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Board Meeting: Aircraft Accident Summary Report - Midair Collision Over Hudson River, Piper PA-32R-300, N71MC, and Eurocopter AS350BA, N401LH, Near Hoboken, New Jersey, August 8, 2009 - Chairman's Opening and Closing Statements, Washington, DC
Deborah A. P. Hersman
National Transportation Safety Board (NTSB) Board Meeting: Aircraft Accident Summary Report - Midair Collision Over Hudson River, Piper PA-32R-300, N71MC, and Eurocopter AS350BA, N401LH, Near Hoboken, New Jersey, August 8, 2009, Washington, DC

Good morning and welcome.  My name is Debbie Hersman and it is my privilege to serve as the Chairman of the National Transportation Safety Board.  This morning, I am joined by my fellow Board members:  Member Robert Sumwalt, and our two most recent additions to the Board, Member Mark Rosekind, and Member Earl Weener, both of whom were officially sworn in on June 30th and, this past week, had their ceremonial swearing-in activities.  Vice Chairman Chris Hart is unable to join us in person as he is with the NTSB team on-site investigating the gas pipeline explosion that occurred late last week in San Bruno, California.

It is my pleasure to welcome you to the boardroom of the National Transportation Safety Board.  This morning, the Board meets in open session as required by the Government in the Sunshine Act.  While this is a public meeting, only the Board members and NTSB staff participate in today’s discussions. 

Three weeks ago, the staff presented to the Board the report we are considering today:  the August 8, 2009, midair collision over the Hudson River, near Hoboken, NJ, of a single-engine Piper airplane and a Eurocopter helicopter.  

Our purpose today is to consider the Safety Board’s investigation report on this accident.  While the NTSB Board Members have had the opportunity to read the accident report and meet with staff, today is the first time that the members of the Board are meeting together to discuss it.  Staff has prepared three presentations, each of which will be followed by a round of questions from the Board members.  We will then consider the report’s conclusions, probable cause determination, and proposed safety recommendations. 

It is possible that some or all of the parts of the report may be modified or revised to reflect today’s discussions and any proposed amendments.  This is because these are the Board’s actual deliberations over the documents.  That is the purpose of the Sunshine Act -- to provide the public with a window into the decision making process.  Approximately 30 minutes after we conclude, copies of the abstract of this report will be available from the NTSB Public Affairs office and on the NTSB’s website.

On behalf of my fellow Board members and the entire NTSB staff, I offer my deepest condolences to the families and friends of the victims of this accident.  Nine lives were lost in this accident, including 5 tourists visiting from Italy.  I also understand that Mr. Giannicola Sinisi, Attache for Justice Affairs of the Italian Embassy, is in the Board room as well.  We recognize that our report on this accident cannot fill your loss, but please know that along with the changes that have already been made following the accident, we hope that the additional recommendations adopted today will be implemented to prevent similar tragedies. 

Also, on behalf of the men and women at the Safety Board, I would like to express my appreciation to the over forty organizations, at the local, state and federal levels, and to the countless individuals who assisted with the accident investigation.  This includes those involved in the recovery efforts, as well as evidence documentation.  The Safety Board could not have done its work on this report without you.  I am attaching to my statement a list of these groups, which you will be able to view on our website.  To all of you, thank you. 

Now, we will proceed with today’s report.  A little over one year ago, on August 8, 2009, a single-engine Piper aircraft that had departed Teterboro, New Jersey on its way to Ocean City, New Jersey, collided in mid-air with a sight-seeing tour helicopter, over the Hudson River, near Hoboken, New Jersey. 

The Piper was operating as directed by air traffic control, hugging the airspace at about 1,100 feet, and waiting for authorization to climb higher.  Meanwhile, the tour helicopter, travelling southbound along the Hudson River towards the Statue of Liberty, was rising beneath the Piper, climbing to about 1,100 feet.  In mid-air, the two aircraft collided, killing all 9 on board.

Mid-air collisions are not a new phenomenon.   One of the most tragic mid-air collisions occurred on June 30, 1956, when 2 commercial airplanes collided over the Grand Canyon, killing all 128 on board. 

The Grand Canyon collision was, at that time, the deadliest aviation accident in history, and it helped change the course for how we regulate our airspace.  In its aftermath, we ushered in sweeping changes that included modernization of the Air Traffic Control system, and, ultimately, creation of the Federal Aviation Agency (FAA).

Sadly, this accident is a grim reminder that, despite a half century of regulatory changes and technological advances, mid-air collisions, like this one, still happen.  Today, we have more control of the airspace, more equipment in the cockpit, and more aircraft in the skies than ever before.  However, even with all of these improvements, in the last 25 years almost 700 people have died in mid-air collisions in the United States.  And, on August 8, 2009, a merger of missteps, that began minutes before the accident, set these two aircraft on a collision course.

