would be very useful and noted that the European Organization for Civil Aviation Equipment (EUROCAE) was developing minimum operational performance specifications (MOPs) for such recorders. As a result, the Safety Board also recommended that the FAA work with EUROCAE to help expedite the MOPS' performance standards and incorporate them into an FAA TSO for a crash-protected cockpit image recording system as soon as possible.

Aviation is the safest mode of transportation available to the world's travelers. It is our responsibility to ensure that it remains that way. These measures will help fulfill that duty. Thank you again for inviting me to participate in today's panel.