ESTABLISHING INDEPENDENT INVESTIGATION AGENCIES:
A GLOBAL CHALLENGE

By James Hall, Chairman
U.S. National Transportation Safety Board

As our transportation systems become increasingly integrated, it is increasingly important for countries that have not already done so to establish independent accident investigation agencies to preserve public confidence in those transportation systems and to ensure that the proper lessons are learned from transportation-related accidents and incidents, according to James Hall, chairman of the National Transportation Safety Board.

In this article, Chairman Hall examines the issues involved with transportation safety and its impact on international transportation systems.

Improving global transportation safety is a difficult task with numerous challenges and opportunities. As our transportation systems become increasingly integrated, it is increasingly more important for countries that have not already done so to establish independent accident investigation agencies to preserve public confidence in those transportation systems and to ensure that the proper lessons are learned from transportation-related accidents and incidents.

Whenever a serious accident occurs anywhere in the world, the 24-hour news media instantaneously transmit pictures and word of the tragedy to millions around the globe. The general public, the victims' families, and government officials all want to know what caused the accident as soon as possible, and they want to be assured that steps will be taken to prevent similar accidents. Only truly independent investigations can get to the root causes and determine the appropriate remedies to avoid similar future tragedies.

THE NTSB ROLE

The U.S. National Transportation Safety Board (NTSB) supports development of independent and multi-modal safety boards worldwide. Independent accident investigative bodies are a necessity, not a luxury. No governmental or industrial entity should be expected to investigate or oversee itself -- that process cannot and does not work. For that reason, 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 transport system.

The NTSB was created in 1967 and has established a worldwide reputation for impartiality and objectivity in determining accident causes and developing recommendations to address safety deficiencies. Independent accident investigation boards now exist in several countries, but in too many nations investigations are still conducted by the same government inspectors who draft regulations and ensure compliance. In other countries, a temporary committee may be formed, chaired by a judge or other non-transport official, for the purpose of investigating an accident. Each has the potential to create unavoidable conflicts of interest.

Because of the competing pressures of safety, economics, government, and societal responsibilities, independent investigative agencies can serve as safety advocates for society to ensure objective and impartial investigations as well as government and industry accountability.

THE NEED FOR INTERNATIONAL COOPERATION

Independent aviation investigative agencies are being mandated in the European Community. But the NTSB and the International Transportation Safety Association, a small but growing group of independent accident investigation boards worldwide, support multi-modal boards that will investigate accidents in all modes of transportation similar to the NTSB, the Transportation Safety Board of Canada, and the new Dutch Transport Safety Board.

Additionally, with the continued globalization of our transport systems, accident investigators cannot work in isolation. It is clear that we all must do a better job of sharing accident investigation facts, safety lessons learned, and potential remedies. There must be a cooperative system for sharing factual, timely information.

No matter where in the world they occur, the causes and contributing factors of transportation-related accidents are strikingly similar. In the summer of 1996, NTSB investigators examined an American Airlines MD-11 passenger jet that experienced an in-flight upset over Rhode Island, injuring two flight attendants and a passenger. A year later, Japanese investigators looked into an incident involving a Japan Air Lines MD-11 that experienced abrupt pitch oscillations while on a flight from Hong Kong to Tokyo. Both the NTSB and Japan's Aircraft Accident Investigation Commission separately issued similar recommendations to the U.S. Federal Aviation Administration, calling for better pilot simulator training, modifications to autopilot systems on transport category aircraft, and revisions to flight manuals.

Although aviation is the transportation mode most associated with international cooperative efforts, accident data can and should be shared by all countries in all modes. Then, we will not have to re-learn lessons already learned somewhere else in the world. Only then will we be adequately protecting our citizens.

PUTTING CHILD SAFETY FIRST

I believe there is one specific area that we all need to focus more attention on, if we are to improve the safety of our respective citizenry -- especially our youngest and most vulnerable. I spend much of my time as chairman listening to the concerns of transportation accident survivors and the families of victims. Many of my conversations are with parents who have lost a child in a traffic accident. They all tell me how frustrated they are at how difficult it is to ensure their children's safety when they are traveling by automobile.

Those discussions made it clear to me that the United States was not doing enough to protect our children from death and injuries in transport accidents. As a result, in 1999, I made child passenger safety in the United States my top priority at the NTSB. But I believe it needs to be everyone's first priority. There should be one level of safety for every child in every country of the world -- especially on our highways. Traffic crashes claim more lives than any other transport mode in every nation.

The statistics here in the United States provide just one grim example:

  • More than 90,000 children, infants to teenagers, were killed in the 1990s in motor vehicle crashes, and over 9 million children were injured.
  • More than 16,500 children under age 10 died in motor vehicle crashes, averaging 33 children each week.
  • More than 57,500 children between ages 15 to 20 died in traffic crashes, more than 110 each week.
  • Six out of 10 children who died were not using seat belts or other restraints.
  • The vast majority of children under age eight who are "buckled up" are improperly restrained.

Every country should have zero tolerance for unbuckled children and should require children to be buckled up in restraints appropriate for their age, size, and weight. Research by the NTSB and other organizations has shown that too many small children, especially those under the age of eight, use seat belts that are designed for adults and, therefore, do not provide adequate protection for youngsters.

To help parents in the United States, the NTSB has urged federal and state governments and the automobile and child restraint manufacturers to establish permanent fitting stations, like those in Australia. At these stations, trained technicians inspect child safety seats to ensure that they properly fit the child based on the child's age and size, that the child is properly buckled into the seat, and that the seat is properly secured in the automobile. Surveys in the United States show that although 96 percent of parents think their child safety seats are installed correctly, four out of five are not. I have also called upon our automobile manufacturers to design their vehicles with children in mind.

We are making progress. Several U.S. states and a number of automobile companies are establishing fitting stations across the nation. We have more work to do. But I hope that other nations will take the lessons we have learned and work toward making their highways safer for their children as well.

TOWARD A SAFER WORLD

However, we should not stop there. We need to put children first in every mode of transportation. We need to design aircraft seats with integrated child seats or make them compatible with universal child safety seats. And we need rules that require our smallest children to be properly secured during takeoff and landing, and during turbulence. Similarly, no child should be allowed in a recreational boat or on a personal watercraft without a personal flotation device. These are only a few of the measures that can be taken in every country to put our children's safety at the forefront. If we all put children first, in the end we will all be safer.

During my meetings with aviation accident survivors and victims' families, I also heard horror stories about the indifferent, often callous, treatment they received from airlines and government authorities. The U.S. Congress and the president heard the same stories. As a result, they gave the NTSB the responsibility for coordinating the family assistance effort following accidents to ensure that families are treated the way we would want our families to be treated in such tragic circumstances.

Actions by airlines and government entities, both here and abroad, following aviation accidents have shown that we are all learning from one another's experiences. And we are all working to make an unbearable situation a little easier for families to endure.

In summary, there are actions governments around the world can take to improve transportation safety for all of us. One of America's founding fathers, Thomas Jefferson, said: "The care of human life and happiness is the first and only legitimate object of good government." He was right - not only for the government of the United States - but for every nation in the world. Government has no greater role than to ensure the safety of its citizens.


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