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Remarks before the Aero Club of Washington, DC
Deborah A. P. Hersman
Aero Club of Washington, DC

Good afternoon everyone.  Thank you, Lisa, for that kind introduction.  I am very pleased to be with you this afternoon.  I would like to take a moment to acknowledge the board and the many members of the Aero Club and congratulate you on your centennial anniversary.  The Aero Club has served as a discussion forum and gathering place for leaders in the aviation community in Washington for decades.  It’s an honor to stand at this podium where so many distinguished speakers have stood and to talk with you about aviation safety.  I represent my fellow National Transportation Safety Board members, Chris Hart and Robert Sumwalt, and the 400 men and women of the hard-working staff of the NTSB

I became the 12th chairman of the NTSB about 2 months ago, and it is only natural for people to wonder about my plans for the direction of the agency.  There are three attributes I believe are critical to the NTSB’s mission and work.  Those attributes are transparency, accountability, and integrity.  Last week, I addressed the NTSB staff as a group for the first time as Chairman.  I challenged them, and I am challenging myself, to “raise the bar” in these important areas. 

Earlier this year, 50 people lost their lives when a Colgan Air Bombardier Dash-8 Q400, operating as Continental Connection flight 3407, crashed near Buffalo, New York.  We held a public hearing regarding that accident in May of this year, less than three months after the accident.  As a publicly-funded agency, the NTSB embraces transparency and the public’s right to know about our investigations.  While we won’t issue our report until early next year, I believe that holding the hearing so early in the investigation allowed the Board to identify relevant issues for the aviation community and dispel some inaccurate theories about the cause of the accident that may have been developing.  In addition to furthering our investigation, one of the purposes of our public hearings is to show the public that the Safety Board is conducting an independent and thorough inquiry, it is from that transparency that we derive our ability to influence decisions that follow an accident.

As tragic as this accident was, it has been nearly 3 years since the wrong runway take-off in Lexington in August of 2006 in which 49 aboard perished, and almost 8 years since the American Airlines 587 accident, which resulted in 265 fatalities.  This highlights the fact that, even as we search for answers to explain why this tragedy occurred, why so many loved ones were left to mourn the 50 people who died in Buffalo, that such accidents are becoming increasingly rare.  Decades of work by the NTSB; by the FAA; by the Department of Transportation; by our counterpart agencies around the world; by vigilant employees and by aircraft, engine and component manufacturers, have resulted in an admirable safety record for commercial aviation.  In the seven years from 2002 through 2008, approximately 120 passengers lost their lives on accidents involving scheduled Part 121 air carriers in the United States.  During that time, the airlines carried almost 5 billion passengers.  Contrast this with our fatality numbers in the seven prior years, when we lost 872 lives, and that number does not count 9/11.

We did not achieve these gains by being complacent, and I trust none of us will allow complacency to intrude into our processes going forward.  Although the Colgan accident was the worst accident this past year, it wasn’t the only one:  we saw a hull loss of a Continental Boeing 737-500 right before Christmas in Denver, we had a forced landing of a USAir Airbus A320 in the Hudson in January:  the outcome of both of these accidents could have been far different.  So when these infrequent events occur, we need to devote all resources necessary to find out what went wrong and to do what we can to make sure they don’t happen again.

We are in a world that moves fast, communicates instantaneously, and demands answers immediately.  Even though our mission remains the same, the world around us has changed drastically.  That has led to an evolution in our relationship with the public, which in many ways — but not in all ways — is filtered through the news media.

Following a major accident we recognize that the press has an insatiable appetite for information, and that the public has an understandable curiosity about the event.  We are also in a world where there is more and more demand to act quickly.  We must, however, balance our responsibility to provide factual data with the unproductive pitfalls of premature speculation about the causes of accidents — above all, we must not make mistakes.  There is too often a general feeling in the media and in the public sphere that we should just, “do something — anything.”  Well, we need to do the right thing!

If the NTSB, as the country’s transportation accident investigation agency, does not provide credible information in a developing accident investigation scenario, other sources will fill the void — and in most cases, it will be with unreliable, unverified, wrong information.  You may recall the speculation about icing in the days after the Buffalo accident.  Although we have not yet reported the probable cause of that accident, we know that airframe icing had little, if any, effect on the performance of that aircraft. 

