Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A. P. Hersman
National Transportation Safety Board
"Improving Aviation Safety: Reactive, Predictive, Preventive"
Aero Club of Washington, DC
Washington, DC - September 18, 2012
(As Prepared for Delivery)


How great to be joined by so many aviation professionals. And, thank you, Aero Club, for inviting me back - it's hard to believe that I was "right here" three years ago today - two months after being confirmed. At that time, the Colgan crash was weighing heavy on the U.S. aviation community and Air France 447 was lost in the Atlantic.

This afternoon, I'll share the perspective of the nation's independent investigator and safety advocate. I'll highlight improvements in how we - the entire transportation community - are advancing safety.

As a result of a lot of hard work by people in this room - including operators, like the A4A members here today; labor, like NATCA and ALPA; manufacturers, like Boeing and Airbus; regulators and legislators - there's been great progress in improving commercial aviation safety. The result: no fatal air carrier accidents since 2009.

In particular, I salute DOT's and FAA's leadership in issuing a long-awaited science-based rule for flight and duty time ... since fatigue has been on our Most Wanted List for more than 20 years. In the aftermath of Colgan, Secretary LaHood and former Administrator Babbitt committed to update flight and duty time regulations.

Last December, the final rule they delivered was the product of a long and difficult journey ... one that we would say still has one more stop on its itinerary ... since to be truly science-based the final rule must recognize that fatigue is a safety risk whether the payload is passengers or pallets.

Maintaining aviation's strong safety record is going to take all the tools in the safety toolkit, including continued emphasis on accident and incident investigation, data collection and analysis, new and emerging technologies, and, to be sure, cooperation.

I see Jim Hall here today. Jim well remembers our longest investigation - the more than four years spent on the USAir flight 427 investigation that involved a rudder hard-over and that began in 1994.

The B737 that crashed outside of Pittsburgh eighteen years ago was only required to have 8 parameters on its flight data recorder.

Today, the minimum is not 8, but 88. And, manufacturers now deliver aircraft with hundreds-to-thousands of parameters.

In 1994, there were no FOQA programs. Today, there are dozens. And, as ALPA knows, in 1994, the number of ASAP programs: zero. Now, they number more than 200 and extend across disciplines. In 1994, ASIAS wasn't even an acronym. Today, it includes data from 43 airlines and other sources.

Yes, there is a wealth of data, which must be used effectively and responsibly.

Yet, it's important not just to collect the data, but to ask the right questions. Because we just don't know what we don't know.

Take the 2008 Learjet-60 accident in Columbia, South Carolina, which got noticed because of the music celebrities on board.

After experiencing tire failures, the pilot commanded reverse thrust to stop the airplane. However, failure of the air-ground signal due to wheel-well damage resulted in forward - not reverse - thrust. At high speed, the airplane overran the runway, careened through a fence and hit an embankment, killing the two pilots and two passengers.

A systems analysis had been performed during the airplane's certification in 1993, and again in 2001, following an accident. Unfortunately, the design issue that led to both accidents went unaddressed until that second crash in Columbia.

Not being able to predict, much less prevent, accidents can be the inability to consider what could happen, rather than what should happen.

This is why the NTSB investigates incidents, such as the 2010 overrun at Jackson Hole and the 2011 overrun at Chicago Midway.

We identify what went wrong - in these cases, delayed thrust reverser and speed-brake deployment - and could have the ability to evaluate the incident against fleet experience to be predictive.

At the core, our role is to issue safety recommendations - to be preventive.

Moving from reactive ... to predictive ... to preventive is a challenge. But, through greater sharing and collaboration, the aviation community can take data points - in mountains of information - and connect the dots not just to maintain, but to improve, the strong safety record.

Congratulations to all of you - government, industry and labor - for this unprecedented period of safety for airlines and for corporate aviation.

However, as you know, our next challenge is general aviation.

GA Safety is on our Most Wanted List. This summer, we held public hearings on improving GA Safety and Search and Rescue. We're also seeing great voluntary safety efforts, like the work of the FAA Safety Team, AOPA's Air Safety Institute, EAA, and NATA's Air Charter Safety Foundation.

But, last year, there were 1,466 GA accidents that killed 444 people.

More needs to be done.

Now, I realize if you are on the receiving end of our safety recommendations, you may think that we spend all our time investigating your organization.

But, with 34,000 annual fatalities across all modes, there's a lot the NTSB does outside of aviation.

You might see yourselves as aviation professionals, but our world is intermodal, as Aero Club President Bob Bergman can surely tell you.

Let me use Bob, your renaissance man, to help me make my point.

After lunch, Bob might ride the Metro back to his office.

You all remember the June 2009 collision of two Red line trains that killed nine people and injured dozens more. We issued safety recommendations to the Washington Metropolitan Area Transit Authority, the Federal Transit Administration, the DOT and more.

You might be surprised to know that the NTSB has investigated seven Metro accidents in the last five years.

Today, things are different at Metro. It ordered new cars. It has a new general manager and new Board Members who know, and who make it clear, that safety is a priority and begins with their leadership.

