Closing Remarks before the Airline Pilots Association International Air Safety Forum

Remarks as prepared for delivery

​It’s February 4th, 2023. About 6:30 am.

FedEx flight 1432, a Boeing 767, is enroute from Memphis to Austin. It’s the first planned arrival at Austin that day. Besides the Captain and First Officer, there’s one other person on board: an off-duty FedEx pilot in the jump seat.

It’s dark. There’s dense, freezing fog and visibility is about an eighth of a mile.

At 6:34 am, the crew contacts the local controller at Austin to report they’re on a CAT III approach to runway 18L.

The controller clears FedEx to land. They acknowledge.​

For those who aren’t pilots, on a CAT III approach, the crew only needs to focus on what’s going on inside the cockpit, on the instruments; they don’t need to look outside the airplane to land.

It would be unusual to do that. 

They don’t even need to be able to see the runway; they can’t anyway because of low visibility. 

And they can’t make out the runway lights. The First Officer can only see a “glow through the fog.”

About three minutes later, the crew lowers the landing gear to its down-and-locked position.

Two minutes pass. The FedEx crew is just about four miles from the runway when they hear: Tower, Southwest 708. We’re short of 18L. We’re ready. 

The controller clears Southwest for takeoff, adding: Traffic 3-mile final is a heavy 767. 

The Southwest crew responds: Cleared for takeoff, 18L. Copy the traffic.

On hearing this, the FedEx Captain and First Officer look at each other. 

Referring to the controller, the Captain remarks, “What’s he doing?” 

He then asks the First Officer to contact the tower to confirm their clearance. 

A few seconds later: That’s affirmative: 18L, you are cleared to land. Traffic departing prior to your arrival is a 737. 

The FedEx crew acknowledges; they’re two miles out. Their altitude is 650 feet above ground level and descending. 

Thirty seconds later, when they’re less than a mile out on final, the FedEx crew hears the controller ask Southwest to confirm they’re “on the roll.” 

Southwest replies: Rollin’ now. 

The word “now” alarms both FedEx crew, whose altitude is now just 300 feet. 

The FedEx First Officer becomes increasingly concerned about the location of Southwest 708, especially because he thinks they sound “strained” on the radio. 

Instinctively, he starts looking outside more frequently than he normally would on a CAT III approach. 

He’s “glancing in, glancing out.” 

At 150 feet, he sees “a white light that did not match the runway lighting.” It quickly morphs into a “silhouette of the left wing of the Southwest airplane.”

He immediately calls for a go-around three times. 

Go around. Go around. Go around. 

The Captain never hesitates. He does exactly what the First Officer calls for.

Knowing that Southwest is rolling down the runway, the FedEx First Officer radios: Southwest abort. 

Three seconds later: FedEx is on the go.

Another three seconds pass: The separation between FedEx 1432 and Southwest 708 is just 160 feet.

That’s less than the length of the FedEx plane, which, recall, is a 767.

After another 10 seconds, the controller responds to FedEx’s “abort,” instructing Southwest to “turn right when able.” 

Why? Because the controller thinks Southwest is still on the runway.

In reality, Southwest’s main gear is lifting off the runway. 

The FedEx crew continues to climb, and Southwest continues to accelerate, both of which increase separation.

Also important are the actions of the Southwest First Officer to decrease the 737’s rate of climb in response to the traffic advisory — something he credits to his military training.

FedEx 1432 circles left and lands on runway 18L without further incident. Southwest 708 continues to Cancún. 

Eleven days later, the FedEx Captain told us he thought the First Officer “did a phenomenal job,” adding: “I'm thankful for him and I can't say enough good things about him and the job he did that day.” 

The First Officer’s account: 

​When I said go around, go around, go around, [the Captain] didn't hesitate, he immediately did it and that’s exactly the way it's trained and talked about in all of our refresher and recurrent trainings that I've been through. And he didn't ask why until we were already climbing away from the ground. So I want to credit that, as well. So it's not just me, there were two of us there and it made a difference.

 ​There were two of us there and it made a difference. 

From our final report: “The quick reaction of the FedEx First Officer after seeing the Southwest airplane and the quick response of the FedEx Captain in performing a missed- approach avoided a potential runway collision.”​

In other words, two experienced and well-trained pilots in the cockpit on that dark, foggy February morning saved 131 lives: two flight crewmembers, three cabin crewmembers, and 123 passengers on Southwest flight 708; and all three FedEx pilots on flight 1432. 

