Honorable Deborah Hersman, NTSB Board Member

Remarks of Honorable
Deborah A.P. Hersman, Chairman
National Transportation Safety Board
to the
International Air Safety Seminar

Milan, Italy
November 2, 2010


Thank you, Bill, for your kind introduction.

I am here with you today because last March Bill Voss and I attended the ICAO High Level Safety Conference in Montreal.  As you all know, Bill is always moving forward; you may remember that at that time he was in a soft cast, but even that didn't slow him down.  He told me about the October 8 Foundation and their role in the Milan conference.  We discussed the support and involvement of survivors and victims' families after an accident, and he extended this invitation to continue our dialogue.

I also want to thank Paolo Pettinaroli, the Chairman of the October 8th Foundation, for his warm welcome and for graciously co-hosting this conference.  Last month marked the 9th anniversary of the tragedy at Milan’s Linate airport.  Paolo, I am so sorry for the loss of your son.  We all appreciate the leadership that you have given to the families of the tragedy and your willingness to see through improvements in transportation safety.

We are gathered for the 63rd annual International Air Safety Seminar, but the Flight Safety Institute was founded – and the first IASS held -- in 1947.  The organization and conference were the inspiration of Jerry Lederer, the pioneer who earned the nickname “Mr. Flight Safety.” 

At a time when the global airline industry was in its infancy, Jerry was already looking towards a future where more flights and more passengers would lead to new complications and dangers.  Not only did Jerry develop tools and methods that prevented thousands of casualties, he personally mentored an entire generation of flight safety technicians who revolutionized the industry.

When we examine the sweep of history – from 1947 until today – we can’t help but conclude that the legacy of Jerry Lederer – and the efforts of those who follow in his footsteps – have been enormously successful.

There’s a well-known story about Jerry Lederer.  He was friends with Charles Lindbergh.  In 1927, when Lindbergh was making final preparations for his record-breaking transatlantic journey, he asked his friend Jerry to give the “Spirit of St. Louis” a final inspection.

Jerry was not impressed with what he saw.  Years later, he admitted that he didn’t hold out much hope that his friend Lindbergh would make it through the flight.

That story probably strikes a chord with many in the audience because, whether you are a regulator, a chief pilot, an aircraft designer, or Chairman of the National Transportation Safety Board, like me, you are charged with being the "Worrier in Chief.”

No matter how safe our industry may be, it is our job to make it better, to recommend improvements, and to push for change.  And I know that is exactly why committed professionals like you are here.  Thanks to Yannick and Corky, who raise the bar on safety for the manufacturers; to Danny Ho, who is willing to lead the industry by addressing fatigue in new ways; and to Jim Burin, who works to keep us all focused on safety for the Foundation; aviation has gotten safer ALL around the world.  Each of you in the audience is here to find out, "What is next? What can I do?  What can my organization do to improve?".  Let me challenge you as industry professionals to think about another facet of aviation, one which you may not be altogether comfortable with.

Before I focus on the heart of my speech, let me say that the aviation industry is a leader when it comes to helping others – whether it be the transfer of technology; support for newly formed regulatory or investigative bodies; and being on the front lines of search and rescue operations, victim recovery, and airlifting of supplies to tsunami or hurricane ravaged areas.

So let me ask you to think back to a time when someone reached out their hand to support you.  For me, I grew up as the child of a military pilot.  We moved around the world.  I lived in Germany twice, and in England, Spain and Jordan.  I always remember being welcomed by other families to the base with a cake or a visit when we first moved in.  I also recall being at an airshow that ended tragically.  However, I saw the squadron rapidly responding to take care of the widow and the family left behind.  Maybe you are part of a big family, a small hometown, or a close-knit religious community, or perhaps the organization you work for treats you like family.  So I ask you, how would you want your family to be treated if you were in an accident?

So, even as our safety record has improved over the past two decades, I think you can tell that I believe that one of the areas most in need of attention has been family assistance.

For us, in the US, this need came into sharp focus in 1994 with the tragic crash of American Eagle Flight 4184 in Roselawn, Indiana, which claimed the lives of everyone on board: the captain, first officer, 2 flight attendants, and 64 passengers.  The details of the crash were tragic – but if anything, the details of the crash itself were overshadowed by the chaos and mishandling that followed, which one witness described as “utter confusion.”

