Keynote Address of Honorable Deborah A.P. Hersman
National Transportation Safety Board
NATCA "Communicating for Safety" Anuual Conference
March 23, 2010
Thank you for inviting me to be here with you today to talk about our recommendations to improve aviation safety in the United States. This past week the Safety Board issued a couple of recommendations identifying procedural improvements following the NWA 188 over flight of Minneapolis. Just a few weeks ago, the Board met and adopted our Most Wanted List of Transportation Safety Improvements which is like our “top ten” list of recommendations that we would like to see adopted to improve safety in all modes of transportation. Not surprisingly, a number of the most wanted recommendations were in aviation. And last month, we met to deliberate on our final report in the Colgan accident. So even though it is early in 2010, there is much to talk about.
But let me begin by bringing up an accident that occurred 33 years ago this month, when 583 passengers and crew were killed when two fully loaded 747 jumbo jets collided on the runway in Tenerife, in the Canary Islands. This remains the worst accident in aviation history, and it spurred many aviation regulatory bodies to examine runway safety as a priority. Today, it remains the poster child for runway safety. You have already heard from Captain Robert Bragg and his first-hand account of this awful tragedy. It is powerful examples like this that move and motivate all of us to join together to ensure that this type of tragedy is never repeated.
In many respects, I think 33 years later, we can say that we have made significant progress. Over the past four years, the rate of runway incursions has been about 6 per 100,000 tower operations. While these incursions are measured in terms of feet, rather than miles, it is not luck that prevents these from becoming another Tenerife. Rather, it is the robust procedures, safe designs, and well-trained and alert controllers and pilots that have prevented these accidents.
In fact, just last week, the Flight Safety Foundation announced the results of its global runway safety initiative. In its evaluation of the 2009 data, the Foundation found no runway incursion accidents and only one runway confusion event, but 25 runway excursions. This represents 28 percent of all accidents, involving 19 fatalities. Compare this to 2008, when there were 38 runway excursions and 36 deaths. While this demonstrates that we still have a lot of work to do, the good news is that the trend line is going in the right direction.
However, even though the record in the U.S. is getting safer every decade, our job at the Safety Board is to focus on the handful of events that don’t go well. And while we always investigate the accidents that result in loss of life, we must also be attentive to the incidents that do not necessarily result in injury. The incidents may result in close calls, overruns, incursions, wrong runway takeoffs, or landing on taxiways. We can learn so much from the event where no metal is bent and everyone walks away, because we have long rejected the tombstone mentality that we can only act after death and injury. The many things that we learn from not only the accidents, but more and more from the incidents, are the basis for many of the Board’s safety recommendations.
As you know, runway safety has been on the NTSB’s Most Wanted List since its inception in the 1990’s. On the Most Wanted List that we just adopted, we included a number of recommendations to improve runway safety including to:
During my time at the Board, this issue area has expanded from simply runway incursions to ‘runway safety,” which is really a broader and more encompassing term – to include a number of other events that would not necessarily be classified as a runway incursion, but nevertheless present a significant threat to aviation safety.
A runway excursion occurs when an aircraft either overruns or undershoots a runway while landing or taking off. During my time with the Board, we have investigated accidents such as the wrong runway take-off in Lexington, KY, and accidents involving large air carrier overruns during winter conditions at Chicago’s Midway, Cleveland, and Traverse City, to name just a few. That’s why we have recommendations on moving maps and requiring landing distance assessments with an adequate safety margin.
You may recall the accident at Midway in December 2005, a Southwest Airlines 737, which was landing in snowy and icy conditions, ran off the departure end of the runway and resulted in our recommendation on landing distance assessments. The aircraft rolled through a blast fence, an airport perimeter fence, and onto an adjacent roadway where it struck an automobile before coming to rest. A child in that car was killed. There were 18 minor injuries of the 103 passengers and crew on board the flight.
We determined the probable cause of the accident was the pilots’ failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing, which resulted in a runway overrun. This failure likely occurred because the accident flight was the pilots' first experience with the airplane's autobrake system and lack of familiarity likely distracted them from thrust reverser usage during the challenging landing. But we also cited a number of contributing factors, including a failure to include a margin of safety in the arrival assessment to account for operational uncertainties. We issued an urgent safety recommendation as a result of that accident, which asked the FAA to direct all Part 121, 135, and 91 subpart K operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent.
Two years later, we are still waiting for the FAA to issue regulations.