Capt. Carvajal and First Officer Bradeen, I want to commend you for your truly heroic actions that day and for your professionalism. Congratulations in advance for being recognized this evening with ALPA’s Superior Airmanship Award, as is First Officer Emily Wiprud, who was in the right seat on Alaska Airlines flight 1282. 

I also want to thank Capt. Ambrosi and Capt. Morse for your exemplary safety leadership and for having me here this afternoon.

And, on behalf of the entire agency, I want to thank every ALPA member for all you’ve done — and continue to do — to strengthen aviation safety.

For years, you’ve sounded the alarm on the safety consequences of not having two highly qualified pilots on the flight deck. 

Fortunately, it’s the “law of the land,” to quote Mike Whitaker, and, as the Austin incident clearly demonstrates, it saves lives. 

Even so, some want to change it, pointing to incidents that weren’t prevented with two pilots in the cockpit. 

To them I say: Imagine how much worse that incident could’ve been — would’ve been — with just one pilot.

Redundancy is at the heart of aviation’s stellar safety record. 

We’d never decrease the redundancy...the safety net...of equipment and systems that pressurize the cabin and provide emergency oxygen...power, steer, and land the airplane...extinguish an on-board fire. 

We build in redundancy because we know that relying on a single point of failure is unacceptable. An unacceptable risk to crewmembers and the flying public. 

The number of qualified crewmembers on the flight deck should be no different. 

Safety isn’t just the responsibility of flight crews. All of us here have a collective responsibility to ensure safety. 

To ensure passenger safety. 

To ensure worker safety. 

To support airlines and manufacturers in their pursuit of safety — even when they’re struggling...especially when they’re struggling.

To protect people. 

That collective responsibility includes the regulator, the FAA. 

Like ALPA, we’ve long disagreed with the FAA’s decision to carve-out cargo pilots from stronger flight and duty-time regulations. 

Fatigue doesn’t discriminate.

Fatigue doesn’t care if you’re transporting people or transporting goods — often lifesaving goods, like medical supplies, medical devices, and vaccines, in the worst of times, the most critical of times.

In fact, we know the need for adequate rest is even greater for cargo pilots because of the time cargo operations usually occur — in the pre-dawn hours during the window of circadian low. 

Think of FedEx 1432.

What you didn’t see in the probable cause — because it wasn’t causal to this incident but is still critical when it comes to safety — is that we determined the flight crew wasn’t well rested. 

Hugo got just three hours of sleep. Rob only had 20 minutes more than that. 

They deserve better protections — and so does every cargo pilot flying today. 

I hope the FAA and FedEx take that seriously and address it now, before an accident occurs. 

Three decades ago, in 1994, we recommended that the FAA update flight/duty time regulations and incorporate the results of the latest research on fatigue and sleep issues.

A year later, on February 16, 1995, a ferry flight operated by Air Transport International was destroyed by ground impact and fire during an attempted takeoff at Kansas City International. 

All three flight crewmembers were killed. All three were fatigued. 

Again, we found that the FAA’s flight/duty time regulations were inadequate, and again we recommended that the FAA revise them within one year. 

That was in 1995.

It wasn’t until 50 people died on Colgan Air flight 3407 that we saw movement when Congress weighed in and required the FAA to take action to address fatigue.

A working group was formed; they developed recommendations to strengthen standards for both passenger and cargo pilots. 

Those recommendations were incorporated into the Notice of Proposed Rulemaking, but — in 2012 — when the final rule was issued, we were shocked to learn that cargo pilots were excluded. 

The final rule was a huge safety win for pilots on passenger planes, but a significant loss for cargo pilots who remain...to this day...under the same rules that the NTSB has begged the FAA to update for nearly three decades. 

I continue to hear that “cost” is the issue. 

The message that sends… and I want to be clear about this…the message that sends to cargo pilots is that their lives are expendable — that their lives are somehow less valuable, less meaningful than the lives of passenger pilots.

That’s the message. 

At the NTSB, we think your lives are priceless. 

In 2013, we sent a letter to the FAA expressing our concerns about the cargo carveout. 

