Good morning. Welcome to the National Transportation Safety Board.
I’m Jennifer Homendy and I’m honored to serve as Chair of the NTSB.
With me today are my Board colleagues: Member Michael Graham, Member Tom Chapman, and our two new Board Members: Member Alvin Brown and Member Todd Inman. A special welcome to you both, and — because they work so hard, and this is the first meeting of this full Board — a special welcome to Board Member staff.
Behind me, we have Michelle Barth, Special Assistant to Member Brown. Braxton Coleman, who serves as Member Brown’s Confidential Assistant, is in the audience.
We have Michael Hampton, Special Assistant to Member Graham; Anne Kerins, his Confidential Assistant, is in the audience.
We have Stephen Stadius, my Special Assistant. Kelly Hessler, my Deputy Chief of Staff, is in the audience.
We have Linda McGunigal, Member Chapman’s Confidential Assistant, and — soon — my Confidential Assistant as well. Ivan Cheung, Member Chapman’s Special Assistant, is on leave.
And we have Joe Sedor, Special Assistant-on-detail to Member Inman; Olivia Marcus, his Confidential Assistant, is in the audience.
Today’s meeting is open to the public, in accordance with the Government in the Sunshine Act.
We’re here today to discuss the final investigation report of the runway incursion and overflight involving Southwest Airlines flight 708 and FedEx flight 1432 that occurred on February 4, 2023, at Austin-Bergstrom International Airport in Austin, Texas.
The NTSB investigative team will walk us through the event in detail shortly.
I’d first like to acknowledge that this incident could have been catastrophic, if not for the heroic actions of the FedEx crew.
I am delighted First Officer Rob Bradeen was able to accept my invitation to join us today; Captain Carvajal had a conflict and sends his regrets.
I was honored to meet Rob last August and fly back to D.C. with him from Memphis, where I visited FedEx and its leadership team. Rob is joined today by his colleagues from FedEx and the Air Line Pilots Association.
Rob, please stand.
On behalf of the entire agency, I want to thank you and Captain Carvajal for your professionalism, for your focus inside and outside the aircraft, for your quick actions, and for what I believe to be excellent communications between two qualified crew members in the cockpit and air traffic control. As a result, none of the 131 people onboard both aircraft was injured. Thank you!
But this isn’t the only incident we’re investigating.
The NTSB is currently investigating nine other runway incursions, two runway excursions, and one runway collision.
We recently published final investigation reports on two wrong-surface landings — one in Tulsa and one in Pittsburgh — as well as close-calls in Boston and at JFK.
We released an abstract of the final JFK report just yesterday, so let me say a few words about that event: It endangered the lives of 308 people on two separate aircraft.
Without a doubt, surface-surveillance technology played a huge role in backing up the controller, who reacted promptly to the alerts.
The NTSB first recommended surface-detection equipment for air traffic personnel in 1991, but our support of technology to promote surface safety goes back much, much earlier.
In fact, we’ve been issuing recommendations to prevent runway incursions using technology since 1973.
As you’ll hear later in staff presentations, Austin-Bergstrom International Airport did not have any such technology at the time of the incident.
Whenever we talk about close-calls and near-misses, I can’t help but recall one other serious incident — one that happens to be the first investigation report I deliberated and voted on as an NTSB Member.
On July 7, 2017, Air Canada flight 759 was cleared to land on runway 28R at San Francisco International Airport but instead lined up on a parallel taxiway where four airplanes, which, combined, were carrying over 1,000 people, were awaiting takeoff clearance.
The flight 759 crew initiated a go-around and reached a minimum altitude of about 60 feet, overflying the four airplanes on the taxiway before starting to climb.
Alarming as they are, events like these are rare; commercial aviation is, by far, our safest mode of transportation.
But the somber truth is that it only takes one.
One missed warning…one incorrect response…even one missed opportunity to install lifesaving technology can lead to tragedy, shatter our stellar safety record, and destroy public confidence in our aviation system.
According to the Federal Aviation Administration, there were 23 category A and B runway incursions in 2023, up from 16 in 2022. Already in 2024, there have been 7.
The FAA classifies runway incursions into five categories: categories A through E, with A and B being the most serious.
Category A is reserved for incidents in which a collision was “narrowly avoided.”
Category B incursions are when “separation decreases and there is a significant potential for collision,” which may result in a time-critical corrective or evasive response to avoid a collision.”
Austin was a Category A incident: the most serious of all incursions.
Now, some might say the increase in runway incursions is due to the increase in air traffic over the years. For FY 2023, there were approximately 54.3 million takeoffs and landings in the National Airspace System and a total of 1,760 runway incursions.
The number of runway incursions does fluctuate year to year, which is why it’s also essential to look at the rate at which these events occur.
At the end of FY23, the rate of Category A and B incursions per one million airport operations was at its highest level in over a decade.
Bottom line: We’re trending in the wrong direction.
At the NTSB, our mission goes beyond investigating when something goes wrong. To make our skies safer…to preserve our “gold standard” of aviation safety…we must be proactive.
It’s why we investigate not just aviation accidents, but also incidents. Because we know all-too-well that “the absence of a fatality or an accident doesn’t mean the presence of safety.”
Let me repeat that: The absence of a fatality or an accident doesn’t mean the presence of safety.
We exist to ensure the presence of safety. That is why we’re here.
Our goal is not to place blame. We want to learn from this incident so it never happens again — not in Austin, not in Kansas City, not in Anchorage, not at ANY airport, period.
At the NTSB, we work under what we call “the party system,” meaning we bring together technical experts from those involved in the incident to help us gather and develop the facts around an investigation.
Parties do not participate in the analysis or development of the findings, probable causes, or safety recommendations, but they are critical to helping us obtain information that we need to carry out our vital safety mission.
At the same time, parties get access to information over the course of our investigation in real time, so they don’t have to wait until the conclusion to make safety change.
I’d like to thank the following organizations for their collaboration with us on-scene and their role as parties to our investigation:
- Federal Aviation Administration
- Southwest Airlines
- Federal Express Corporation
- Southwest Airlines Pilots Association
- Air Line Pilots Association, International
- National Air Traffic Controllers Association
- The Boeing Company
- Honeywell Aerospace Technologies
Thank you, all.
Now, turning back to the report…
Each Board Member has studied the draft report and met individually with the investigative team, but this is the first time we’ve gathered as a Board to discuss the report.
In a moment, NTSB staff will present the pertinent facts and analysis and summarize their findings in detail.
After their presentations, Board Members will question staff on the key safety issues uncovered during the investigation. These include:
- Communications between pilots and controllers;
- Airport Surface Detection Equipment and flight deck technology;
- Training on the Surface Movement Guidance and Control System plan and low-visibility operations; and
- The need for 25-hour cockpit voice recorders.
Staff will then propose the relevant findings, probable cause(s), and safety recommendations for Board consideration.
Following the incorporation of any amendments voted on today, the final report will be available on our website in a few weeks; this allows time for staff to make final edits. However, an abstract will be available immediately after the Board meeting.
The public docket for this investigation was released on November 9, 2023, and contains more than 3,500 pages of additional relevant material. It’s available on our website at NTSB.gov.
I’ll now ask Deputy Managing Director for Investigations Brian Curtis to introduce members of the NTSB team participating in today’s meeting; we’ll then go right into staff presentations.
Good morning, Mr. Curtis.