Some family members reported that they received delayed and conflicting reports about the status of the passengers on board.  They were given little or no information about support and counseling options, and most questions from the airline focused on medical histories that could be used to limit liability.  The airline even held a mass burial of remains without notifying family members.

One woman who became a leading spokesperson for family assistance, Terri Severin, who lost her sister and four year old nephew in the accident, received some of her nephew’s personal effects -- 8 years later.

One family member eloquently summed it up this way: “It is astounding that the FAA and NTSB can have teams on site or en route within hours of a plane crash.  They can take apart and reassemble this piece of machinery to find the cause, but nothing is done to reassemble the lives of the people left behind.”

Unfortunately, this was not an isolated example.  Several other crashes in the mid 1990s had similarly mishandled responses, misidentified remains, and misinformed families.  The accidents caught the attention of the American people and of the politicians.  The victims’ families from Roselawn banded together with family members from Valujet 592, USAir 427, and TWA 800, ultimately convincing Congress to pass the Aviation Disaster Family Assistance Act in 1996.

The Act – as some of you know – requires airlines in the United States to have disaster contingency plans in place so that assistance can be deployed immediately when a tragedy occurs.  It also assigns the National Transportation Safety Board the responsibility to oversee the government’s family assistance efforts.  To meet this need, the Safety Board created a Transportation Disaster Assistance division, or TDA, and hired professionals from the mental health and forensic pathology fields to lead this effort.  TDA is responsible for overseeing the four critical aspects of family assistance: notification, dissemination of information, victim recovery and identification, and locating and returning personal effects.  

The National Transportation Safety Board has now been directing family assistance in the United States for more than 13 years.  At this point, our outstanding professionals within TDA are prepared to handle almost any circumstance that arises.  But, naturally, this has taken time and a willingness to constantly learn from past mistakes and refine our approach. 

Recognizing the need to maintain investigative independence, the TDA division initially served as a firewall between investigators and family members.  It took time for TDA staff and the rest of the Safety Board’s staff to develop a solid relationship.  To be honest, at first there were some investigators who were not keen on the NTSB providing assistance to families in the aftermath of an accident and initially there was a sense that TDA was a separate entity working within our offices.  Perhaps in those days, erring on the side of caution, the firewall was built too tall.

At the same time, the TDA staff had to learn to interact with our investigators and define their work as impartial representatives of the government with a clearly-defined role.  Given the emotional nature of a tragedy, it is difficult – but crucial – for our disaster assistance team to balance the Board's independent, investigative responsibilities with our role as managers of the post-accident survivor and family assistance.

It is also a constant learning process to determine which accidents TDA should respond to.  We are required by law to provide assistance in what are called “legislated” events  – that is, ones involving Part 121 carriers, and in 1998 it was also extended to Part 129 carriers operating within the United States.  So all foreign carriers that fly into the U.S. must also have a disaster plan on file with the U.S. Department of Transportation and the NTSB. 

We examined this issue further last week at our Airline Code-Sharing Symposium.  However, TDA responds to more than one hundred domestic accidents each year including corporate/business aviation accidents and helicopter EMS accidents, as well as accidents in the other modes of transportation.  I know the the NTSB is not alone in this endeavor and that many in this room could share with us their experiences in providing assistance in similarly tragic events.

Fourteen years since the passage of the Disaster Family Assistance Act, we constantly review and refine our approach.  But ultimately, we can only judge our success by real, on the ground, results.

And that is why I have come here to Milan.  Because it is becoming increasingly evident to me, based on my conversations with Bill Voss, family groups, and my colleagues from other transportation safety organizations around the world, that there is a growing interest in and need for family assistance programs.  That is certainly true here in Europe with the recent enactment of legislation by the EU that will govern future aviation accident investigations.   

Throughout this past year, as I have traveled to international conferences, I hear from my colleagues that there is a growing need to create a more formal process for the assistance of families and survivors.  While accidents involve different operators, different aircraft types, and ultimately have different causes, in the end they do have one thing in common:  they all leave loved ones behind.  The expectations for family assistance may be different in every country, but I was particularly struck, at the annual International Transportation Safety Board Association’s meeting composed of my counterparts from around the world, when my colleagues were looking at me – literally – to take the lead in providing guidance and assistance.

