Remarks by Mark V. Rosenker, Chairman
National Transportation Safety Board, U.S.A.
SAFESKIES CONFERENCE
Aviation Safety Issues
Canberra, Australia
November 1, 2007

Good afternoon Ladies and Gentlemen. I would like start by thanking the organizers of the SAFE SKIES CONFERENCE and the staff at the ATSB for that outstanding lunch -- and also for the invitation and opportunity to be with you here today. It is always a pleasure to visit Australia and particularly to be among friends and professionals dedicated to aviation safety. I hope I can live up to at least a portion of all those nice things that Kym Bills has mentioned in that very generous introduction.

I note the program topic – “The NTSB’s Top Ten Aviation Safety Issues”. I can assure you that I’m not going to try and transpose our top ten in the USA to your top ten issues here down under. In fact it’s not my intention to spend our time together today trying to quantify and list issues. Why? – Because, in reality one could say EVERY Safety Issue is important. We should note we have developed a very safe air transportation industry. Consider for a moment the number of travelers - or the number of departures - that take place around the world every day. More than 2 billion passengers traveled by commercial air transportation in 2006. However- Any accident - is one too many, and it is certainly our mandate as aviation safety professionals to attempt to identify and focus on mitigating risks; in order to minimize loss of life and personal injury, and to further improve the safety record in the air transportation sector.

So, having noted the positive safety progress of the air transportation industry – and having said every safety issue is important, we should recognize there are priorities requiring very specific and immediate attention. An example of this recently occurred in August this year when the left wing of a Boeing 737 operated by China Airlines burst into flames as it was parking on the ramp in Okinawa, Japan. Perhaps you saw the news video of this accident replayed on your television. Fortunately, the ground crew, flight and cabin crew, and the passengers themselves - reacted very promptly and were able to escape the burning aircraft without major injury. In this investigation, a mechanical deficiency was revealed in the wing slat track mechanism, which allowed it to by-pass the stop and puncture the fuel tank as the slats were being retracted after landing. More importantly, the investigation led by the Aircraft and Railway Investigation Commission of Japan, supported by teams from the US NTSB and the Taiwan ASC, were able to rapidly identify the deficiency and the corrective action was transmitted to industry-wide users in the form of an FAA Airworthiness Directive within 4 days following the event. Over 20 other aircraft were identified with potential attach hardware failures that could have resulted in puncturing the fuel tank.

I’m sure many of you are aware of the NTSB’s “Most Wanted” list of Transportation Safety Improvements. It is well documented on the Board’s web site at www.ntsb.gov, for those of you that are interested. Since the list’s initiation in 1990, various subjects have been added and removed over the years as advances have been made – but the frustrating fact remains, issues such as runway incursions, ground collisions, in-flight icing conditions, improved flight recorders/video image recorders and human fatigue issues continue to await meaningful improvements even though they have been areas of emphasis for more than a decade. Just imagine if today’s industry experienced a runway collision that was in any way similar to the tragedy of the 1977 PanAm/KLM Tenerife collision between two wide body airplanes – in which 583 persons lost their lives that day.

What we have to do now is maintain our momentum for an ever-increasing level of aviation safety; which is going to take further initiatives and energies – an intense safety management initiative, and a more involved role by all of the effected parties - industry, operators and governments.

As the air transportation industry moves to adopt the Safety Management Systems (SMS) approach, the world recognizes Australia as an early leader in its concepts and implementation. We note the Civil Aviation Safety Authority (CASA) Civil Aviation Order 82 regarding SMS has existed since 2002. I recently read an insightful comment from CASA CEO Bruce Byron in the CASA Newsletter of September 2007. He stated, “Risk management is at the center of aviation safety”. He made that point as he addressed the challenge of the future -- collecting, managing, and analyzing the increasing amounts of data and transforming that data into an actionable product. I certainly agree that risk management is a key component - literally the lynch pin to more effective accident prevention programs.

So how do we continue with SMS to develop a strategic plan and allocate resources to take advantage of technological advances? I must return to my earlier point regarding management initiative and commitment. Senior corporate managers and government leaders need to focus on the task of developing the predictive aspects of SMS. This concept sets SMS apart from traditional safety programs. Executives with the responsibility for human and financial assets have the ability to direct those resources toward risk assessment and avoidance. It is a long term commitment –and the short term benefits may not be immediately evident. I recognize that any time we re-direct resources away from a production role, a training captain, maintenance or ramp supervisor, it makes it more difficult to get the job done. On the other hand, when strong safety policies are developed by the persons directly involved, and communicated from management to the working parts of the organization, it bears fruit in a safety culture that promotes mitigating risk over the status quo and/or continued exposure to avoidable risk. In the past several years we have had several air transportation accidents involving latent risks that were easily discoverable with risk management techniques.