Two weeks later, UPS flight 1354 crashed in Birmingham, Alabama. The Captain and First Officer were killed. Both were fatigued.

Despite that, FAA’s rule went into effect just five months later with the cargo carveout intact. 

There’s been no movement since.

Now, every time I bring up the cargo carveout, someone pulls me aside to highlight the benefits of fatigue management plans, which were also required in the 2010 Act. 

We support fatigue management plans, but not in lieu of safety standards. 

I’ll also hear about all the great things industry and labor have done on fatigue through collective bargaining, sometimes exceeding federal regulations, which I applaud...encourage. 

But not everyone is covered by a collective bargaining agreement.

And, frankly, you shouldn’t need a collective bargaining agreement to be safe! 

 Collective bargaining agreements are for wages and working conditions. They are not for safety. They should not be. 

Because what that means is that the union somewhere in negotiations was faced with an untenable choice: better pay or ensuring workers get home safely to their families…better pay or safety.

Safety is not negotiable. 

Safety is not negotiable.

After 27 years — 27 years — the FAA told us in a letter that it had no plans to address the cargo carveout. So, we closed the recommendation unacceptable.

I hope the FAA reconsiders. Please reconsider because we remain deeply concerned that fatigue will continue to be a safety issue in our investigations of cargo accidents and incidents going forward. 

I know you’re concerned as well. Thank you for your continual calls for action on this issue. Don’t stop. 

I’m not. 

We owe it to those who lost their lives. We owe it to their families. We owe it to all those pilots in the cockpit now and their families. We owe it to future generations...kids...who want to be pilots, and their families. 

That’s why we can’t stop. 

Let’s turn to runway safety technology. 

We found that the lack of critical safety technology contributed to the near collision at Austin. 

In other words, surface-detection equipment would’ve made a difference. It would’ve prevented it. 

Instead, there was no redundancy to back up the controller, who couldn’t see the runway or Southwest 708 through the dense fog. 

But there was redundancy for American Airlines flight 106 and Delta Air Lines flight 1943. On January 13, 2023, the two planes came within 1,400 feet of one another at JFK, endangering the lives of 308 people on board. 

But, unlike Austin, JFK IS equipped with ASDE-X. 

We determined that ASDE-X prevented that runway incursion from becoming an accident — an accident that would’ve had disastrous consequences. 

While FAA is no longer installing ASDE-X, we’re pleased they’re investing in new technology to improve situational awareness for air traffic controllers. 

I’m also happy to report that Austin is among the first airports that will get it. 

But we can’t stop there. 

It took the JFK controller five seconds from the time he received the alert to cancel Delta’s take-off clearance.

Every second matters when it comes to safety. Every second.

And what if he didn’t act within seconds? It’s happened before.

That’s why, for 24 years, we’ve also recommended that the FAA require the industry to install technology in the cockpit that directly warns flight crews of traffic on a runway or taxiway and traffic on approach to land.

Why? Again, to provide you with redundancy so you’re not forced to rely on the controller...to look out the window in poor visibility…to glance in, glance out. 

The FAA has had well over two decades to act... but hasn’t, which is why these recommendations are classified as “open, unacceptable.” 

Austin and JFK are just two recent examples, but they’re not the only close calls we’re looking at.

We’re currently investigating eight other runway incursions, three runway excursions, one runway collision, and, as of this week, one ground collision. 

​Last summer, we issued reports into two wrong-surface landings: one in Tulsa and one in Pittsburgh. 

If we’re serious about improving runway safety, we must provide pilots with improved situational awareness. 

I’ve talked a lot today about what you need and deserve. What passengers need and deserve. 

Unfortunately, what you deserve doesn’t just “happen.” 

That’s where you come in. 

Over the past couple of weeks, I’ve been reflecting on the tremendous power of unions...a lot of that thinking came over the Labor Day weekend, but not because it was Labor Day. 

I spent the long weekend with the families of 34 people who died on September 2, 2019; it was Labor Day. 

At 3 am, a fire broke out onboard the small passenger vessel, the Conception, off the coast of California. It was a dive boat excursion. 

Everyone was asleep. Five crewmembers were asleep in the wheelhouse above the main deck. Thirty-three passengers and one crewmember were below deck in the bunkroom.

