Good evening and thank you for having me. I truly appreciate the opportunity to be surrounded by those who have a passion for improving aviation safety.
Aviation safety has been something that has been of tremendous interest to me for 40 years. You see, I got into aviation by accident.
When I was 17 years old, I heard on my car radio that there had been a plane crash on approach to my hometown airport in Columbia, South Carolina. I decided to go see if I could find the crash. As I approached the crash site, I saw the coroner and decided to tuck in close to him. As he walked towards the accident site, I stayed close to him. And as the law enforcement officers raised the yellow tape for him, I slipped in with him.
And, don't ask me how this happened, but on the way home, I drove by the airport and stopped in to Miller Aviation and signed up for flying lessons.
So, yes, I sort of got into aviation by accident.
As I progressed through my pilot certificates and ratings, I continued to think of that accident. I occasionally returned to the accident site. I would try to understand what was going on in the cockpit of that aircraft as they approached Columbia Metro on a low overcast day.
And, while at the University of South Carolina, instead of studying whatever I was supposed to be studying, I would spend countless hours sitting on the floor of the Government Documents Library, reading NTSB accident reports.
So, although perhaps I got in to aviation "by accident," so to speak, I truly had a lifetime appreciation of accident investigation and a passion for working to prevent accidents.
I know many of you are excited to be here at the IHSS, so that you can learn and share the latest thoughts on helicopter safety initiatives. That said, I suspect there may be a few of you who are discouraged. Perhaps you may be discouraged that despite your passion and hard efforts, helicopter crashes are still occurring; discouraged that your goals aren't being met as quickly as you would like; discouraged, perhaps feeling your work is all for nothing.
And, why do I suspect some of you may feel a little discouraged? Because, as one safety professional to another, I know from experience that when we care about something as much as we all do, I know how we can feel after tireless efforts and crashes still occur.
You may be asking yourself: "Is it all worth it? It is really worth all of the time I have spent on these safety initiatives?"
Well, to answer that and keep it all in perspective, let me quote words that are enscribed into the grave of Oskar Schindler. If you have seen the movie "Schindler's List," you will recognize that Schindler saved thousands from death. "And whoever saves a life, it is considered as if he saved an entire world."
Well, just remember this: to go out and make a significant difference, you don't have to go out and save an entire world. You only need to keep one person from getting into trouble in a helicopter. If you have done that, it is as if you have saved an entire world.
Admittedly, though, the paradox is that you probably never will be able to fully appreciate just what you've done.
In many cases, you have prevented a problem from ever being introduced into the system. The person who you may have saved probably will never realize that it was a group of dedicated safety professionals who gathered in Montreal for the first time in 2005 and formed the International Helicopter Safety Team. The people whose lives you've saved have probably never even heard of the IHST's initiative to reduce the worldwide helicopter accident rate by 80% by 2016.
They will probably never realize the efforts made to:
- Influence a significant change to pilot training by using simulators, like those efforts by two Terrys: Terry Eichman and Terry Palmer.
- or to work passionately to promote and translate SMS for small helicopter operators, like the work of Keith Johnson.
- or to push for ADS-B in the Gulf of Mexico.
- or to come to the NTSB and tell the NTSB chairman and staff that in order to conduct more thorough data analyses, the Helicopter JSAT needs better helicopter accident data from NTSB, like Matt Zuccaro, Joe Syslo, and a few others did. (And, we listened by the way. We have inculcated into our investigative procedures a special helicopter data collection checklist as a result of that meeting).
- Or to spend countless hours poring over data, looking for that gold nugget, as Fred Brisbois has done.
You will probably never receive the direct satisfaction of knowing that you have helped someone.
But let me assure you â€¦ the work you are doingâ€¦ it does matter. It does make a difference. It is important. And yes, it does keep people from dying in helicopter crashes.
And, frankly, if you don't do it, just who in this industry will do the work that needs to be done?
As one safety professional to another, I want to thank you for your tireless efforts.
We have a plaque outside of our training center that says: "From tragedy we draw knowledge to improve the safety of us all." And, that is what we do at NTSB. We take something tragic and through our investigations, try to learn from it so it won't happen again.
Sometimes, things take longer than we would hope, but, with a lot of pushing, things eventually get implemented.
On September 10, 1999, about 1204 Alaska daylight time, a Eurocopter AS-350B-2 helicopter, N6007S, was destroyed when it crashed on the Juneau ice field near Juneau, Alaska. The helicopter crashed on a level surface while flying near cruise speed, in a level attitude. The helicopter was being operated by TEMSCO Helicopters (TEMSCO) as a VFR, on-demand sightseeing flight under 14 CFR Part 135. The certificated commercial pilot and four passengers received minor injuries. The remaining passenger received serious injuries. The pilot was not instrument rated.
