Good morning. Welcome to the Boardroom of the National Transportation Safety Board. I am Debbie Hersman, and it is my privilege to serve as Chairman of the National Transportation Safety Board. Joining me are my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind, and Member Earl Weener. Today we meet in open session, as required by the Government in Sunshine Act, to consider two aviation accident reports.
We begin with the accident report on the August 9, 2010, single-engine de Havilland Otter that crashed near Aleknagik, Alaska.
On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the families and friends of those who lost their lives and to those who were injured in this accident. Many of you are in the Boardroom today, and some are watching via webcast. We recognize that your lives were forever changed when the crash occurred, and we know that nothing can replace the loss of your loved one or repair the trauma of a life-changing injury.
Over the past several weeks, the Board Members have read the proposed report and individually met with staff to discuss it. Today, however, is the first time that all of the Board members are meeting together to discuss it.
Staff will make presentations on the major issues of the accident investigation. The presentations will be followed by a round of questions from the Board Members. We will then consider the conclusions, probable cause determination and proposed safety recommendations. Because these are the Board's actual deliberations on the report, it may be revised as a result of actions taken during this meeting. Approximately 30 minutes after we conclude, an abstract of this report will be posted on the NTSB's website.
I'd like to express the Safety Board's gratitude to the many groups and individuals who helped in the hours and days immediately after the accident and who assisted the Board in the investigation. There are many to acknowledge, including the Dillingham Flight Service Station for their response and assistance, Dr. Dani Bowman and the emergency responders who made it to the accident site the night of the crash, the United States Coast Guard and the Alaska Air National Guard teams who evacuated the victims and survivors from the crash site the following day, and the Armed Forces Institute of Pathology that assisted our investigation by performing an autopsy on the pilot.
Alaska, our nation's last frontier, is larger than Texas, California, and Montana combined. Its width: greater than the distance between New York and Los Angeles. More than 80 percent of Alaska's communities, including the state capital, are not connected to highways or road systems. The state's sheer size and the absence of surface transportation heighten the importance of aviation.
Alaska has six times as many pilots per capita as the lower 48. Yet, while aviation, especially general aviation, is a big part of life in Alaska, the risks of flying in Alaska are greater than in the continental U.S. There is unforgiving terrain — 39 mountain ranges with high peaks and deep gorges, and more than 100,000 glaciers. Then, there's the challenging and rapidly changing weather conditions. Lastly, there are the uncontrolled airports, dirt strips, lakes and rivers that serve as regular landing spots.
Perhaps no one understood Alaska aviation better than the former World War II pilot and former U.S. Senator Ted Stevens, who had survived a 1978 Anchorage plane crash. Nor was anyone a more passionate and effective advocate for Alaska than Ted Stevens. From his position, and with the help of capable and dedicated staff members, including Bill Phillips, Jim Morhard, and Sean O'Keefe, their work over the years made immense contributions to Alaska. He provided the funding for Anchorage's largest commercial airport — now Ted Stevens International Airport – and was an early champion of the Medallion Foundation, Capstone and ADS-B projects. He secured support for aviation safety projects such as improving rural airport lighting and installing weather cameras all around the state. For Senator Stevens and his staffers, their collective legacy is a better connected and safer aviation system in Alaska.
By statute, the NTSB investigates every aviation accident. We investigate more than 1,500 general aviation accidents annually, including about 100 each year in Alaska. Although 100 accidents per year is too many, that number is down from about 180 accidents per year in the 1990s.
Today's discussions are difficult because aviation in Alaska is safer today than it was in the past, due to the efforts of many of the people on the airplane, including the accident pilot who was known by his fellow Alaska Airline pilots as the "Legend of Alaska" and who dedicated much of his life, professionally and personally, to aviation safety efforts in Alaska. But we are here today to understand, in spite of all of that experience, how this accident might have been prevented.
On August 10th of last year, I accompanied our team, led by Alaska-based Investigator-in-Charge Clint Johnson, to Dillingham. Clint, and fellow Alaska investigators Larry Lewis and Jim LaBelle, all have extensive Alaska general aviation experience. They know firsthand the challenges of investigating accidents in the field without the benefit of recorders, radar data, and witness information.
After nine months of exhaustive investigation, numerous consultations, and a host of expert opinions, here is what we know:
We know the airplane, a de Havilland turbine Otter floatplane, was equipped with state-of-the-art avionics to assist with navigation, situational awareness, and terrain avoidance.
We know that the pilot was highly experienced, from a flying family, and familiar with the route and the local terrain. And, days earlier, he had lost his son-in-law in an aviation accident in Alaska.
We also know that the pilot's medical history included a 2006 stroke … and that in 2008 and 2009 he was issued a first-class medical certificate.
We know that minutes prior to the crash, the last position report showed the plane on course.
What we do not know — and may never know – is what happened in the last three minutes of that fatal flight.
Reconstructing accidents is not easy. But, with many of the accidents we investigate, our team — and all of the parties — benefit when there is a greater wealth of data. Unfortunately, there was no flight data recorder on this airplane. With a simple recorder, such as this unit, our investigative team could have learned much more, even from just 15 parameters, and gotten more information about what happened on the accident flight.
While modern recorders can tell us much about the airplane's speed, altitude and attitude, we don't have an event recorder for the human body. After three autopsies, there were no read outs that explain why decisions were made, why actions were taken, or why they were not taken.
The human will always — always — be more complicated than any machine.
To gain insight into human performance in those fateful last three minutes, we extensively examined the pilot's medical records, interviewed family and colleagues for a 72-hour history to establish his rest schedule, and evaluated his experience flying in Alaska, flying floatplanes, and flying in the area of the Muklung Hills. Multiple autopsies were performed and experts were consulted.
Based on what we learned, our team developed theories. Theories were argued. And argued some more.
Our charge is to conduct thorough and objective accident investigations. The evidence and the facts must guide us to our findings.
Today we will hear about the evidence and facts collected over the last nine months.
Now, one final comment. As part of our investigative process, we sometimes delve into subjects that are sensitive. While our discussions today may touch on some of those issues, our purpose in doing so is solely to better understand the circumstances of the accident.
Dr. Mayer, will you please introduce the staff.