Next year, 2011, will mark the 15th anniversary of the passage of family assistance legislation in the United States.  Since that time, we have developed a program that has matured into a valuable asset for family members and ultimately, for our investigators.  To mark this anniversary, we will be hosting an international family assistance conference in Washington, D.C., on March 28 and 29.  I am grateful to Bill Voss and the Flight Safety Foundation for offering to cohost this endeavor.  So while we hope to provide some information to interested parties about how to build a program, we also seek to learn from our colleagues about how to improve ours.  I hope that many of you will come to Washington in March – or encourage your colleagues and industry leaders in your country to attend.

In addition, our staff is working under the leadership of Marcus Costa at ICAO, along with other colleagues from around the world, to update the ICAO circular on this subject.  I see my good friend, Jean-Paul Troadec from BEA, whose staff is also supporting this effort.
 
Having been a member of the NTSB for over 6 years, I have been on scene at about 20 major transportation accidents.  And I can tell you first hand that having the family assistance team on site has benefitted both the families and our technical staff, because our pilots, engineers, and air traffic control experts can focus on what they do best - determining the cause of the accident. 

When it comes to working with survivors and family members, I recognize that there are resource limitations, cultural sensitivities and, quite frankly, emotional anxiety.  But I will tell you three things:  1) It is the right thing to do; 2) You can't afford NOT to do it; and 3) You will likely see some incredible strength and grace from your fellow man (and perhaps yourself) in the process.
 
The agenda for this conference includes topics that will continue to incrementally improve the safety of a very safe industry.  Tomorrow you will discuss programs like Safety Management Systems, or SMS, and I challenge you to think broadly about the integration of safety programs throughout the industry. 

One of the greatest challenges for SMS is linking all the stakeholders together so that everyone in the chain provides feedback.  An effective organization will take that feedback and learn and grow.  SMS works best if individual, company, and agency programs are linked together to create a holistic approach to safety.  And there is an obvious need to recognize the survivors, family members, and family assistance programs as a part of the overall aviation safety system.

One recent example of family members' involvement in aviation safety in the United States occurred in the aftermath of the Colgan Air/Continental Connection Flight 3407 tragedy.  The group of survivors’ families quickly coalesced into a powerful force for change in aviation safety in the United States.  Because of their persistence and determination, they received personal meetings with political leaders, including President Obama, and ultimately helped convince the Congress to enact tough, new safety standards for commercial aviation on issues like pilot fatigue and training.  The family members developed and pursued their own priorities, some of which were not consistent with NTSB positions, but many of their initiatives were based on recommendations that the Safety Board had been advocating for years. 

The family members of victims are often the “human face” of an accident to the world.  They can compel change but, alternatively, if they are not well-served, their frustrations and grief will be broadcast on television and across the internet for the entire world to see.  Organized assistance between the investigative agency and the airlines provides families with information when they most need it, protects family members from the media spotlight, and allows them to grieve in private.

 Our mandate is to help families through the post-accident process.  However as family members often become engaged in the effort for safer laws and regulations, they can focus the attention of the press and the public on important issues. 

A former president of the National Air Disaster Alliance, Doug Smith, said, “these groups are so vital because families are able to come together in common grief and, as they become united, force issues that can create significant change and movement not only as it relates to a crash, but to the entire industry.”

I want to pause to consider those final words – “to the entire industry.”

This is a crucial point.  When Jerry Lederer was founding the Flight Safety Institute, he almost certainly didn’t envision the globalized world that would exist six decades later.  The participants of this conference may hail from all corners of the globe but, ultimately, the aviation industry will rise or fall as one.

I would like to close by inviting Bill Voss and Paolo Pettinaroli to join me on stage so that I may present them with a challenge coin.  Gentlemen, these coins contain the words that are etched in glass at the entrance of the NTSB Training Center which is dedicated to the victims of transportation accidents and their families.  They say, "From tragedy we draw knowledge to improve the safety of us all."

I thank you for putting on a conference that will no doubt save lives by improving procedures, equipment, and training, but like Jerry Lederer, I challenge all who are in attendance today to take the next step in developing best practices, and to honor the lives that are lost in accidents, by taking care of those they leave behind.

Thank you.  I hope to see you all in Washington in March 2011.