Depending on the origin of the information, it may be self-serving to the source and damaging to other participants in the investigation.  For that reason, therefore, the NTSB spokesperson is the source of all publicly-released factual information about the investigation.  We try very hard to provide the public the facts to assure them the investigation is conducted in a thorough and unbiased manner.  Our purpose at an NTSB press briefing is not to provide the media with details to determine the cause of the accident, but to demonstrate to the public that the process of the safety investigation is being conducted in a professional manner.

This is at the root of the recent controversy involving a party’s participation in our investigation of the Hudson River midair collision.  That party, as did all parties to our investigation, signed an agreement stipulating that the NTSB would be the sole source of information regarding the investigation.  Yet, in the days following the accident, that party’s representatives conducted public press conferences regarding details of the ongoing investigation.  A week after the accident, the NTSB took the unusual step of removing the organization as a party to the investigation.  Although we regretted having to take that action, we believe that an investigation works more efficiently and successfully when the parties adhere to a disciplined approach.

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 NTSB’s long history of open and visible investigations is consistent with the President’s commitment to transparency.  This open policy has certainly proven to be effective over time.

Nevertheless, we must continuously strive to do better and adapt to new communications platforms.  The Internet and electronic technology are changing and expanding at breathtaking speed.  The NTSB will 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 the public and our stakeholders.  Recently we took the step of opening our dockets to the public via our website.  We hold our Board Meetings and Investigative Hearings in a public forum, and we webcast them so that anyone with an Internet connection can watch, whether they are in Peoria or Perth. 

When I asked our staff last week to raise the bar on accountability, I knew I was asking a lot from a group of dedicated professionals whose work days are already quite full.  We investigate about 1600 aviation accidents per year.  As of yesterday, the NTSB has investigated almost 133,000 aviation accidents.  In 2008, the NTSB responded to 28 air carrier events.  In addition, we received 178 notifications of foreign accidents or serious incidents involving U.S. operators or products.  As a result, NTSB Accredited Representative teams traveled to 27 accidents in foreign countries, in order to assist local investigation authorities.  

Our vehicle recorders laboratory has experienced a steadily increasing workload over the past 5 years.  Last year the lab processed over 350 cockpit voice and flight data recorders, along with digital cameras, video recordings, GPS navigation devices, cockpit displays, and engine monitoring devices.  The caseload in 2008 has increased 73% since 2005, while laboratory staffing has decreased by one.  And our lab support for foreign accident investigators accounts for nearly 30 % of the flight data and cockpit voice recorder volume.

Raising the bar on accountability will require the NTSB to work harder, be more nimble and also get the necessary resources that we need for our accident investigations so that we may serve the traveling public, and meet international commitments.  We can build on the technical strengths of our eminently-competent professional staff, in such a way that we place our investigators at the forefront of technology.  Certainly we must retain the investigative skills of early generation jet transports like the DC-9 and the B737-200, as well as business and general aviation aircraft, but we have to stay ahead of new technologies being assimilated into every sector of the aviation industry.

In the last 5 years, I have noticed that today’s fast moving and capacity-filled environment demands that we do things with reasonable urgency.  When I started my professional career, we didn’t even have e-mail addresses, and if you had a mobile phone, you carried it in a bag.  When I came to the NTSB just five years ago, we had pagers.  Today our Blackberries are functional globally, and they provide us with content-filled messages and access to the web.  Such developments enable us to be more efficient and to respond even more quickly, but with these improvements has come a commensurate expectation that we work better, faster and stronger.  We can no longer accept weeks and months of review and slow-crawl responses as we complete each step in the 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, we must act quickly to issue a recommendation — if the situation merits it, we will go forward with recommendations well 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 played a causal role in an accident.  Recommendations that 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.

This year our Office of Aviation Safety has already scheduled four investigative hearings.  I feel strongly that public hearings demonstrate both transparency and accountability.