Very briefly allow me to mention an example of how wrong corporate culture can be detrimental to safety. The NTSB investigated a Northwest Airlink crash near Jefferson City, Missouri in October 2004 involving a Canadair CL-600. This type of regional jet transport is capable of carrying up to 50 passengers. The flight crew was instructed to return the airplane to a mainline station following maintenance. No passengers or cabin crew were aboard. Following the accident we discovered from the flight recorders and other data that the crew performed several semi acrobatic maneuvers upon departure and then climbed to the maximum operational altitude for this airplane, flight level 410 (or 41,000 feet).Upon arriving at this altitude they announced between themselves that they had now joined the “410 Club”. Shortly thereafter, through mismanagement of the airplane pitch attitude and power settings, the airplane approached aerodynamic stall and both engines stopped operating. The crew was unable to restart either engine during the ensuing 16 minute descent - in night conditions – and they delayed informing the air traffic controller of the true nature of their emergency, until 6 minutes before the crash –too late for vectors to a suitable airport. Of course there were many direct operational and mechanical causal factors involved, in addition to the egregious behavior of the flight crew. However, my point in relating this event to you is to emphasize the ever important issue of corporate culture. This accident did not occur in a vacuum-the 410 club had other members, and would be members. One has to ask, “Where was management and oversight” as this corporate entity matured. This accident is a tragic example of the importance of a strong senior management commitment to set the tone of a safety policy and to receive feedback from the operation through the very basic SMS interactions of monitoring and voluntary reporting with line personnel. This company did not collect data on safety performance, so the nature of these internal risks could not be recognized, resulting in an inexcusable accident.

It is appropriate to give equal time to international aviation and some of its inefficiencies that exist in various locales. This past summer I hosted the Director General of Civil Aviation of Indonesia, Mr. Budhi Suyitno.(He preferred I call him “Budhi”). We had a very spirited discussion regarding the Adam Air B737 crash of 1 January 2007, near Sulawesi, Indonesia. The accident resulted in 102 fatalities when the airplane disappeared during a regional flight. When “Budhi” visited me in Washington, DC, the recorders had been sitting at the bottom of the sea in the Makassar Strait for 7 months. Not long after that, 23 lives were lost in Yogyakarta, Indonesia as a result of the Garuda Airlines B737 crash in March 2007. One needs to go back only a matter of months to uncover a startling record of air accidents and serious incidents involving other Indonesian carriers: Mandala Airlines, Lion Air and Merpati.

Where are the ICAO Standards and Recommended Practices when it comes to Indonesia? Where is the obligation of the State to provide oversight to its air carriers when it grants an Air Operator’s Certificate to a local business? Or of the air carrier to provide safe and reliable air transportation to its customers? In August 2007, President of the ICAO Council, Roberto Kobeh Gonzalez declared during an address to the Strategic Aviation Safety Summit in Bali, Indonesia: “There is an urgent need to implement a concrete, realistic, and achievable plan of action”. I believe everyone in this room can fully endorse the words of President Kobeh. Whether we are speaking of ICAO’s Global Aviation Safety Plan, and the industry developed Global Aviation Safety Road Map or we are addressing Australia’s commitment to continue to institute SMS across the aviation industry, we have to address the commitment of the state regulators and the operators to reach the intended safety objectives.

Ladies and gentlemen, it is not yet time to retire all of the accident investigation authorities of the world. Humans are going to continue to make errors– and our investigators at the ATSB and the NTSB, the AAIB and other transportation organizations - will be there to dig into the accident causal factors. SMS will not prevent all accidents: HOWEVER, SMS does present us with an additional opportunity to make a difference – to increase the level of safety in our industry – and, most importantly, to involve all stakeholders in developing and implementing the solution. With SMS, the industry is on its way to finding more efficient methods of safety data collection, and analysis of incident data. It gives us a proactive way to reduce the accident potential – or as we say in SMS terminology -- to avoid or mitigate risks as much as possible-- with the end result of preventing major accidents before they occur.

Am I concerned about the next accident ??– of course I am. But I’m also excited about the opportunities provided by SMS. Recall the PanAm/KLM runway collision!!!. Perhaps the improvements of “Next Gen” ATC may reduce the danger of runway incursions -and it may very well be SMS based –I’m optimistic that Australia, along with you here today, will be a part of this fresh approach as we move toward tomorrow’s advances in aviation safety.
Thank you very much.

Speeches & Testimony