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Remarks at the International Society of Safety Investigators 40th Annual Seminar in Orlando, FL
Deborah A. P. Hersman
International Society of Safety Investigators 40th Annual Seminar in Orlando, FL

Good morning everyone.  And a special konichiwa, guten morgen, ni hao, and bonjour to the International Council members and to our international attendees.

Thank you, Frank, for that kind introduction.  I would also like to thank Jayme Nichols, Grant Brophy and Tony Brickhouse for the invitation to be with you this morning.  


It is my privilege to kick off ISASI’s 40th Annual Seminar. When preparing for my speech, I spent some time thinking about this year’s theme Accident Prevention beyond Investigations.”  It is a theme that encourages us to ponder “What is next?”  This is a room full of people who spend their time solving puzzles, putting the pieces back together to figure out what failed and how a design can be improved, or  why people made the wrong decisions in the seconds before a disaster.  So the theme is a great one, “What is next for you, for me, for us?”

Seven weeks ago today, I became the 12th chairman of the NTSB.  Many of you, well, maybe most of you, don’t know me, so let me give you a little glimpse of “what is next” for the NTSB during my tenure.  There are three attributes that I believe are critical to the NTSB’s mission and work.  They are transparency, accountability, and integrity.  Last week, I addressed the NTSB staff as a group for the first time.  I challenged them, as I am challenging myself, to raise the bar in all three of these important areas. 

Some of you may be wondering, “What’s next for the NTSB’s relationship with our international counterparts?”  I believe some of the same themes crossover to the international arena. Today, in addition to transparency and accountability, I will also focus on cooperation.

For the past five years I have had the privilege to serve as a Member of the United States National Transportation Safety Board (NTSB) alongside my colleague, Member Sumwalt (who many of you know is a bona fide member of ISASI, and he will be speaking to you on Thursday).  During my time at the Board, I’ve accompanied our NTSB staff investigators on 17 major transportation accident investigations. These events have covered all modes of transportation: airliners, emergency medical service and sightseeing helicopters, business jets, private aircraft, light rail trains, freight trains, container ships, recreational boats, school buses, and motor coaches. Allow me to express my utmost respect for you – the professional air safety investigators and your peers who come from the various business and educational sectors associated with the transportation industry.  I would like to recognize the NTSB investigators that I have worked with in the audience, please stand (Bob MacIntosh, Frank Hilldrup, Joe Sedor, Lorenda Ward, and Scott Dunham), and the many NTSB alumni here today.  I have the privilege to be the public face for the work they do.  Like these investigators, many of you have dedicated your careers to determining the causes of aviation accidents and coming up with solutions to safety problems encountered in your investigations.

Last night I had the opportunity to talk with Lucky Finch; one of ISASI’s founding members.  I understand that this is ISASI’s 40th Annual Seminar and since the NTSB is just over four decades old, I thought it might be worthwhile before we discuss what is next, to look back at where we came from.  Forty years ago, Embraer, Airbus and Thierry were being conceived and birthed, as were Jimmy and David.  Bombardier aerospace was just a glimmer in a snowmobile’s eye.  Forty years ago, Ron Schleede and Bill Hendricks will tell you they put together their accident reports by themselves using only their brilliant investigator skills, a legal pad and a typewriter.  Forty years ago, Bob MacIntosh has told me that we had to dial an operator to make an international call.

Today we are in a world that moves fast, communicates instantaneously, and demands answers immediately.  Even though the NTSB’s mission remains the same, the world around us has changed drastically.  Therefore, we must constantly be asking ourselves, “What is next?” 


What is next for media relations?  I know many of you were here yesterday for the tutorials on the subject of media relations, which included one of the Safety Board’s public affairs officers. As many of you know, major accidents are not covered by just local or even national press, but more and more by international correspondents.  Following a major accident we recognize that the press has an insatiable appetite for information, and the public has an understandable curiosity about the event.  Yet we must try to balance the equation of providing factual data to the public without speculating on the causes of the accident. You’re going to hear me mention transparency, accountability and cooperation, several times this morning, and public relations is a perfect place to start. As an agency funded by the public, the NTSB fully embraces transparency and the public’s right to know about our investigations.  In fact it is through the process of showing the public that we are conducting independent, thorough investigations that we derive our ability to influence decisions that are made following an accident.   

If the NTSB, as the government’s transportation accident investigation agency, does not provide credible information in a developing accident investigation scenario, other sources will attempt to fill the void. And in most cases, that void will be filled with information that is unreliable, unverified, and sometimes just plain wrong.   Many of the people who talk to the media have impressive credentials, and I do not begrudge them trying to explain to the general public highly technical situations.  However, if their opinions are the only information the public receives in the days following the crash – and these opinions are rendered hundreds of miles from the scene – then the public will be ill served. 