We know from evidence that some in the bunkroom woke up and tried to escape. But the main exit and the emergency exit — if they even knew where it was —ended up in the same location: the main deck, where the fire was raging.

Even if they weren’t in the same location, the emergency exit was difficult to find. It was accessible only by climbing up three bunks, finding a wooden panel, and maneuvering through a 22-inch square opening. 

This remains the worst marine disaster in terms of lives lost in NTSB’s investigative history. I was the Board Member on scene; it was before I was Chair. 

And I will never forget briefing the families in the Family Assistance Center. 

Earlier that day, I boarded the Vision, the other small passenger vessel owned by Truth Aquatics, which also owned the Conception

I looked at the layout of the bunkroom. Turned the lights off. Tried to locate the escape hatch. Even with no smoke, it was nearly impossible for me to locate...and I knew where to look. 

Once we found it, it was tough to open and get through the hatch. 

The families knew I had visited the Vision. So during the briefing, a man stood up and asked: Could our loved ones have gotten out?

I had to say no. 

No one...no mother, father, sister, brother, son, or daughter should ever have to hear that. It was heartbreaking. 

It’s been five years. The U.S. Coast Guard has done some work to address our recommendations, which we appreciate. 

But the families and I spent the anniversary of this tragedy calling on the Coast Guard to require passenger vessel operators to implement a safety management system, something the NTSB has been fighting for for decades. 

These families have been bravely fighting for change...to implement NTSB recommendations...so no one ever, ever, has to experience the loss they’ve endured. 

And they’re doing it alone. They’ve done an amazing job. But it’s an uphill battle. 

It’s bad enough to lose someone you love. Now imagine the pain of also feeling completely powerless to affect change. Having no one else, other than the NTSB, fighting alongside you. 

Labor knows the power of speaking with one voice. And when I say “power,” here’s what I mean. 

The power to move the needle when the regulator can’t or won’t. 

The power to fight for better, more just, and, yes, safer working conditions. 

And when I say “safer,” I mean for everyone. 

Safer for those soaring through our skies, professionally or for pleasure. 

Safer for those living, working, and playing here at ground level. 

That is our shared vision. 

That is what ALPA and NTSB are working so diligently to achieve. 

That is why, following the near collision at Austin, representatives from your Critical Incident Response Program were there to offer Hugo and Rob support. 

Just as they’re there for every member who needs help. 

That is what labor does: you show up for one another. 

And, through your peer-support program, you’re showing up for the whole person...living your long-held belief that mental health is health, period. 

But you’re not just helping one another as individuals. You’re leading the entire industry, helping us “move forward together” on mental health.

To that end, I want to recognize Capt. Travis Ludwig, who represented ALPA as co-chair of the recent FAA Aviation Rulemaking Committee (ARC) on Mental Health and Aviation Medical Clearances. 

We had observer status on the ARC, so we know that Travis played an important role in helping the committee understand the airline pilot’s perspective — not to mention helping the committee issue a final report in three short months!​

That report echoes many of the recommendations ALPA has been making for a long time, which Travis brought to the NTSB’s mental health roundtable that I hosted last winter. 

Addressing stigma. 

Removing barriers that prevent people from seeking help: Commercial pilots. GA pilots. Student pilots, who often don’t have peer-support programs to turn to. Kids who dream of a life or career in aviation. Air traffic controllers. FAA inspectors. Ramp workers. 

Making sure those who do seek treatment aren’t punished by a broken bureaucracy with long, costly, invasive, and often unnecessary delays. 

Thank you, Travis, for being a champion for mental health. 

Clearly, this is an area I’m passionate about. I am because there isn’t a single one of us here who hasn’t faced a difficulty in life: Divorce. Loss of a loved one. Financial stress. Work stress. Aging parents. Parenthood.

You should be able to go see a counselor without reporting that to FAA, which was one of the ARC’s recommendations.

All too often, pilots are faced with a choice that no one should have to make: their lives, or their livelihoods. 

The next generation...my daughter’s generation...they’re not going to accept the status quo. 

And they shouldn’t have to. 

In March, the ARC finished its work. They evaluated the barriers that pilots and controllers face when confronting mental health challenges and issued 24 recommendations, all of which must be implemented to fully overcome those barriers. Now we need action on those recommendations. 