The pilot said that, during a gradual descent over a large, featureless, snow-covered ice field, a localized light snow shower momentarily reduced his forward visibility. He also stated that he was "unable to discern any topographic features, only a dark shape on the horizon." He stated that immediately before impact, he believed the helicopter was 500 feet above the surface. Three pilots who were in the area at the time of the accident all stated that overcast conditions, localized snow showers, and flat light conditions hindered their ability to discern the surface of the glacier. They added that weather reports and forecasts from Juneau often did not represent the actual weather in the mountains and over the ice field.
When that helicopter didn't return as expected, TEMSCO launched another helicopter (N6052C) to search for it. The pilot said that, while searching the upper portion of the ice field, deteriorating weather conditions to the north and east required him to proceed south, down the ice field. He slowed the helicopter to 15 knots and attempted to use a mountain ridge to the right of the helicopter for visual reference. He said, "Visibility in front was enough to see all the way to the top of the Herbert (greater than 3 miles). The ceiling sloped down to the east 45Âº with a height at the ridge of approximately 700 feet." He said that flat light conditions made it difficult to see the ice field below but he thought his helicopter was 500 feet about the surface. It wasn't. Seconds later, his helicopter crashed into the snow covered terrain
Well, guess what? When the second helicopter also didn't return, TEMSCO sent a third helicopter (N6099Y) and crew to search for the other two. The pilot said he located the first downed helicopter about 2 miles in front of him. He said that he slowed the helicopter to about 30 knots in an attempt to gain visual reference by using a mountain range to the left of the helicopter and the debris field associated with the N6007S accident site to the front of the helicopter. He said that the ceiling at this location was at least 1,000 feet above ground level, and visibility in the direction of N6007S was more than 6 miles. He said he thought he was at least 500 feet above ground level and that flat light conditions hampered his ability to see the topographical features of the ice field below. I think you can see where this is headed.
Three crashes by the same operator within less than 5 hours, all at about the same location. Incredible! The fortunate thing is that, despite having to spend a very cold night on the glacier while waiting for rescue, there were no fatalities or severe injuries.
NTSB determined that flat light was a factor in the three crashes.
A person who I suspect most of you know, a guy named Clint Johnson, was the NTSB investigator on those three crashes. I can only imagine Clint's frustration of going out on these crashes because only three months earlier, he investigated a similar crash on the glacier that was related to flat light. Unfortunately, in that crash, there were 7 fatalities.
In response to these four crashes, largely in part to Clint's efforts, the NTSB issued a safety recommendation for "installation of radar altimeters in all helicopters conducting commercial, passenger-carrying operations in areas where flat light or whiteout conditions routinely occur" (NTSB recommendation A-02-35). That recommendations was issued in 2002, the year my daughter was in third grade.
Just last week, FAA issued the rule to require radio altimeters. My daughter is now a sophomore in college. Yes it took 11 years, and additional accidents where lack of radio altimeter was a factor have occurred â€“ including a HEMS flight that crashed into the Potomac River outside of Washington DC in January 2005 that claimed two lives â€“ but we finally have a requirement for radio altimeters.
Yes, things move slowly. Too slowly. Yesterday I testified to Congress on safety issues. There was a congressman who ripped into one of the DOT administrators, asking why it takes so long for regulations to be issued. It's certainly a good question.
In 2006, NTSB conducted a safety study of 55 air ambulance crashes, 41 of which involved helicopters. The NTSB issued four safety recommendations in that study, including one for installation of H-TAWS on HEMS flights, and a requirement that all HEMS legs be conducted under Part 135 regulations, even when the patient is not onboard. The FAA responded by requiring these things, but it took eight years for that regulation to be implemented.
As many of you will recognize, 2008 was the most deadly on record for U.S. HEMS operations, with 29 fatalities. That year, NTSB placed HEMS on our Most Wanted List, and in February 2009, NTSB held a 4-day hearing on HEMS. I had the privilege of chairing that hearing. Emerging from that hearing, the Board issued 21 broad-sweeping recommendations. Some appear to have been addressed through the helicopter rule announced last week, and some have not been addressed.
So, as you can see, sometimes the slowest way to get something done is to wait for the regulatory authority to make the change. Another way â€“ one this is often faster and more efficient, is to urge voluntary compliance â€“ and that is precisely what you are trying to do through the IHST.
My colleague, Earl Weener, tells me that the nearly 80% reduction in airline fatalities in the past decade are attributed largely to your sister organization â€“ The Commercial Aviation Safety Team, CAST. That reduction resulted from not a single regulation. All of the safety enhancements that emerged from CAST were voluntary in nature.
I don't want you to underestimate or discount the work that you are doing. It is so important and it can be enacted so much more quickly than regulatory efforts.
I started out by applauding your efforts. And, if you get nothing more out of my comments, just remember the words carved into the tomb of Oskar Schindler: "And whoever saves a life, it is considered as if he saved an entire world."
I guarantee, your work is saving an entire world. Thank you and keep up the great efforts!