Today, we will discuss those missteps, and how the technology designed to prevent such a collision, and the concept of “see and avoid” other aircraft, both failed.

What I find so striking about this accident is that the airplane pilot was simply following his directions.  And although the helicopter’s conspicuity was improved by anticollison lights and a high-visibility paint scheme on the blades – these enhancements didn’t help.  Both aircraft were equipped with radios and traffic information systems, yet they didn’t hear or see each other, and the technology did not prevent the accident, and the air traffic system neither separated them nor alerted them that they were about to collide.

Much of our discussion today will focus on how to improve the safety of flight in dense traffic corridors, including the Hudson River, and let me say, that these safety improvements are critically needed.  

And while there is still work to be done, the good news is that many important changes have already taken place.

This past year, in the days and weeks after the accident, the Safety Board saw an unprecedented collaboration between the Federal Aviation Administration and the National Air Traffic Controllers Association (NATCA) – two groups who, despite past differences, are working together to improve the safety of the airspace around New York City. 

Within days of the accident, the FAA convened a task force – the New York Visual Flight Rule Airspace Task Force – made up of ATO (the Air Traffic Organization), NATCA, and representatives from local FAA air traffic control facilities, Flight Standards, representatives of fixed-wing and helicopter operators, and the Port Authority of New York and New Jersey.  The task force looked at how aircraft operate in the New York City area, and within weeks, issued safety recommendations.  Many of those recommendations mirrored early recommendations issued by the Safety Board.  

The FAA also published a final rule modifying the airspace above the Hudson River and defining how aircraft should operate there, including new maps issued by November, just 3 months after the accident. 

Beyond that, the FAA has revised its Letters of Agreement (or LOAs) with air tour operators in the area, as well as established new LOAs with the towers for the major airports and with New York TRACON. The modified agreements include changes to procedures, among other things, so that transiting aircraft are handled by ATC and do not operate in the Hudson River corridor.

While some improvements were focused exclusively on the New York/New Jersey area, some changes in the last year have national implications.  For example, the FAA has accelerated its nation-wide deployment of the Traffic Analysis Review Program (TARP) – software that automatically detects losses of aircraft separation at terminal facilities.  In addition, the controllers and the FAA have been working to address fatigue in a cooperative manner.

Of all of these improvements, perhaps the most encouraging has been the FAA and NATCA’s efforts to establish the ASTAP (Air Traffic Safety Action Program) nationwide.  And while recent headlines have highlighted the high number of ATSAP reports, the value of the system is that we are now getting those reports.  By encouraging non-punitive, open reporting and then mining the data, the industry can identify safety threats and precursors – before catastrophe strikes.

I might add that the ability to avoid future accidents like this one is dependent on a fully implemented ADS-B (automatic dependence surveillance-broadcast) program.  The FAA has taken the initial steps to move towards an ADS-B-based ATC environment, but that is an expensive proposition.  If we are serious about changing the paradigm and moving forward, then it’s critical that ADS-B, both in and out, be a part of this next phase of safety for collision avoidance.

In light of the many positive developments we have seen – steps that occurred in advance of our final report – I am hopeful that this is the prologue to the future and that, when it comes to embracing change to improve the system, the recommendations we issued today will see that same proactive response.

One final comment before staff begins its presentations.  While not a recommendation considered today, I’d like to take a moment to emphasize how important non-volatile memory chips contained in electronic flight displays are to the Safety Board’s accident investigations.  Built into the electronic flight displays of glass cockpit aircraft, non-volatile memory chips provide critical flight data that, quite frankly, we aren’t often able to otherwise come by.

As the Safety Board identified in its 2010 safety study on glass cockpits, which we released this past spring, electronic flight displays are enjoying great popularity in the general aviation fleet as we modernize aircraft and move from traditional “round dial” cockpits to “glass” cockpits.  What the study identified is that flight data retrieved from electronic flight displays has a significant safety benefit – it provides a window into the cause of an accident.  And it’s been our experience that flight data is recoverable in over 85% of general aviation accidents involving aircraft equipped with non-volatile memory chips.  This is particularly significant since general aviation aircraft do not carry dedicated flight recorders.

Not all flight displays are built with non-volatile memory, although, we understand that there is no technological or cost barrier not to do so.  It is the choice of the manufacturer.  Neither of the Garmin flights displays on board the airplane or helicopter in this accident had this feature. 

Given its safety benefits, I would encourage every manufacturer to incorporate non-volatile memory into all of its avionic products.  And further, I would like to remind manufacturers that there is an international standard for light weight flight data recorders, specifically EUROCAE ED-155.  Manufacturers can raise the safety bar even higher by designing their devices to the ED-155 standard for crash hardening and data recording, and I hope they will do just that.

Staff, please proceed with the presentations.