Deborah A. P. Hersman
Thank you, Barry (Eccleston) for that gracious introduction. First, I'd like to recognize the NTSB team in attendance: John DeLisi, Director of the Office of Aviation Safety, and from our Office of Communications: Kelly Nantel, Lynn Dorfman, and Tom Zoeller.
I'm especially delighted to see Mylene Scholnick and the International Aviation Women's Association in attendance and also one of the most amazing gentlemen I have ever met, my dear friend, Mr. Hans Ephraimson-Abt, a true champion for those we have lost too soon in air crashes.
It is wonderful to be with you at the fabled Wings Club with its celebrated history, notable members and guests: from C.R. Smith to Fred Smith and from Jacqueline Cochran to Kathryn Sullivan.
It's clear that for today's Wings Club members, aviation is still as much calling as career. You are all committed to this endeavor that Igor Sikorsy described years ago: "Aeronautics was neither an industry nor a science. It was a miracle."
As Wings Club members, you have achieved and witnessed many of those "miracles" from your midtown perch. In 1942, when the club was founded, you saw aviation as an instrument of war, an agent of peace and a growing means of commerce.
Your first board included aviation greats Eddie Rickenbacker and Juan Trippe and members – pioneers and visionaries – who laid the foundation for 21st century aviation.
Look at the safety progress! In 1942, when your first leaders were drawing up the club's bylaws, unlike today, the trip to the airport was the safer part of the journey.
Fast forward to 2013. Talk about the spirit of St. Louis: Every day, the equivalent of the population of the St. Louis area – more than 2 million -- are aloft on U.S. airlines – defying gravity, safely and surely.
Today's safety record has been achieved through the work of Wings Club members and the entire aviation community -- operators, manufacturers, regulators, labor, service providers and, yes, the independent accident investigator.
As David Hinson outlined in the 32nd Wings Club Sight Lecture, a host of developments brought us to today's record -- improved airframes and engines, enhanced technology for air traffic control, weather detection, simulated flight training, and more. There’s also a greater appreciation of human factors with improved practices, such as Crew Resource Management.
Yet, how did commercial aviation learn it needed these improvements?
Most of the lessons were hard earned … and learned … through crashes, lives lost, and tarnished records. Accidents followed by painstakingly thorough and transparent investigations conducted by the investigator that Congress specifically created to be independent.
Independence, which is essential to the NTSB's effectiveness in finding out what happened -- and why -- and recommending a path toward the solution.
That's what I want to talk about today: defying gravity and building upon today’s strong commercial aviation safety record. And, about the unique role played by the NTSB: 400 people you may likely never meet, 400 people you may not want to know, but 400 people you need to know about.
Since 1967, the NTSB has conducted more than 132,000 aviation investigations and issued over 13,000 safety recommendations. Each year we investigate about 1,400 general aviation accidents - and we assist in dozens of foreign investigations around the world. Right now, we are supporting efforts from Bagram to Bali and from Paraguay and Pakistan.
ICAO Annex 13 establishes a framework for working with our international counterparts, whether it is an Airbus event in the United States or a Gulfstream event in Germany. The value of U.S. participation in foreign investigations is that we can identify issues before they become problems here at home. In short, NTSB participation provides U.S. stakeholders with access to early findings and advances the safety of U.S. products.
Yet, with the last fatal U.S. airline crash - Colgan Air near Buffalo - 52 months, or some 40 million flights ago, some may think that the NTSB and independent investigation is "so last century."
And, I know, that at times, with the NTSB's independence and transparency, you may love us, or loathe us.
If we're investigating your operation, your product or your client, the spotlight is uncomfortable. No one enjoys the national glare of attention and examination. Nor is an investigation's openness always welcome.
But, in other investigations, where the focus is elsewhere, the findings and fixes may help you, the broader aviation community, and, most importantly, air travelers.
Recall the Alaska Airlines MD-83 plunging into the Pacific Ocean in January 2000. John DeLisi, who worked on that investigation, recalls that operators quickly checked, found problems, and the NTSB's materials lab looked like a "jackscrew farm" with so many units sent to Washington for examination.
Our investigation was just starting, yet there was consensus among the team that the jackscrew assembly had experienced unusual wear. The result: operators promptly changed maintenance procedures on their MD-80 series aircraft. Safety was served.
