Skip Ribbon Commands
Skip to main content
Bookmark and Share this page


Opening Remarks before the 2009 Bombardier Safety Standdown Seminar, Wichita, KS
Deborah A. P. Hersman
Bombardier Safety Standdown Seminar, Wichita, KS

Thank you, James.  It is truly a privilege to be here this morning and for the NTSB to continue with the FAA as a Federal partner in this year’s Bombardier Safety Standdown.  Rick, I have to say, I don’t think I had the opportunity to speak at a conference opened by Bon Jovi and Rush. 

James, I’d like to take the opportunity to recognize Bombardier’s leadership because this seminar has grown beyond your company to serve the industry as one of the premier events for disseminating safety information to pilots, mechanics, and managers of business jets and turboprops.  It has been over a dozen years since Bombardier held the first standdown, and in a recession, everyone would probably understand if your management or your financial team, decided to skip a year.  Your dollar commitment to the program demonstrates your priorities.  Many conferences I have attended this year have been under booked because companies don’t have the funds to permit their staff to travel.  I understand that the attendance this year remains high and there was a waiting list of over 200.  So for all of you who are in audience this morning, your presence here in these tough economic times is an important indicator of your organization walking the walk, not just talking the talk about a commitment to safety.  

As many of you know, the NTSB is a small, independent, federal agency.  I am here representing my fellow board members, Vice Chairman Chris Hart and Member Robert Sumwalt and the men and women of the NTSB, I’d like to recognize one of our Senior Air Safety Investigators, Jim Silliman, who has investigated over 650 aviation accidents in his 15 years with the Board.  The NTSB is about 400 people strong, with about a third of that number involved in aviation. Our agency’s annual budget would run the Department of Transportation for less than one day.   Our mandate is to investigate transportation accidents, determine their probable cause, and issue recommendations to prevent future accidents.  Our independence is crucial. We call it the way we see it. We are not the regulator, we do not have a research budget or even the money to fund the safety improvements that we recommend.   We can only affect change through persuasion.  The success of our recommendations is predicated on the quality of our investigations, the strength of our arguments, and the credibility of our perspective.

Each of us here on the dias have roles to play in the safety equation.  The FAA sets standards for operations and equipment, manufacturers continuously improve the efficiency and reliability of their products, operators educate, train and establish a safety culture, and when those things fail to prevent an accident, the NTSB investigates.  While some of our recommendations call for the FAA to promulgate regulations and some of our recommendations ask for design changes from manufacturers, we recognize that we all play different roles in the safety equation.   My challenge for you today is to determine how you can be a catalyst for change, to improve the safety of an already safe industry.

Voluntary action by industry to identify and address safety improvements has a direct impact on accident statistics.   However, as important as the regulatory and business attitudes about safety are, perhaps most important component in reducing accidents in aviation is you, each individual sitting in this room and your own discipline.  Personal discipline combined with the skill and knowledge based training, that you experience here in this seminar, can make a huge impact on safety.  All too often in our investigations we see that it is the big and small decisions that pilots make when preparing for duty, performing as the monitoring pilot, following checklists, or responding to an unexpected event on the flight deck that define a successful or disastrous outcome.

Let me discuss our role, the Safety Board is charged with investigating every fatal civil aviation accident in the US, so as the official census keeper of all aviation accident statistics, we have an obligation to talk about the disastrous outcomes.  We do this because the role of accident investigation in the safety equation is really to prevent a similar event from reoccurring.  Occasionally we have a good story to tell about pilot discipline and training, like the USAir crew’s successful forced landing on the Hudson earlier this year, but more often we see the results of poor decision-making and lack of adherence to standard procedures in our investigations.  While the overall aviation safety record in the United States is among the best in the world, the 2008 accident statistics revealed a mixed picture year-over-year. We were particularly concerned with the spike in fatalities in on-demand air charter operations.

Focusing on Part 135 on-demand flight operations, which include air medical, air taxi and air tour flights, last year, operators logged over 3.6 million flight hours and had 56 accidents, killing 66 people – representing the highest number of fatalities since 2000.  That includes the 29 killed in helicopter emergency medical services, making 2008 the deadliest year for that aviation sector… in an effort to be a catalyst for change in this industry the Safety Board held a 4-day public hearing on HEMS safety this past winter and last month we issued recommendations, not only to the FAA but to the Department of Health and Human Services that funds the Medicare and Medicaid reimbursement of such flights.  We did this by following the money and recommended that they audit operators and only provide reimbursement to operators that meet established safety standards.  While 2009 was looking up for the HEMS industry, unfortunately we had a three-fatal accident on Saturday in Georgetown, SC. 

In general aviation, there were a total of 1,559 aircraft accidents, 275 of which were fatal, killing a total of 495 people -- one fewer than the previous year. Of those Part 91 accidents, 96 involved turbine-powered airplanes, 21 of which were fatal, killing a total of 38 people. he Safety Board launched full go-teams on several of these business jet accidents.  One involved a business jet that impacted terrain during an attempted go-around at the Owatonna Regional Airport in Minnesota, killing all 8 aboard.  Our investigation is focused on the weather, the runway condition, aircraft systems and the flightcrew’s knowledge of those systems.

Last September I launched with our go team to an accident involving a business jet that overran a runway while departing Columbia, South Carolina. The 2 crewmembers and 2 passengers were fatally injured, and the other 2 passengers suffered serious injuries.  The beginning of the takeoff roll appeared normal, but after a tire blowout the airplane continued down the runway and beyond the threshold, through the perimeter fence, across a roadway, and onto an embankment. In this investigation the CVR and FDR coupled with the evidence on scene enabled us to focus in on the importance of appropriate tire pressure and knowledge regarding the use of thrust reversers and the air-ground logic in the aircraft.  Although the accident investigation is not complete, we’ve already issued six early recommendations regarding inadvertent thrust reverser stowage, which can occur when the requirements for deploying thrust reversers are not fully met, such as when the air/ground sensor squat switch circuits are damaged.  We recommended that manufacturers incorporate design changes into the aircraft that provide feedback to the crew in the cockpit and that crews be trained to recognize such an event.  I will continue to push our staff to be a catalyst for change by issuing early recommendations.  As soon as we have identified and documented a problem that affects safety, we have an obligation to act on it.

