Thank you and Happy New Year.
It is hard to believe we are already in 2010. Where did 2009 go?
When I think of 2009, I think of the opening line of A Tale of Two Cities - “It was the best of times. It was the worst of times.”
The second Monday of 2009 started with a USA Today front page article discussing the exceptional safety record of U.S. commercial aviation. The following Friday the headlines were filled with “Miracle on the Hudson.” In the mind of the American public, the actions of that crew became the epitome of professionalism.
But, four weeks later, we witnessed an equally public aviation accident where the outcome was, unfortunately, far more tragic: the crash of Continental Flight 3407, operated by Colgan Airlines.
And, with that accident, media and Congressional questions of pilot professionalism took on a different meaning. Crew training and qualifications, commuting, crew fatigue, and oversight of regional airline operations – all have been placed under a microscope by Congress, NTSB, FAA, media, and the public.
To further fuel debate, in October we had the Minneapolis-St. Paul over-flight event. More questions emerged about who is flying our planes, and what they are doing behind the cockpit door. Congress jumped into action, with hearings and proposed legislation to ban laptops in the cockpit and downloading CVRs to check for crew compliance with regulations. This, with numerous demands for increased pilot professionalism.
For me, the issue of pilot professionalism is not just the “topic du jour.” For years, I was a contributor to Professional Pilot magazine. The very first article I authored for Pro Pilot was on the topic of professionalism. That was in 1985.
What is professionalism? Professionalism is first and foremost an attitude, but is manifested by a series of behaviors consistent with that attitude. One definition of professionalism includes “meticulous adherence to undeviating courtesy, honesty, and responsibility, plus a level of excellence that goes over and above the commercial considerations and legal requirements.”
Let me say up front that the vast majority of flights in the United States are conducted with high degrees of professionalism. Over three decades of flying for a living afforded me the opportunity to work with some of the finest, most professional pilots you'd ever want to meet.
That said, since joining the Safety Board, my concern for professionalism has only been intensified.
My second week at the NTSB began with my being launched to Lexington, KY for the Comair accident. In concluding the investigation, the Safety Board found that, “the crew's noncompliance with SOPs, including the captain's abbreviated taxi briefing and both pilots' non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew's errors.”
Another data point was my first aviation-related board meeting, which involved a Canadair Challenger that overran a runway at Teterboro. The Board found that the crew failed to ensure that the airplane was loaded within weight and balance limits, and as a result, attempted takeoff with a CG well forward of takeoff limits. When the captain was unable to rotate at Vr, he rejected the takeoff, ran off the runway's end, and careened across a six-lane highway where they struck a car. The aircraft did not stop until it collided with a building.
The Safety Board concluded the pilots' failure to ensure the aircraft was within approved weight and balance limits was “symptomatic of poor airmanship” and a broader pattern of deficiencies in skills expected of professional pilots – skills such as leadership, workload management, communications/briefings and crew coordination.
In my next aviation-related board meeting, the Board deliberated the 2004 Pinnacle Airlines crash at Jefferson City, MO. You may recall that in that accident the young regional jet crew was on a ferry flight. Evidently, they decided that since it was just the two of them onboard, they would, “have a little fun,” as they told ATC prior to things going sour. 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, swapping seats in flight (against airline policy), and 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.
The NTSB determined the probable cause of the accident to be, in part, “the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover…”
In April 2009, the Board deliberated an accident that didn't receive a lot of attention, but nevertheless, the investigation uncovered issues related to lack of professionalism.
Shortly after liftoff, an American Airlines MD-82 experienced a malfunction that led to an engine fire warning. The crew delayed initiating the Engine Fire checklist for almost one minute after the fire warning, and then accomplished only two items on the checklist before interrupting it while the captain made a PA announcement of the impending return to the airport. The crew waited over two minutes from the initial fire warning before shutting off fuel to the engine, and delayed 3½ minutes before pulling the engine fire handle and activating the engine fire extinguishers. These critical delays exacerbated the situation and compounded their problems.
In going through the CVR transcript, I noticed several things that pointed to a casual crew attitude. For example, the taxi checklist was conducted in a non-standard manner. The crew also violated sterile cockpit regulations when taxiing out. And, after starting engines, the captain stated, “I'm ambivalent right now. I got six months to go.” Although perhaps an offhanded comment, when combined with other behavior in the cockpit, I can't help wondering if this comment was, in fact, a true indication of how the captain approached his job on the day of the accident. Quite simply, he wasn't mentally in the ball game when the emergency unfolded.