What we don’t need is another report that sits on a shelf. 

So we must continue to fight for change. 

Together. 

Two qualified pilots. 

Adequate rest requirements for all. 

Transforming our industry’s approach to mental health. 

Fighting to implement life-saving technologies and ensuring new technologies do what they’re supposed to, which is to supplement trained aviation professionals, not supplant their expertise and judgement. 

ALPA has been at the center of each of these safety issues, and far too many more to name. 

I’ll leave you with this: I am with you. I am with you.

The NTSB is with you. 

And we are not — we are not — going back on safety.

We’re not.

We’re not going back to February 12, 2009, when inadequate pilot training and fatigue contributed to the tragedy of Colgan Air flight 3407, which crashed into a residence on approach to Buffalo-Niagara International Airport, killing 50 people. 

We’re not going back to May 11, 1996, when ValuJet flight 592 crashed in the Florida Everglades because a shipper improperly prepared, packaged, labeled, and transported hazmat that caused a fire in the cargo compartment, killing all 110 people onboard. 

We’re not going back to January 13, 1982, when icing caused Air Florida flight 90 to crash into the 14th Street Bridge, just five miles from here. The crash killed 73 of the 79 people onboard the plane and four people in cars on the bridge.

We’re not going back to December 1, 1974, when there were two fatal crashes involving Boeing 727s. 

The first was a ferry flight that crashed north of New York City, killing all 3 crewmembers. 

The other was TWA flight 514, which crashed in the Blue Ridge Mountains on final approach to Dulles, killing all 92 passengers and crew onboard. Confusing air traffic terminology contributed to the crash. 

In December, I’m speaking at the memorial ceremony marking the 50th anniversary of the TWA flight 514 tragedy. 

We remember so we don‘t forget those we lost. 

We remember so we don’t forget those we lost...so we learn from the past... so we don’t turn back the clock on safety. 

In the areas where we’ve made safety advances, we’re going to hold our ground. 

Because you know and I know those advances didn’t come for free.

The cost was decades of struggle. Thousands of safety investigations into accidents and incidents in every corner of the world.

Safety improvements we’ve gleaned by working together in the wake of far, far too many tragedies.

Improvements that came at a high cost: thousands of lives lost. 

Family members...friends... colleagues...and saying, together, enough.

Enough. 

These safety gains have come from embracing zero as the ONLY acceptable number of fatalities and injuries across our aviation system — across our entire transportation system. 

We are NOT going back on safety.

You will not let that happen.

We won’t let that happen.

Instead, we’re going to keep moving forward...forward...together.

We’re moving forward together on safety, arm in arm, in a show of unity and solidarity that binds us. 

Solidarity — not just with those who carry the same union card we do, but workers everywhere.

I’m talking about our brothers and sisters across the labor movement. Workers fighting to exercise their collective bargaining rights. About workers not yet in a union and who may never be.

I’m talking about those who came before us — especially those who gave their life fighting for a better, safer future for all of us. 

We’re all fighting for someone, or several “someones.” 

For me, one of those people is my grandfather. He worked at Fafnir Bearing Company in New Britain, Connecticut. For 41 years, he worked on machines that made roller bearings used in aviation, automobiles, you name it. He was a proud member of UAW Local 133 and, in his “spare time,” he delivered home heating oil, fixed air conditioners, and was a volunteer firefighter.

My grandmother worked in an elementary school cafeteria. She didn’t have a union — we can’t all be perfect!

But I was a union member. I was a proud member of Teamsters Local 70. Labor’s in my DNA. And, I suppose you could argue, so is aviation. 

That’s why I know the reason we’re not going back...THE reason we’re going to keep moving forward together on safety...is in large part thanks to unions like ALPA. 

But we can’t do it alone. 

We need all of labor...all of industry...manufacturers...the GA pilot community...victim advocates...academia...researchers...students...the FAA...and the NTSB... all working together to improve safety. 

Together. 

Together. 

That’s the ONLY way — as we look towards this post-COVID world, where we’re seeing enormous change and, yes, strain — the ONLY way we remain the world’s gold standard for safety. 

That is how we keep from going back.

That is how we keep saving lives.

That is how we get to zero for decades to come. 

Together.

Thank you.

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