I strongly believe that the traveling public deserves and is entitled to safe transportation, regardless of the mode of transportation they happen to be on. So, I made a commitment when I came to the Safety Board that although I have a strong aviation safety background, I will not limit my attention or interests to just aviation safety issues.
Well, I have been living up to that commitment. Yesterday, I testified to US Senate on rail safety issues. Ten days ago, I spoke to a group of motorcyclists. Last month, I spoke to a natural gas distribution company about establishing safety culture in the pipeline industry. In the last two months, I’ve gone out and ridden on locomotives and on bridges of boats. And tomorrow, I’m meeting with staff on an accident involving an 853-foot freighter that ran aground.
But, as important as those other transportation modes are, and as much as I have enjoyed dealing with and learning about other modes, I’ll have to admit that it is good to be back in an aviation audience. And, what a group of aviation safety giants this happens to be.
I have had a long-standing interest and involvement with Flight Safety Foundation (FSF). I started this with the ICARUS Committee in 1993. Over the years, I have attended and participated in numerous International Aviation Safety Seminars and Corporate Aviation Safety Seminar functions. When I left the airline in 2004 to manage a Fortune 500 corporate flight department, literally the first day I was there I said that I wanted us to join the Foundation. So, I have long been an advocate of FSF.
I came to the Safety Board in August 2006. The last nine months have been a blur – very busy. My second week on the job started with me getting launched to Lexington, Kentucky, for the investigation of Comair flight 5191. Member Hersman was the member on duty for that accident, but I was sent to observe how a board member performs their job on an accident scene. As you know that accident was the worst aviation accident in terms of fatalities that this country had seen in nearly five years.
As tragic as that accident was, it speaks well to the safety of commercial aviation in the United States. Nevertheless, there is more to aviation than just what happens in the U.S, and there is more to aviation than just commercial airlines.
The FSF must continue its quest for the “continuous improvement of global aviation safety and prevention of accidents.”
There are two commitments that I made when I came to the Board. First, is that I would work in a professional and collegial fashion with fellow Board Members and our professional staff. That doesn’t always mean agreeing and it doesn’t mean being a “yes man,” either. What it does mean is that when we do disagree, we can do it without being disagreeable.
The other commitment I made is that when an item comes before me for board action, I will study the issues so that I can ask intelligent questions and clearly understand what we are dealing with.
Now, let me briefly give you my overall thoughts and philosophy on accident investigation.
First, the goal of every investigation should be prevention. We are not here to point fingers, lay blame or assign fault.
Secondly, I strongly believe that we should not focus exclusively on the obvious human error. It is one thing to say a person committed an error. It is quite another to try to understand all of the factors that may have influenced that error. Where was the rest of the system that should have prevented a simple error from being catastrophic?
And since the purpose of our investigations is to prevent accidents, if we focus solely on errors of front line operators, then we may miss valuable prevention opportunities because systemic flaws may remain undetected and thus, uncorrected.
Outside my office I have framed the cover from an issue of ISASI Forum, the journal of International Society of Air Safety Investigators. It says, “The discovery of the human error should be considered as the starting point of the investigation, and not the ending point.”
I hung it outside my office to remind us all of the importance of going beyond simply stating that someone committed an error. We need to answer why the error was made.
I want to make sure that we don’t get away from that philosophy here at the Safety Board. I am very interested in trying to understand why people do things that they do and I am very interested in examining the safety culture of an organization.
I simply define safety culture as “doing the right thing, even when no one is watching.”
In the accident involving Pinnacle Airlines flight 3701, at Jefferson City, MO, October 2004, our investigation uncovered a number of things involving crew performance. Post accident analysis revealed that the crew performed a number of unauthorized actions, including intentionally causing the stall warning system to activate on three occasions, imposing dangerous sideloads on the aircraft’s tail structure by intentionally mishandling the rudder, allowing the first officer to occupy the captain’s seat while the captain sat in the first officer’s seat, along with a series of other serious errors.
Once level at FL410, the crew allowed airspeed to bleed off, leading to stall and loss of control. The high altitude upset disrupted airflow through the engines and both flamed out. Unfortunately, the crew was unable to restart either engine and they paid for this behavior with their lives.