Our runway safety issue area also encompasses landing and taking off on the wrong runway or, worse, landing on a taxiway. Just this past fall, a Delta Air Lines 767 completing a flight from Rio de Janeiro to Atlanta was cleared to land on runway 27R but, instead, landed on the parallel taxiway just north of the runway. It was dark and visibility was reported at 10 miles. While our investigation is not yet complete, the preliminary information indicates that neither the flight crew nor the tower controllers realized that anything was wrong until the aircraft was rolling out on the taxiway. Fortunately, at that moment in time, there was no traffic on the taxiway. One can only imagine that a few minutes earlier or later the circumstances could have been entirely different.
It is interesting to note that because this aircraft landed on a parallel taxiway and not a parallel runway, this incident was not classified as a runway incursion. Regardless of how the FAA classified the incident, the Board took a strong interest in the event because we want to know what led a professional flight crew to mistake a taxiway for a runway, whether the controllers could have detected the misaligned final approach to landing and intervene, and whether there are technological tools that can be used to prevent such incidents from ever occurring in the first place. You can be assured that if this event had resulted in a fatal collision, there would be – far and wide – immediate and understandable calls for changes.
We should not have to wait for an actual accident to improve aviation safety. And trust me, we won’t. I can tell you that when the Board completes its investigation, we will do everything we can to advocate for the kind of changes that will reduce the likelihood of such an event from occurring again in Atlanta or at any other airport.
The NTSB has a long record supporting technology that can provide early warning information directly to flight crews and controllers. When systems have included such capabilities, the benefits are clear. Think about aircraft equipped with systems like EGPWS, which has virtually ended controlled flight into terrain accidents in the U.S., and TCAS which has practically eliminated midair collisions involving aircraft equipped with these systems. The testing of ground safety systems, such as runway status lights, has shown them to be both effective and well-accepted as a means of providing flight crews with additional reaction time to deal with potential hazards affecting their aircraft.
The FAA has been evaluating various technologies that can, in the case of a potential runway incursion, provide a direct warning to pilots of that risk. Whether it is runway status lights, final approach runway occupancy signal, or efforts to develop an ADS-B based surface alerting application that would provide a direct cockpit warning of a runway incursion risk, the FAA is taking commendable actions. But like their response to the recommendations that the Board has made for landing distance assessments, the FAA has been slow to act.
The challenge is that many of these systems are still being evaluated. In 2011, 11 years after the issuance of the recommendation for a direct warning to the cockpit, only 22 airports will have runway status lights installed. And while the FAA is working to develop standards for a system based on ADS-B to provide a direct cockpit warning, the current regulations do not include a requirement for ADS-B.
And even though the FAA has announced that it will provide funding for users who agree to equip their aircraft with an electronic flight bag, which includes moving map displays, or an aural runway alerting system, the program is limited to no more than $5 million. As a result, the program is not likely to be widely adopted.
Beyond runway safety, one area that the Safety Board has become particularly focused on is the goal to reduce accidents and incidents caused by human fatigue in the aviation industry. Our focus on fatigue is not limited to the aviation industry. We are seeing fatigue as a causal or contributing factor in numerous accidents across all transportation modes.
Having said that, however, the issue of fatigue has taken on a renewed sense of concern since the Board considered the February 2009 Colgan Air accident near Buffalo, NY. While the Board did not conclude that the flight crew’s fatigue was a contributing factor to the accident, the report noted that the pilots probably were fatigued. And why? The crew was based in Newark. The captain lived in Florida and commuted to the Newark base, and in the previous three nights, he had spent two nights sleeping in the crew room at Newark. The first officer lived in Seattle and, prior to reporting for duty, flew on a red eye on a cargo flight from Seattle to Memphis and switched in Memphis for another flight to Newark. Over 70% of the Colgan pilots based at Newark commuted, 20% of them from over 1,000 miles away.
While as controllers you may not be subjected to commuting hundreds of miles to get to work, you are no less affected by fatigue. That is why the issue of fatigue and how to manage fatigue was added to our Most Wanted List several years ago after we investigated a number of accidents and incidents where errors made by controllers were attributed to fatigue. We asked NATCA and FAA to work together to address this critical issue. We know from the research that time on task can also be a significant contributor to fatigue. And when we are fatigued, no matter how well we think we are performing, we simply do not perform our best.
The Board has made recommendations to the FAA to set working hour limits for flight crews, aviation mechanics, and air traffic controllers. We further recommend that these limits should be based on fatigue research, circadian rhythms, and sleep and rest requirements. We also recommended that the FAA develop a fatigue awareness and countermeasures training program for controllers and those who schedule them for duty. Finally, we’ve called for the FAA to develop guidance for operators to establish fatigue management systems.
