I want to thank my fellow Board members for their participation today.
In closing, I'd like to recognize the staff of the Safety Board who investigated this accident and developed this excellent report; in particular, the staff from the Offices of Aviation Safety, and Research and Engineering. I commend staff for making sure that every stone was turned over in the investigation and for your commitment, day-in and day-out, to improving aviation safety.
This investigation has highlighted what the Safety Board has long known – that standard operating procedures provide an important buffer against errors caused by fatigue, and that good crew resource management translates into a better performing team in the cockpit.
The 14 safety recommendations we have adopted today, if implemented, will go a long way toward improving the safety of Part 135 flights, by:
- providing pilots with adequate guidance and training to better understand the point during the landing sequence when committing to stop – and not a go-around – is the safest option;
- incorporating crew resource management training and standard operating procedures in Part 135 operations;
- creating consistency in pilot checklists so that pilots train like they fly and fly like they train;
- addressing fatigue and sleeps disorders; and
- ensuring that terrain awareness and warning system-equipped aircraft have the most current terrain database.
This is a full plate of recommendations, and I urge the FAA to move promptly to implement them.
There is some good news – the FAA has already taken action to address CRM. The FAA has mandated that, after March 22, 2013, Part 135 operators will be required to provide CRM training. Unfortunately this is a recommendation that is nearly 10 years old and has been on the Safety Board's Most Wanted List of Transportation Improvements for the past 5 years. Although it wasn't in place in time to help this crew work together more efficiently, it can help prevent future accidents by ensuring that flight crews communicate and collaborate on each and every flight.
We at the Safety Board often quote the Spanish philosopher George Santayana, who said: "Those who cannot remember the past are condemned to repeat it." Many of the safety issues identified in this report are not new issues. We've identified them as factors in other accidents and issued recommendations to address them.
The challenge as we move forward is to remember them, and learn from them, so that they are not repeated.