Honorable Deborah Hersman, NTSB Board Member

"Dedication to Excellence"
NATCA Communicating for Safety Conference
Las Vegas, Nevada -- March 5, 2013


I'm so glad to be here with you today. Several NTSB colleagues are here, too, including Board member Earl Weener, who is talking with you tomorrow and former controllers Dan Bartlett and Betty Koschig.

This is a return trip for me. I joined you in Orlando and talked about three things:  runway safety, fatigue and professionalism. Today, three years — or more to the point, 150,000,000 operations later — I am delighted to provide an update, but, more importantly, to be a part of communicating for safety.

One-hundred-and-fifty-million operations. Every day, NATCA members handle thousands of aircraft — airliners, business jets, GA aircraft, emergency medical services, public-use aircraft, military movements and so much more.

Every day — to quote a familiar phrase — you guide these aircraft home.

Every day, you contribute to what is arguably the world's safest aviation system.

And, every day, as more and more people realize what cuts to the federal budget could mean, it is understood that your work contributes immensely to our economy and our quality of life.

Today, especially as we face these fiscal challenges, I want to focus on something that comes from within: your "dedication to excellence." While we are in a period of unparalleled safety for the scheduled airlines, you and I know that comes from a lot of hard work and a lot of things going right.  You know, that not every flight has a happy ending. And, as you'll hear from Member Weener tomorrow, much work remains to be done to improve general aviation safety.

Yet, it's a GA story I want to share today. I don't tell it to make a point about improving GA safety; but to showcase your dedication to excellence.

January 4, 2013, was a typical winter day in South Florida — warm and humid. In the early afternoon, a pilot took off from Ft. Pierce in a Bonanza bound for Knoxville, Tennessee. He'd filed a VFR flight plan.

It wasn't long into the flight when the pilot contacted Daytona approach control. He reported vibrations in the propeller and engine to the controllers and they feared the Bonanza had a big problem.

Daytona advised that the closest alternates were all IFR with cloud ceilings of 900 to 1,000 feet.

The controllers leapt into action: One coordinated with ATC facilities along the plane's route — clearing a path for the stricken Bonanza, while another controller offered to take the flight on a less-congested frequency.

Among the Daytona team, they discussed and considered all options. But, the only thing the Bonanza pilot heard was a reassuring, calming, professional voice.

The approach controller routed the pilot to the closest airport with a surveillance approach:  Flagler County Airport in Palm Coast. Then he gave the pilot vectors for an unpublished approach that would take him over land, not ocean. The route itself was a backup — the plane was tracking Interstate-95's six lanes of pavement.

The supervisor called 911 to line up emergency services and kept them on the line.

The next report from the pilot:  "zero engine oil pressure" and "cool cylinders."

That afternoon the Daytona controllers showed as much teamwork, under pressure, as could be humanly achieved.

Sadly, the plane did not make it. It crashed into a house one mile short of the runway. The pilot and the two passengers perished.

But that tragic ending was not for lack of controller effort, ingenuity and determination. NTSB investigator Betty Koschig interviewed the Daytona TRACON controllers and was deeply impressed by their commitment, compassion and dedication to excellence. 

That story, and others like it, plus those millions of safe operations every year — that's a powerful testament to your dedication to excellence. And, it's that dedication to excellence that I want to talk about today.

I'll start with NATCA's new "Turn Off, Tune In" anti-distraction campaign. Paul (Rinaldi), I appreciate your leadership on this issue. At the NTSB, we've seen the deadliness of distraction in all modes of transportation. We've investigated accidents caused by distracted truck and bus drivers, by distracted mariners, by distracted locomotive engineers and by distracted drivers of personal vehicles.

Distraction is a serious problem, which is only going to get worse as more and more devices and electronic options compete for our attention.

Operating a 40-ton truck, piloting a ship, driving a car, controlling air traffic — all demand and all deserve our full attention, because in our work, we see the consequences when attention lapses occur.

Over the years, the NTSB has recommended measures to address distraction in every mode of transportation.

Further, to encourage people to "turn off and tune in" in all modes of transportation, we put eliminate distraction in transportation on our 2013 Most Wanted List.

You also won't be surprised to find improve the safety of airport surface operations on the 2013 list. That's because, while commercial aviation has made great safety strides, significant risk remains on the airport surface. We continue to investigate runway overruns, wrong runway departures, and collisions between aircraft and with ground equipment.

But, let's look at two issues that were on our Most Wanted List in the past — fatigue and professionalism — where NATCA's focus and dedication to excellence have made a difference.

First, fatigue, which has long been a serious safety issue across all transportation modes — particularly with so much shift work where bodies are denied their need to sleep at night.

Sleep science is so much more mature than when the NTSB first identified fatigue as a safety issue decades ago. Now we know that no matter how long you work on the midnight shift your body will never adjust.

We've seen the safety consequences. They can be fatal. Other times, they're close, too close.

For example, a conflicting clearance at O'Hare in March 2006. An A320 is cleared to cross runway 4L. Less than 15 seconds later, the same controller clears a 737 to take off on 4L. The 737 pilots see the A320 moving toward the runway, reject the takeoff and stop before reaching the taxiway intersection.

What happened? The controller forgot the A320 instruction. He'd worked an eight-hour shift the previous day. During his nine hours off duty he had four hours of sleep before returning to work the next morning at 6:30.

I could go on. Fatigue is serious. Our need for sleep is deadly serious. It is non-negotiable. Every body, everybody, needs restorative rest. You cannot just tough it out.

Three years ago in Orlando, I met with a collaborative group of professionals from both NATCA and FAA that were committed to addressing this issue. We are encouraged by the work that continues today to manage the risks of fatigue, to mitigate the challenges of shiftwork and to recognize the value of rest.

It is National Sleep Awareness week. We are all challenged in our lives to get adequate recuperative rest, but it is even more essential in your work.  Addressing fatigue takes commitment, policies, scheduling, recognition of medical issues and sleep disorders and education.

But, it's not all on the organization. Managing the risks of fatigue requires each one of us to have our own personal dedication to excellence and report to work as rested and ready as we can be; we are accountable to the people we serve, to our colleagues and to ourselves.

But like everything else, addressing fatigue comes down to organizational culture. It takes a sustained focus to change behavior and culture. That starts at the top with strong commitment and support from senior leadership.

I commend NATCA and FAA for your dedication to excellence and the commitment to address fatigue and change your culture ... one recuperative break at a time.

Finally, I would like to commend NATCA and FAA for rolling out the National Professional Standards Program this morning.

And, as with fatigue, this new program on professional standards takes leadership commitment and culture change. The training, the education, the policies and practices — the follow through — are all vitally important to continuous improvements of your profession.

Because there are safety consequences.

This is why your efforts with distraction, fatigue and professionalism and your dedication to excellence are so important.

Yet, the real moment of truth is what is happening every day ... every night ... in the towers, TRACONs and centers — one operation at a time. That's when it comes down to you as a group, but you, individually. With all those aircraft and people counting on you to guide them home.

That's why I opened my remarks talking about the struggling Bonanza pilot and the Daytona controllers who were there for him. That truly is a story of communicating for safety and dedication to excellence.

It's spring training time, so I will close with a quote from baseball great, Ted Williams (who was also a fighter pilot).

He said, "A man has to have goals — for a day, for a lifetime — and that was mine, to have people say, "There goes Ted Williams, the greatest hitter who ever lived."

Your goal is equally high:  Dedication to excellence, safe operations, saving lives and guiding people home.

It doesn't get any better than that.