Our investigation could have focused solely on “pilot error,” but instead, we asked questions about why this crew may have thought they could get away with these things. What was going on in that organization that could have possibly enabled this thinking?
These pilots were not typically rogue pilots. In fact, both were generally described as being good pilots. One first officer described the captain as “the best stick and rudder pilot he had ever flown with.” Another pilot who flew with the captain a week before the accident told investigators that the captain operated in a standard manner with no deviations from the Standard Operating Procedures (SOPs).
In spite of these remarks, clearly, on this accident flight they were not doing the right thing when they thought no one was watching. So, I couldn’t help wondering why this crew, an otherwise decently performing crew, would think that on this night they could do the things they did? And during the board meeting of that accident, I asked pretty strong questions about the safety culture of that airline.
I believe good recommendations emerged from our investigation – recommendations that address potential systemic weaknesses. Recommendations like Safety Management Systems (SMS), Line Operations Safety Audit (LOSA), Flight Operations Quality Assurance (FOQA) and Aviation Safety Action Programs (ASAP).
I’d like to move slightly and now talk about the mission of the Safety Board. The letters “NTSB” stand for “National Transportation Safety Board.” It doesn’t mean, “National Accident Investigation Board.”
We do accident investigation very well, but by its very nature, accident investigation is very reactive. I want to make sure that the NTSB is being proactive – preventing accidents without having a smoking hole to prompt safety improvements.
I want to thank FSF for taking the lead in runway safety. As you know, on March 27 – the 30 th anniversary of the runway collision at Tenerife – NTSB held a forum on runway incursions.
Dr. Earl Weener spoke on behalf of FSF and he pointed out that although runway incursions are important, the Foundation’s scope is more broad. In addition to runway incursions, you are looking at runway excursions and runway confusion, such as wrong runway departures.
I would like to see the NTSB consider broadening our Most Wanted List focus to be more comprehensive, such as what you are doing.
As I wrap it up, I’d like to leave you with something to inspire – something provocative.
I note that the Flight Safety Foundation’s objectives are to:
- Pursue the active involvement and participation of the diverse elements of global professional aviation;
- Anticipate, identify and analyze global aviation safety issues and set priorities;
- Communicate effectively about aviation safety; and,
- Be a catalyst for action and the adoption of best aviation safety practices.
As you know, the last major air carrier to experience a passenger fatality in the U.S was American 587 in November 2001. [Note in December 2005, a Southwest Airlines B737 overran a runway at Chicago Midway, resulting in the death of a six year-old occupant of an automobile that was struck by the aircraft.] Since the American 587 accident, we have had the following accidents:
- Pinnacle CRJ dba Northwest Airlink at Traverse City, April 12, 2007
- Shuttle America dba Delta Connection at CLE Feb 18, 2007
- Comair dba Delta Connection at LEX Aug 27, 2006
- Corporate Express dba American Connection at Kirksville, MO, October 2004
- Pinnacle Airlines at Jefferson City, MO, October 2004
- Executive Airlines dba American Eagle at San Juan, May 2004
- Air Midwest dba US Airways Express at CLT, January 2003
Each of these accidents involved regional airlines. This is where the accidents are occurring. This is one of the fastest growth segments in commercial aviation and today, regional airlines are carrying a substantial percentage of the flying public.
For the last number of years, the NTSB has been interested in “one level of safety.” When a passenger buys a ticket on an airline to go from say, Hibbing, Minnesota to San Francisco, he or she may find that the flight from Hibbing to the hub city is being operated by a code-sharing regional airline, while the longer portion may be on a major airline.
In this scenario, the tickets would be sold on major airline’s ticket stock, the passenger would check in through the major airline’s ticket counter and they would board planes that are painted in that major airline’s livery.
Clearly that passenger deserves the same level of safety while traveling on the regional airline portion of that flight as they deserve on the portion flown by the major airline.
So, safety is important for all segments of the industry, including regional airlines. Yet, when I look at your membership lists, I see a surprisingly small number of regional airlines on your membership roles.
Peter Drucker said, “The best way to predict the future is to create it.”
If you don’t like what you see when you look into your safety crystal ball, create a new future.
I hope your future will involve the regional airlines – and other segments - of the industry. They need FSF and I dare say that you need them.
I challenge you to spread your wings.
Thank you for inviting me and thank you for your commitment to improve aviation safety.