WMATA has committed to implementing all of our recommendations.

And, the recent surface transportation reauthorization - MAP-21 - addressed another recommendation. It gives FTA crucial safety oversight authority to set national transit standards.

What about this evening when Bob heads home? He may be on the Beltway along with thousands of other cars and commercial vehicles, you know, like those 80,000-pound FedEx trucks.

Let's see a show of hands if you've ever told a nervous flyer, "The ride to the airport is more dangerous than your flight."

Well, you're right.

About 85 people die every day on U.S. roadways. By this weekend, the equivalent of the people here at lunch will be gone. Five times as many - injured.

Unfortunately, we don't hear about most of these crashes.

The ones that get media attention are the crashes that cause multiple fatalities. This year, we wrapped up investigations of two I-95 bus crashes - the one in the Bronx that killed 15 people and another in Doswell, Virginia, that killed four.

Over the last ten years, the NTSB has investigated 25 bus crashes. Again and again, we see the same failings: a fatigued driver, poor occupant protection and marginal operators who are only put out of service after a fatal accident.

I commend the Federal Motor Carrier Safety Administration for its aggressive stand on bus safety, such as the recent one-day shutdown of 26 bus operations and for tough new rules prohibiting interstate truck and bus drivers from using handheld cell phones.

And, NHTSA is addressing improved occupant protection. Manufacturers are now voluntarily including seatbelts as standard equipment on new buses.

So, where's Bob now?

He's pulling into his driveway. Maybe Bob is thinking about the next Nats game in their hunt for the pennant.

But, I doubt he's thinking about pipelines, which, yes, are a form of transportation and supply our homes, schools, and offices with natural gas and our airports with jet fuel.

Did you know that there are some 2.5 million miles of pipelines in this country?

That's enough to circle the earth 100 times.

We recently issued a report on a pipeline rupture in Marshall, Michigan. Enbridge, the Canadian operator, did not recognize the rupture for more than 17 hours and attempted to restart the pipeline twice, which released 840,000 gallons of crude oil into the Kalamazoo River.

This summer, Enbridge paid a record $3.7 million fine. That fine pales in comparison with the $800 million dollars - and counting - cost of the cleanup, the most expensive U.S. onshore cleanup in history.

Last year, we released a report on Pacific Gas and Electric's gas explosion in San Bruno, California, that killed eight people and injured 58 more.

In both cases, we found problems with their risk management programs, their emergency response and with safety oversight.

Repeatedly, we've seen that federal and state officials are stretched thin.

They need regulations with teeth and the resources to enable them to take corrective action before a spill. Not just after.

Coming from aviation, you may be surprised to know that fewer than 120 federal inspectors are charged with overseeing those millions of miles of pipeline.

Yes, the NTSB covers all modes. Our goal: improved safety. But, more to the point: it's about saving lives.

Remember, it just takes one accident - on YOUR ride back to the office, in the infrastructure running underneath YOUR community or involving YOUR company to change everything.

I'll close with a story from my summer vacation in Alaska. And, as you know, travel in Alaska definitely involves planes, trains, buses, and ships. I even got to see the trans-Alaska pipeline - a highlight of every transportation wonk's vacation.

We spent one of our final days on a school bus in Denali National Park looking at the scenery. But, the real draw is the wildlife: seeing the "Big 5" - grizzly bears, wolves, moose, caribou and Dall sheep. When we got on the bus, our driver, M.J., warned that the "wildlife are wild" and gave us, what I would call, a standard safety briefing.

She cautioned us at every stop to stay close to the bus because they had seen grizzly bears in the area.

But, M.J. reassured us, "We've been doing these trips for 30 years and no one has ever been killed by a bear."

We did see bears - at first, just small brown specks moving down the hillside. In the parked bus, we sat and watched what looked like a mother and a big cub make their way down the mountain. But, once they were almost close enough to lean out the window to get a good photo, M.J. drove away.

She said the bears were used to the buses, but they shouldn't get too close to people. Nobody complained, but we had hoped for better photos after 8 hours packed into a school bus.

Well, four days later my husband and I are back at home reading The Washington Post ... and we find this headline: "Backpacker killed by a grizzly bear in Denali National Park, marking first fatal mauling in park history."

The article continued: "What prompted the attack is not known but a camera was found nearby and photographs reveal that the victim had been as close as 50 yards and had photographed the animal for at least eight minutes."

So, what does my story have to do with transportation safety?

If you think about, it just takes one instance, one accident, to change the narrative.

We are in an era of relative safety in commercial aviation, but the lack of accidents does not mean that the risks are not there.

Last month, the NTSB completed our investigation into the accident at the Reno air races. For the 37-year history of the races, there had been no crashes that killed fans - until last September when a highly modified P-51D crashed into the box seating area and killed 10 spectators and injured scores more.

Yes, one tragic event can change everything. When it comes to safety, we must be ever vigilant.

So for, Bob, and everyone, on all your travels, remember, as the sergeant used to say on Hill Street Blues, "Let's be careful out there."