Good morning. I am Deborah Hersman, Member of the National Transportation Safety Board, and Chairman of this Board of Inquiry.
Today we are opening a public hearing concerning the accident that occurred on October 14, 2004, at Jefferson City, Missouri, involving Pinnacle Airlines Flight 3701.
I'd like to begin by acknowledging the family members of those who lost their lives in this accident who are with us today. On behalf of the National Transportation Safety Board, and may I also say, on behalf of all the parties who have joined this investigation, I want to express our condolences for your loss.
This hearing is being held for the purpose of supplementing the facts, conditions, and circumstances discovered on-scene and throughout our continuing investigation. No determination of cause will be rendered during these proceedings. However, this process will assist the Safety Board in establishing the facts to determine the probable cause of this accident and make recommendations to prevent similar accidents in the future.
While airline accidents are rare events, they are widely publicized and scrutinized by experts around the globe. When an accident such as this does occur, it is the responsibility of the National Transportation Safety Board, with assistance from designated parties from government, industry and labor, to find out what happened, why it happened, and how we can prevent this unfortunate event from recurring.
The purpose of this hearing is two-fold. First, the issues that will be discussed at this hearing, while technical in nature, serve to assist the Safety Board in developing additional factual information that will be analyzed for the purpose of determining the probable cause of the accident. Second, this hearing also provides an opportunity for the aviation community, and the public, to see a portion of the total investigative process. This transparency reinforces our role as an independent agency accountable to the traveling public and provides an opportunity for citizens to view the efforts being put forth by investigators to determine the cause of this accident.
I want to assure the families of the crew that the Safety Board will pursue every lead toward an ultimate solution to what caused this accident. We will also fulfill our broader mandate to determine the cause of this accident and formulate recommendations to prevent such tragedies in the future on behalf of the millions of aviation passengers in the United States and around the world.
Public hearings such as this are exercises in accountability:
- accountability on the part of the Safety Board that it is conducting a thorough and fair investigation;
- accountability on the part of the FAA that it is adequately regulating the industry;
- accountability on the part of the airline that it is operating safely;
- accountability on the part of manufacturers as to the design and performance of their products;
- accountability on the part of the work force -- including pilots and mechanics -- that they are performing up to the high standards of professionalism expected of them.
The purpose of this inquiry is not to determine the rights or liability of private parties, and matters dealing with such rights or liability will be excluded from these proceedings.
Over the course of this hearing, we will continue to collect information that will assist the Safety Board in its examination of safety issues arising from this accident. Specifically, we will concentrate on the following issues:
- Aircraft and Engine Certification
- Operator and FAA Oversight of Flight Operations and Crew Training
At this point, I would like to introduce the Safety Board staff and other participants in the Public Hearing. I'll begin with the other members of the Board of Inquiry.
Mr. John Delisi, Chief of Major Aviation Accident Investigations
Mr. Tom Haueter, Deputy Director of the Office of Aviation Safety
Dr. Vern Ellingstad, Director of the Office of Research and Engineering.
Mr. William English of the Office of Aviation Safety will serve as the Hearing Officer.
Next we have a Technical Panel consisting of the following Safety Board staff:
Dr. Daniel Bower, Aircraft Performance Group Chairman
Dr. Evan Byrne, Human Factors Group Chairman
Capt. Dave Kirchgessener, Operational Factors Group Chairman
Ms. Lorenda Ward, Investigator in Charge
Mr. Robert Swaim, Systems Group Chairman
Ms. Carol Horgan, Powerplants Group Chairman
Ms. Dana Schulze, System Safety Group Chairman
Mr. Joe Jackson, Accredited Representative, Transportation Safety Board of Canada
Mr. Terry Williams from the Safety Board's Public Affairs Office are here to assist members of the news media.
Mr. Erik Grosof from the Office of Transportation Disaster Assistance is here to assist any family members in the audience.
Ms. Karen Stein is the report writer and Ms. Jennifer Bishop is the Chief of Writing and Editing, both are from the Office of Aviation Safety.