Even worse, depending on where the information comes from, it may be self-serving to the originator and damaging to the other participants in the investigation.  For that reason, the NTSB spokesperson at the scene is the source of all publicly released factual information about the investigation. We try very hard to provide the public with reasonable detail of the facts to assure them that the investigation is being conducted in a thorough and unbiased manner. In fact, many times we ask the public for their support regarding witness information and other site details. Our purpose at an NTSB press briefing is not to provide the media with details to solve the accident, but rather to demonstrate to the public that the process of the safety investigation is being conducted in a professional manner.

President Obama has committed to making his administration the most open and transparent in history. While the NTSB is an independent agency, I believe the President’s commitment is consistent with the NTSB’s long history of open and visible investigations.  The value we place on transparency in our investigations in order to meet the expectations of the public may be very different from the processes in place in other nations, including some that are represented here. In fact, you may personally disagree with our protocol, but it is hard to contend that the NTSB’s open policy has not proven to be effective over time. For international participants in investigations within the United States, we have published ICAO differences in ICAO Annex 13 to keep all states advised of our policies regarding the release of factual information.

What’s next regarding how we communicate with the public and our stakeholders?    

The Internet and other electronic tools are changing and expanding at breathtaking speed.  I would like to see the NTSB make better use of those tools to bring our message faster and with more content to the news media, to Congress, and most importantly, to our stakeholders.  Recently we took the step of opening our dockets to the public via our website.  We not only hold our Board Meetings and Investigative Hearings in full view of the public, but we webcast them so that anyone can watch, what this means is that these meetings are more transparent that even before – available not just to stakeholders and the media, but these meetings are now easily accessible to international viewers without any expensive travel costs or inconveniences. 

This year our Office of Aviation Safety has already scheduled four investigative hearings, one on the safety of helicopter emergency medical services (2008 was one of the worst years on record for the HEMS industry with 9 accidents resulting in 29 fatalities), one on the USAir dual engine failure following an encounter with multiple Canada Geese and subsequent forced landing in the Hudson River; one on the 50-fatal Colgan accident in Buffalo, New York, on February 12; and finally, next week, I will be chairing a hearing on the Empire Airlines domestic cargo flight for Fed Ex that landed short of the runway in Lubbock, Texas, in freezing drizzle conditions.

While all of this work raises the bar on transparency, we aren’t doing it alone.  We had the participation of international representatives at each of our hearings: American Eurocopter and Canadian Helicopters were witnesses at our HEMS hearing, Airbus and EASA were witnesses at the Hudson hearing with BEA serving as an accredited rep on our technical panel; Bombardier and Transport Canada sat as witnesses at the Colgan hearing with the TSB serving on the technical panel as an accredited rep; and next week, we will be joined by ATR and EASA at the hearing on the Empire accident.  Even though our system may be different from yours, we are working together to achieve a transparent and seamless aviation system and we rely on the support we receive in our investigations from our partners that serve as accredited representatives, and those who represent labor unions, regulatory authorities, and manufacturers.  Aviation is a global endeavor, if you take away one thing from my talk this morning, I want to make it clear, that we recognize the value of working with and learning from our international counterparts – this is the only way that we will succeed.  We are working together to accomplish this, so what’s next?
I’d like to briefly touch on the other subject of the tutorials, criminalization, I can be brief and to the point.  The NTSB’s relationship with the U. S. Department of Justice is excellent and well established.  Unless the Attorney General and I, as the Chairman of the NTSB, agree that circumstances reasonably indicate that an accident may have been caused by an intentional criminal act, our NTSB investigators have unimpeded authority to conduct the investigation. The NTSB has priority over any judicial or other agency’s investigation for aviation accidents.   We control the accident site, and our investigators are free to pursue the fact gathering process as necessary. We recognize that our position in accident investigations may be different from that of investigative agencies in other nations.  Frankly, we are grateful that the United States Congress provided the NTSB with primary jurisdiction over most aviation accident investigations. However, we all have to work within the system that exists in the state of occurrence.  This demands effective coordination and communication at every level of the investigation as well as understanding and respect for the conditions that our investigative counterparts are facing.   


When I asked our staff last week to raise the bar on our accountability, I know I was asking for a lot from a group of dedicated professionals whose work days are already very full.  We investigate about 1600 accidents per year.  In 2008, the NTSB responded to 28 air carrier events; the 20 in scheduled service were all, fortunately, non-fatal. Last year our vehicle recorders laboratory received and read out more than 200 recorders. In addition, we received 178 foreign notifications of accidents or serious incidents involving U.S. operators or products.  As a result, NTSB Accredited Representative teams traveled to 27 accidents in foreign countries to assist the local investigation authority.