  • The first public hearing was on the safety of helicopter emergency medical services (HEMS) —
    • From 2003 through 2008, HEMS accidents claimed 77 lives.  2008 was one of the worst years on record for the HEMS industry with 9 accidents resulting in 29 fatalities – just last month with issued some recommendations stemming from that public hearing and our investigations (which I will talk about more later)
  • The second hearing was on the January 2009 USAir dual engine failure following an encounter with multiple Canada geese and subsequent forced landing in the Hudson River;
  • The NTSB held a 3-day hearing on the previously discussed February Colgan accident near Buffalo, in which we focused on cold weather operations, sterile cockpit rules, crew experience, fatigue management, and stall recovery training; and,
  • Finally, next week I will chair 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.

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

I will also push the recipients of our safety recommendation letters to raise the bar of their own accountability.  We simply cannot accept, “We’re working on it,” as a satisfactory response from a regulating agency or an operator regarding an identified safety risk.  We will expect the implementation of corrective action and we will expect the risk to be mitigated or, at the very least, the articulation of 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.  In August he convened an ARC charged with providing recommendations on fatigue.  This is an issue that has been on our Most Wanted List of Transportation Safety Improvements since its inception.  We have seen some negotiated rulemaking activities last for 2, 3 or even 10 years, his quick fuse turnaround time for the ARC was impressive – now we await some real changes to the HOS rules.  Furthermore, just a couple of weeks ago, the FAA announced changes to the airspace around New York City, following the mid-air collision over the Hudson River last month.  The NTSB will analyze those actions to see how they track with our recommendations, but this is an example of the regulator asking, “What’s next?,” and then acting on the answers the receive.

Can we modernize and become more nimble without affecting the quality of our products?  Yes, we can and we will.  The 21st century requires new thinking.  We hear a 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.
As I am challenging staff to increase efficiency, I am also calling for continuous review by the management team — this is our own version of SMS.  Our investigators are looking beyond causal factors. 

  • In a fatal Citation bird-strike accident in Oklahoma City, NTSB staff identified organizational and oversight failures.  While not causal, these failures created a poor safety culture. 
  • In recent HEMS recommendations, we “followed the money,” so to speak, and issued recommendations asking the federal agency that controls reimbursement for HEMS operators to establish safety standards and to audit operators.
  • This week we testified on the Hudson River midair collision.  This was approximately one month after I launched to the accident with our team.  We must provide timely answers to lawmakers’ questions as they look to us, asking, “What’s next?”

After watching our staff in action these five years, I have every confidence they are up to the job, and I will support them in every way in raising the bar for the NTSB and for those who participate in our investigations.  By ensuring that investigators maintain, improve, and expand technical competence — issuing recommendations as soon as they are warranted — and by improving our internal processes, the NTSB will be more nimble, stronger, and more accountable.  

Finally, I want to touch on integrity, which I believe is choosing to do the right thing, instead of the popular thing.  At the NTSB, we investigate accidents and analyze the actions of those involved.  We demand professionalism and vigilance by pilots, flight crew, air traffic controllers and others in the transportation community.  I have challenged the men and women of the NTSB to “hold up a mirror” and be true to our investigative findings by following our recommendations to others with regard to the dangers of cell phone use while operating motor vehicles.  I have issued a policy stating that NTSB employees may not use a wireless device while driving on NTSB business, and that they may not use an NTSB-issued wireless device while driving in any capacity:  on-duty or off-duty.  By “talking the talk,” and “walking the walk,” NTSB professionals — already dedicated to safety — must have the integrity to conduct their activities in accordance with our own recommendations.

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.  Our Office of Transportation Disaster Assistance has developed a system with the airlines to provide a dedicated location at an accident scene — but away from the prying eyes of the press — for those family members to gather and to facilitate our keeping them informed on the progress of the investigation.  And we continue to keep them personally informed 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 to enhance our system of keeping them informed and listening to what they have to say.  

In closing, I would like to express my personal appreciation for the many expressions of support and encouragement I have received from the aviation community — many from those in this room.  I know that you care as deeply as I do for this agency with which I have been entrusted.  The NTSB has a sterling reputation that comes from the work and efforts of the many dedicated men and women who have come before me in this position of chairman for the past 42 years and from the work and efforts of the staff of this small agency with a large mission.  I will do all that I can to maintain and improve on that reputation while serving on this board — and I believe these guiding principles that I’ve discussed are key to attaining that goal.

I want to thank each of you for the work you have done to create and expand the aviation safety network in this country and around the world.  I look forward to working with you during my term as Chairman.