If you have been following the aviation related developments in the Congress over the last year, you know that the leadership of the aviation committees in both the House and the Senate have been focused on a number of issues that were brought to the forefront of the public’s consciousness as a result of the Colgan accident. And while the Safety Board did not find that all of the issues we discussed were causal to the accident, there were many issues that merited further exploration – issues that were not unique to Colgan or even regional carriers. In fact, some of the issues transcend the piloting profession and have a broader application to the aviation industry.
I started at the Board almost six years ago, and in that time we have investigated numerous accidents in which individuals did not perform to the level of their training or to the expectations of their peers and the public. If we look back over the last year, at the issues raised in the Colgan accident investigation, as well as the mid-air collision over the Hudson last August and the NWA 188 overflight of Minneapolis in October, some of the actions by aviation professionals have raised issues of training, judgment, and attention to the task at hand. These events have led us to explore issues of pilot and controller professionalism and excellence.
So, if you were waiting for me to raise the issue of controller day care at the JFK tower, here it is. Now, I don’t want to dwell on that episode since the FAA and NATCA leadership have taken action to address the situation, and much has already been said. But while this may seem like an isolated event, from our perspective at the Safety Board, we are concerned about these disturbing lapses in judgment. You know, Washington is a town where perception is not always the reality. But in this case, I’m afraid that what we perceive is a reality and that we are witnessing events which demonstrate a decline in the professionalism of the aviation industry. Incidents like bringing children into the safety sensitive area of a control tower or losing your situational awareness and overflying the destination – as the pilots of NWA 188 did – have led us to conclude that something is happening in the industry that deserves greater scrutiny.
Just to footnote my reference of Northwest 188, last week the Safety Board issued two recommendations to the FAA arising from this incident. In particular, we asked the FAA to establish and implement standard procedures to document and share information at those ATC facilities that do not have such procedures. The information that is shared between controllers electronically must be at least as comprehensive as the information that was passed by paper strips.
The Colgan accident raised concerns about the recruitment, training, and retention of flight crews. And, as you know, the FAA forecasts that thousands of experienced and seasoned controllers will be retiring. All of this begs the question, where are we going to get the next generation of pilots and controllers?
In May, the Board will be conducting a three day public forum on pilot and controller excellence. I want to extend an invitation to you to participate fully in this project. But I also want to assure you that this public forum is not intended to embarrass anyone; it is not about assigning blame or pointing fingers.
Instead, this is a deliberate attempt by the Safety Board to dedicate time to learn and discuss these important safety issues. And while many concerns have been raised in our accident and reports, we have not had the opportunity to explore the challenges and the possible solutions in greater detail – a focus that we think they deserve. We want this forum to contribute to the public dialogue that is ongoing right now – in an informed manner. Let’s put the facts out on the table and, as an industry, let’s try and see if we can identify some best practices for addressing these challenges.
You know, it has been said that professionalism is not the job you do, it is how you do your job. We think this forum would be an excellent opportunity for NATCA to discuss its best practices. I know from my experience with the Board that America’s air traffic controllers are a truly dedicated and professional work force. We often see outstanding performance in the course of our investigations: controllers who are on the crash phone before an excursion when they see an airplane moving way too fast for conditions on the surface of the airport and controllers who are actively monitoring the many aircraft on their scope and communicating about lost aircraft. And when you ask them about their performance, they say that they were “just doing what they were trained to do.” And while I’ve listed some accidents and incidents that raise questions and concerns about controller training and tools, I also know that more often than not, you are giving 100 percent to your job – and in turn, 100 percent to ensuring the safe transportation of millions of your friends, neighbors and citizens who travel every day by air.
Last night, you recognized that professionalism and dedication to safety by acknowledging the work of your colleagues with the Archie League Awards. Let me join in extending my congratulations to these men and women for their exemplary work. In reading the citations for their awards, there is one theme that seems to emerge: that faced with a potentially dangerous situation, these controllers responded calmly and deliberately, providing clear and concise instructions and directions that safely brought the aircraft back to the airport.
The Board’s forum in May is about these controllers. Through our work we are very good at finding out what went wrong, but frankly, it is just as important to know what is going right, because we want to replicate that throughout the entire national airspace system. It is the stories like the ones you heard last night that we need to hear more about. I know that they were honored for their professionalism and for raising the bar on safety in their center or tower, but I’m sure if I go around the room I would hear more examples just like those – examples of people doing the right thing every hour of every day, week in and week out. Doing your job well isn’t impossible, but it is hard. It requires discipline, commitment, and focus.
The people who take time to be here at a conference like this are committed to doing the right thing and doing the right thing right. For all you do, I thank you individually for keeping us all safe. And to Paul and Trish and the many other leaders at NATCA, thank you for working so hard to promote safety in our industry. We can do more to raise the bar on safety. I look forward to working with you to ensure the continued safe operations of our aviation system.