Raising the bar on accountability will require the NTSB to be strong and nimble in its accident investigations in order to serve the American traveling public, and to meet our international commitments. I would like to build on the technical strengths of our very competent professional staff to place our investigators at the forefront of technology.  Certainly we will retain the investigative skills of early generation jet transports like the DC-9 and the B737-200, or the Cessna, Beech and Piper designs of the 1980s.  As Frank mentioned in his opening, new technology is being assimilated into every sector of the aviation industry, like synthetic vision of a cockpit heads-up display and ADS-B for air traffic management.  The aircraft coming off the production line are a new breed, filled with these innovations. Boeing, Airbus, Embraer, Bombardier, Gulfstream and all the general aviation manufacturers now offer leading-edge technology, and engine manufacturers are satisfied only with the highest levels of efficiency in their new designs. The implementation of electronic flight control systems, optimized power plant management, advanced composites, basic electrical and environmental engineering support systems, and navigation options such as the electronic flight bag and surface moving maps requires that our technical staff and other participating investigators are constantly learning to stay current with this technology.   The rapid changes in technology provide challenges, but they also hold the keys to solutions we couldn’t have imagined 40 years ago… so with respect to technology, it is very exciting to think about what’s next.

In the past 5 years that I have served on the Board, I have noticed that today’s fast moving and capacity-filled environment demands that we do things with reasonable urgency.  When I first started my professional career, we didn’t have e-mail addresses and if you had a phone, you needed to carry it in a bag and have an antenna for it.  When I came to the Safety Board just over five years ago, we had pagers.  Today our Blackberries can work internationally and they provide us with content-filled messages and access to the web.  All of these developments have enabled us to be more efficient and respond more quickly; but along with these improvements has come a commensurate expectation that we can work better, faster and stronger.  As we complete the field portion of an investigation, you will continue to see our investigators conduct component examinations as an immediate follow-on activity. We will communicate with participants to our investigation at Internet speed. We cannot accept weeks and months of reviews and slow crawl responses as we complete each step in our investigative process. Similarly, when we identify a safety deficiency, we can’t wait for a recurrence to address it.  If the failure has been identified, documented and analyzed, then what is next?  Waiting for months to issue the final report?  No, in some cases we may need to act quickly to issue a recommendation, so if the situation merits it, we will go forward with recommendations even before we complete the final report.

The NTSB has an obligation to alert the transportation community to acute safety problems, whether or not the problems may have played a causal role in the accident.  Recommendations we issue during the course of an investigation do not signal that we have determined the cause of the accident.  They simply point to a safety vulnerability that deserves immediate attention.

In recent weeks, we’ve issued recommendations on still on-going investigations of the Hudson River midair collision, the crash of a corporate jet in South Carolina, and, in a surface mode, on the collision of two transit trains in Washington, D.C.  I will continue to encourage such timely action by our investigative staff in the future.

I will also push recipients of our safety recommendation letters to raise their bar on their own accountability. We simply cannot accept “We’re working on it,” as a satisfactory response from a regulating agency about an identified safety risk.  What we will accept is corrective action implemented and the risk mitigated, or at the very least, a clear forecast of when corrective action will be completed.  I have been encouraged by new FAA Administrator Randy Babbitt’s recent efforts to act quickly on safety problems.   Just a couple of weeks ago, the FAA announced changes to the airspace in the New York area following the mid-air collision over the Hudson River last month. The Safety Board will analyze the FAA’s action to see how closely they comport to our recommendations, but this is an example of the regulator asking, “What’s next?” and then acting on the answers they received when they asked the question.

Can we attain a stronger and more nimble posture without affecting the quality of our work?  Can we modernize without affecting the quality of our NTSB products?  Yes, we can and we will. The 21st century is well under way and it requires new thinking. We hear the chorus of support for the integration of safety management systems (SMS), and a realignment of responsibility and accountability for operators as we move toward a more performance-based approach to safety.  While we hope that SMS will prevent many accidents, we recognize there is a key role that accident investigation will continue to play in the identification and mitigation of safety deficiencies even in the SMS environment.
So what is next for us?  While I am challenging staff to increase their efficiency, I am also calling for continuous review by the management team – this is our own version of SMS.  Our investigators have recently showed us that they are looking beyond causal factors, in a fatal Citation bird strike accident in Oklahoma City they identified organizational and oversight failures, that while not causal, created a poor safety culture.  In recent HEMS recommendations, we “followed the money” so to speak, and issued recommendations asking the government agency that controls reimbursement for HEMS operators to establish safety standards and audit operators.  You should also know that we are also holding parties to our investigations accountable to their obligation just as we are being held accountable to our constituencies.  Today, while I am here with you, Vice Chairman Hart will be testifying on the Hudson mid-air collision before the Senate, and tomorrow morning I will be delivering the same testimony to the House.  This reckoning on the status of our investigation comes approximately one month after I launched to the accident with our team.  We must provide some answers to law makers’ questions as they look to us with the question of “What’s next?”