Another accident that the board deliberated a few months ago involved a Cessna Citation on a charter medical flight. The flight crashed into Lake Michigan shortly after takeoff, killing six, including a very talented organ transplant team. The investigation found that the accident captain had a history of not adhering to procedures or complying with regulations, and he routinely abbreviated checklists. The NTSB concluded that the pilots' “lack of discipline, lack of in-depth systems knowledge and failure to adhere to procedures” contributed to their inability to cope with the situation experienced during the flight.
A hallmark of an aviator's professionalism is insistence on strict adherence to procedures, checklist usage, and sterile cockpit compliance. This is not for the flights where everything goes right. Instead, it is for those flights when things go to hell and you need something to fall back on. You fall back on procedures, SOPs and discipline that have been practiced repeatedly over time. You insist on doing things this way so that when faced with an unfamiliar situation, you are mentally prepared to deal with it because you can fall back on procedures and discipline that are familiar to you.
Unfortunately, there are many more examples than I have time to review today. More importantly, how does the industry improve the level of professionalism in the cockpit? I certainly don't have all the answers, but I believe part of the answer is through management and peer pressure, which plays a large role in influencing both behavior, and the associated attitude of professionalism.
Attitudes can change over time, and often these changes occur because of social pressure, from both management and peers that reinforce group norms through both tangible and intangible consequences for deviating from those norms. Examples of attitudes that have evolved over time include societal views of smoking, drinking and driving, and seat belt usage. Laws, peer pressure and an acute awareness of the consequences of non-conformity have all helped to shape contemporary attitudes on these topics.
In the case of improving pilot professionalism, the laws (regulations and company policies) are already present. In support of these laws, management and pilot associations must provide crews with sufficient training to allow them to develop the required discipline, and as important, must take a firm stance that sterile cockpit discipline, precise checklist usage and strict adherence to SOPs will be followed. To do otherwise is simply not acceptable.
Another critical component of professionalism involves individual accountability and responsibility. Although management must do what it can to influence behavior, it is up to each individual crew member to set high goals for themselves and for their peers in terms of professional performance.
We have a saying at the NTSB that from tragedy we draw knowledge to improve safety of us all. I'm hoping that we can learn from these unfortunate situations and make air transportation safer. The traveling public demands it and they deserve it.
In speaking of professional performance, I think it's only befitting to not simply focus on pilots, but to turn my microscope upon the NTSB. Just as we hold those in the piloting profession to high standards, you, as well as the public at large, have the right to expect the same commitment of the NTSB.
Along these lines, Chairman Hersman has identified three attributes that she pledged would become hallmarks of the NTSB under her leadership: transparency, accountability and integrity. To me, all three of these attributes contribute to the level of professionalism we exhibit as an agency.
Transparency: As an agency, we have always strived to ensure that each investigation is conducted in a transparent manner, through the party system process and through public hearings and board meetings that are open for public viewing. However, we have stepped up the level of transparency by making available online the entire public docket for accidents. This makes accessing these documents easier and less arduous, especially for frequent users, such as you. In addition, for 2010, the Board is planning an increased number of public hearing, forums, and symposia on a variety of topics relevant to improving safety of our Nation's transportation system. We invite your attendance at these meetings.
Accountability: Accountability means that when we take an action or make a decision, we are willing to stand up and explain why we did it. I know from experience that this audience is not shy in asking why the Board rendered a decision on a particular case, and I certainly don't mind discussing why I voted the way that I did. We don't hide at the NTSB.
Integrity: I once heard someone say that, “Wisdom is knowing the right path to take; integrity is taking it.” As transportation advocates, we have to practice what we preach. Along those lines, Chairman Hersman set a policy that NTSB employees will not drive and conduct business on cell phones or text while driving. To me, that is integrity.
By consciously committing ourselves to these principles, I believe we will not only continue to uphold the faith placed in the NTSB by Congress and the public, but we will enhance the safety of our Nation's transportation system, as well.
I strongly believe that the NTSB remains the gold standard around the world for accident investigation and transportation safety recommendations. We cannot, and will not, rest on our laurels. After all, everyone in this room is quick to point out when you believe we have erred. That's the way it should be - you play an important role in serving as a system of checks and balances on the Board's actions and decisions, and we appreciate your role in effecting safety.
In closing, it is my personal pledge to you that the NTSB will continue working diligently toward its mission of protecting the safety of the traveling public, to do so through conducting our jobs in a transparent manner, through remaining accountable for our actions and decisions, and through upholding the principles of integrity. We also will continue to expect the same high level of professional performance of crews throughout the nation, crews that are consistently disciplined and compliant. However, it will take all of us to make sure this happens.
I ask for your commitment in joining the NTSB in this mission.
Thank you and may God Bless our great Nation.