Ms. Carolyn Dargan, Ms. Eunice Bellinger and Ms. Jennifer Barnes are present to provide administrative support as needed. They will also be providing copies of exhibits to the witnesses. Ms. Shavonne Reed is assisting with the display of the exhibits.
In addition, Mr. Brad Vardy, from Transport Canada, will be observing the hearing.
Finally, I am joined by Ms. Nancy Lewis who is my Special Assistant.
The Safety Board's rules provide for the designation of parties to a public hearing. In accordance with these rules, those persons, governmental agencies, companies, and associations whose participation in the hearing is deemed necessary in the public interest and whose special knowledge will contribute to the development of pertinent evidence are designated as parties. The parties assisting the Safety Board in this hearing have been designated in accordance with these rules.
As I call the name of each party, would the designated spokesperson please give his or her name, title, and affiliation for the record:
Federal Aviation Administration - Mr. Dan Diggins
Pinnacle Airlines - Mr. Michael Crook
Bombardier Aerospace - Mr. James Donnelly
Air Line Pilots Association - Mr. Lindsay Fenwick
General Electric Engines - Mr. Paul Mingler
Honeywell - Mr. Michael Cummins
While on scene we received excellent support from the Jefferson City Police Department, they secured the accident scene and assisted us in establishing a command center. I would like to take the opportunity to thank publicly all of the other private, municipal, county, state and federal agencies that have supported the Safety Board throughout the investigation.
On June 2, 2005, the Board of Inquiry held a prehearing conference. It was attended by the Safety Board's Technical Panel and representatives of the parties to this hearing. During that conference, the areas of inquiry and the scope of the issues to be explored at this hearing were delineated and the selection of the witnesses to testify on these issues was finalized.
Copies of the witness list developed at the prehearing conference are available in the foyer. There are numerous exhibits that will be used in this proceeding. Copies of the exhibits may be ordered through our Public Inquiries Branch at 202-314-6551, and can be found on the Board's web site, www.ntsb.gov.
The witnesses testifying at this hearing have been selected because of their ability to provide the best available information on the issues of aviation safety pertinent to this accident investigation.
These proceedings tend to become highly technical affairs because aviation issues can be complex and multi-layered. Neither I nor any other Safety Board personnel will attempt, during this hearing, to analyze the testimony received nor will any attempt be made at this time to determine the probable cause of the accident. I would also like to caution to parties to refrain from making such analyses and cause determinations during the hearing. I will limit such discussions if we begin to venture into those areas.
The hearing is intended to establish a record, as is defined by our rules, analyses and cause determinations will be made by the full Safety Board after consideration of all of the evidence gathered during our investigation. The final report on the accident, reflecting the Safety Board's analyses and probable cause determinations, will be considered for adoption by the full Board at a public meeting here at the Safety Board's headquarters at a later date.
The Investigator in Charge of the accident investigation will summarize certain facts about the accident and the investigative activities that have taken place to date. Following this, the first witness will be called.
The witnesses will be questioned first by the Board's Technical Panel, then by the designated spokesperson for each party to the hearing, finally followed by the Board of Inquiry.
As Chairman of the Board of Inquiry, I will be responsible for the conduct of the hearing. I will make all rulings on the admissibility of evidence, and all such rulings will be final.
The record of the investigation including the transcript of the hearing and all exhibits entered into the record will become part of the Safety Board's public docket on this accident and will be available for inspection at the Board's Washington office. Anyone wanting to purchase the transcript, including parties to the investigation, should contact the court reporter directly.
As I mentioned earlier, the purpose of the hearing today is to find out what happened and why it happened. Our work at the NTSB is to promote transportation safety by analyzing accident causes and finding ways to prevent future accidents. We are not here to malign anyone, for actions taken or not taken leading up to the accident. Our sole purpose today is learn what we can from this accident and begin developing recommendations for changes-whether mechanical, operational or behavioral-that will improve aviation safety in the future.
Ms. Ward are you ready to summarize the investigation and enter the exhibits into the public docket? Please take the witness stand and proceed.