After watching our staff in action for the past five years, I have every confidence they are up to the job, and I will support them in every way I can to raise the bar for both the NTSB and those who participate in our investigations.  By ensuring investigators maintain their technical competence, issuing recommendations as soon as they are warranted, and improving our internal processes, the NTSB will be a more nimble and more accountable organization.  


Now to cooperation, coordination and support between the NTSB and accident investigation authorities from other countries.  Our partnerships with multinational organizations such as the European Aviation Safety Agency (EASA) and the Interstate Aviation Committee of the former Soviet Union (MAK) have provided many valuable contributions to worldwide safety improvements.  Some of these improvements reflect directly on our U.S. manufactured products. For example, we recently issued coordinated recommendations with the Spanish CIAAIC on the MD-80 takeoff warning system related to the Spanair accident in Madrid, with the UK AAIB related to the British Airways  B-777 dual power loss at Heathrow, and with the Canadian TSB and MAK of Russia on the issue of the Cessna 208 flight in icing conditions.   

It is no revelation to this body that aviation investigations are more and more becoming global affairs.  The crash of Air France flight 447 in June involved a multi-nation search effort.    I will defer to Paul discuss their investigation tomorrow, but our support and good will are extended to both the BEA and the people who have lost loved ones in this accident.

I would also like to note that we have been participating for over a decade with the United States Department of Transportation “Safe Skies for Africa” program. This initiative has now expanded into the ICAO Safety Roadmap in Africa and we remain fully engaged. We believe it is important to further our relationships with partners like EASA, MAK, and the regional safety initiatives around the world because these relationships are critical to teamwork, consultation, and cooperation necessary in every investigation and ultimately to the  overall credibility of the ICAO Annex 13 process. 

Before I close, I would like to say a word about the families of accident victims, our most vulnerable stakeholders.  Since 1996, the NTSB has been charged by the U.S. Congress to coordinate federal resources for family members.  At an accident scene, our Office of Transportation Disaster Assistance has developed a system with the airlines to provide a dedicated location for those family members to gather away from the prying eyes of the press, as well as a process to keep them informed on the progress of the investigation, even after we leave the accident scene.  This has been a positive development, and we will endeavor in the next two years to further develop our relationships with family members and enhance our system of keeping them informed and also hearing what they have to say. I’m happy to see that other nations have been moving in a similar direction, and I sincerely hope that the trend continues.

This conference is a perfect example of what the next 40 years hold for global aviation and accident investigation.  Although the US is hosting this year, more than half of the attendees are guests from 32 other nations.  This forum is a great opportunity to meet with and work with your colleagues; I saw impressive signs of cooperation last night with Tom and Thierry of rivals Airbus and Boeing putting their heads together and residents of China, Hong Kong, and Taiwan discussing aviation safety at the same table.  All kidding aside, I have shared some of my priorities with you, so I ask our international partners, what’s next, how can we support you?

In the news we’ve been hearing much about civility, in the Congress, on the tennis court, but not here…to the international community, I would like to recognize your graciousness.  As many of you know, last Friday was the 8th Anniversary of 9/11.  My first meeting that morning was with Raymond Benjamin, ICAO Secretary General; then I met with a delegation of air safety officials from Brazil, and later in the afternoon I had a phone call with representatives of ATR (who will be participating in our hearing next week). One gentleman was French and the other was Italian.  Each meeting was opened with an expression of remembrance and support (in English, I might add) for the American people on the anniversary of 9/11.  This acknowledgement was appreciated and so considerate.   Danke, tak farid, muchas gracias, mange tak and thank you.

In closing, I would like to express my personal appreciation for the cooperation and support the aviation community has offered me.  I am not an aviator, but I have been humbled by the many well wishes from each of you, as I know many of you care deeply about this agency I am entrusted with.  Thank you for inviting me here today, and also for everything you’ve done to improve aviation safety around the world.  I look forward to working with you during my term as Chairman.

So, what do the next 40 years hold for ISASI and aviation investigations?  Can we be more transparent, accountable, and cooperative?  International borders still exist, but they too are becoming more transparent and are no longer boundaries; the internet has connected us all; the world is preparing for the next flu pandemic that can travel through time zones as rapidly as an overnight package; the aircraft that bring us together, whether designed by Embraer or Airbus are made with parts that are manufactured all over the world; the people who rely on you to do your work do not represent the U.S., South Africa, China or Britain, they represent humanity.  In the end, as leaders, as safety professionals, as human beings, we have been given a noble charge; we are our brother’s keepers.  I’m optimistic that, with your support, we can build on the enthusiasm and dedication fostered here to continue the historic period of air safety we’ve experienced, and to strengthen the ties of the international air safety community.