In July we issued our findings from a third business jet accident that occurred last year, which crashed about 2 minutes after takeoff from Wiley Post Airport in Oklahoma City. Two pilots and three passengers were killed.  We determined that the probable cause was structural damage to the airplane’s wing sustained during impact with one or more American white pelicans – keep in mind that these birds were three times larger than the Canadian Geese  USAir 1547 encountered.  Aside from the bird strike issues, which are becoming a more prominent hazard in aviation, the Board documented that the company operating the accident flight did so contrary to its Part 135 operating certificate, which, at the time, did not authorize operation of the accident airplane or any other fixed-wing aircraft.  Even though it did not relate to the cause, the Safety Board addressed this issue in our report because neither of the pilots were trained or qualified to, nor was the airplane maintained to the Part 135 standards.

I have to tell you, when I looked over the program lineup over the next couple of days, the seminars could have been drawn from several recent NTSB investigations.  This afternoon a session is dedicated to Safety Management Systems, or SMS.  In January, the NTSB issued a recommendation to the FAA asking them to develop a safety alert to encourage all Part 91 business operators to adopt an SMS. This recommendation was prompted by the investigation of a business airplane that crashed into a residential area near Sanford, Florida, following an in-flight fire.  The Safety Board determined that the probable causes of the accident were the actions and decisions by the corporate aviation division’s management and maintenance personnel to allow the airplane to be released for flight with a known and unresolved discrepancy, and the accident pilots’ decision to operate the airplane with that known discrepancy, a discrepancy that likely resulted in an in-flight fire.  

The NTSB is in the business of looking at how things could have been prevented, and while hindsight is 20/20 – SMS provides an opportunity for high performing companies to constantly evaluate their performance and establish an organizational commitment to safety.  Given how effective an SMS would likely have been in the Sanford accident, those corporate flight departments without one should study the lessons learned in the investigation and ask themselves if they can justify operating without one. 

This year’s Standdown also seems to draw upon the Safety Board’s Most Wanted List of Safety Improvements. This list is updated every year, and often reflects a big picture view of accident trends and shortcomings in the transportation safety net.  One item on this high-priority list is to promote improvements in crew resource management, by requiring CRM training for on-demand air taxi flight crews.  The Safety Board has investigated several fatal accidents involving Part 135 on-demand operators in which the carrier either had not implemented a CRM program or the program was much less comprehensive and effective than would be required for a Part 121 carrier. Effective CRM programs might have interrupted the chain of events that led to the accidents. 

Another item on our Most Wanted List is to Improve Runway Safety by requiring landing distance assessment with an adequate safety margin for every landing to prevent runway excursions, and to give immediate warnings of probable collisions/incursions directly to flight crews in the cockpit to prevent runway incursions. The Safety Board has investigated numerous runway incursions and excursions involving business aircraft.  While there are many reasons for these events, suffice it to say that it takes only seconds for things to go awry.  There are many hazards on the surface of the airport, so it is good to see a session dedicated to addressing potential mitigation of the hazards in this challenging environment.

A third item on our MWL list involves Reducing Accidents Caused by Human Fatigue by setting work hour limits for flight crews, aviation mechanics and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements.  Tomorrow afternoon, you will hear from an expert on managing fatigue in flight operations, Dr. Mark Rosekind.   

Fatigue has been a factor in several Part 121 air carrier accidents investigated by the Board during my tenure, and I expect that everyone in this room can share with me their own personal fatigue experience.  Last month we issued recommendations regarding sleep apnea following the Go! event involving a crew that overflew their destination in Hilo, HI, because both pilots had fallen asleep. 

And although the 50-fatal Colgan accident in Buffalo remains under investigation, I believe that the NTSB’s public hearing in May, less than three months after the accident served as a catalyst by bringing fatigue in aviation to the forefront of the public’s consciousness, including a discussion of the effects of commuting.  It probably comes as no surprise to you that fatigue has been on our Most Wanted List since its inception and that it continues to be a significant factor in many transportation accidents in all modes.  I would like to take this opportunity to recognize that the FAA, under Administrator Randy Babbitt’s leadership, was a catalyst for change when they convened a quick fuse ARC on pilot hours of service.  In my experience these groups have traditionally accomplished their work over a number a years, not days… I am hopeful that the time has come to see a real change in fatigue.   

In closing, I want to challenge each of you to be a catalyst in your workplace.  Professionalism is what makes all of you safe and successful in the cockpit and in the maintenance hangar.  What is a professional?  It is a mindset that causes one to be precise with checklist usage and adhering to SOPs and regulations.  It is staying abreast and current with knowledge and skills, through opportunities such as the ones you’ll be exposed to over the next few days.  In reading some of the materials we were provided at check-in yesterday, it is becoming a “knowledge ace”.  Professionalism may also be the willingness to say “I don’t know” or “I am wrong.”  Ultimately it is “doing the right thing, even when no one else is watching.”

I don’t want to cut into any more of your valuable training time, so let me leave you with the thought …  You never know on which flight your career will be judged, so approach each and every one  as if it is the most important one you’ll fly.

The NTSB stands ready to support you in your efforts to improve safety.  Good luck, good learning, and thank you for inviting me to be with you today.