Who knows how many lives were saved?
Yet, love us or loathe us, commercial aviation needs us. It is the public -- those 730 million passengers who fly on U.S. airlines each year - that the NTSB represents. They count on an honest broker with the ability to identify existing - and emerging - safety issues and push for needed improvements.
Just as importantly, the public counts on an independent expert to represent their interests in an investigation and to keep them informed.
FAA has investigators. Industry has investigators. But, as the independent safety investigator, the NTSB is able to: ask the tough questions, call the balls and strikes and challenge the community to find solutions to crucial safety issues.
Asking the tough questions. In our investigation of the 2009 Colgan Air crash near Buffalo, we asked a lot of tough questions... questions about pilot training and professionalism, about standard and sterile cockpit procedures, about pilot records, and more.
But, perhaps the toughest question was about pilot commuting. How can you be rested and ready for duty when you slept the previous night in a lounge chair and were up at 3 a.m. sending emails or when you commuted the night before from Seattle to Newark via FedEx through Memphis?
We asked: Shouldn't there be better regulations for flight crew rest and addressing fatigue?
In a recent investigation, we found fuel starvation in an emergency medical services flight - the helicopter pilot had been texting during flight, but also during the preflight check.
The use of personal electronic devices is prohibited during flight.
But, we asked: What about during crucial preflight activities?
It's because of that Congressionally endowed independence that the NTSB can ask the tough questions. Sometime we raise issues that one side doesn't want to talk about. Other times we raise issues that no one wants us to talk about.
And, there have been times, when we've pushed ahead while others have retreated. That’s because, the NTSB's only stake in the outcome is preventing the next accident.
Congress understood that where you stand really does depend on where you sit.
Next, calling the balls and strikes. Umpires don't pull in the big bucks, appear on trading cards, and they aren't always popular. But they don't go into that line of work to win popularity contests. They do it to make a difference and to ensure fairness on the field.
To a person, aviation professionals come to the NTSB to make a difference and to enhance safety in our skies.
Like umpires, the NTSB calls them as we see them. And, like umpires, we do it from a position of neutrality with an unbiased up-close view of the action.
Here's an example of a "called strike." In our investigation of the October 2004 crash of a Pinnacle Airlines repositioning flight, we highlighted the pilots' unprofessional behavior: flouting the rules and taking the aircraft its certification ceiling: flight level 4-1-0.
We've called "out" controller professionalism as well - such as when, in 2009, a controller in the tower was distracted by personal phone calls, and a private plane and a helicopter collided over the Hudson River, killing nine people.
Frequently in investigations, just like in baseball, one team's strike is another team's ball. But, with our vantage point "objectively" behind the plate, the NTSB has the perspective to make the tough calls.
Lastly, challenging the community to find solutions. We conduct investigations, follow the facts, and flag the issues.
Look at mid-air collisions. For decades, investigators went to repeated wreckage sites caused by mid-airs. Those investigations highlighted the need for a fix so pilots could quickly respond in close-call situations.
But, it took decades before industry applied its ingenuity and responded with TCAS.
Similarly, there were repeated CFIT crash investigations and NTSB calls to warn pilots of approaching terrain. The response - TAWS - and then, even more effectively, enhanced ground proximity warning systems - saved countless lives. It is truly the warning track before the fence for those outfielders tracking that long, high ball.
In the TWA 800 investigation, we determined that the center wing tank's flammable fuel/air mixture ignited to cause the explosion. We called for a fix, and in time, FAA and industry engineers figured out how to reliably and more economically develop an inerting system.
And all of you New Yorkers remember, just two months after 9/11, the American Airlines crash in Belle Harbor. Following the investigation, we challenged Airbus to make the rudder system on its A300 and 310 aircraft safer. It did. Airbus installed a monitoring system that warns pilots who reverse their rudder inputs.
It used to take dozens of crashes and decades between problem identification and solution.
But today, the responses are expected to be much quicker. For instance, when we flagged New York City airspace issues after that 2009 mid-air, FAA put together a workgroup and made changes within months.
While the NTSB has no dog in the hunt, we do not fly solo.
The party system allows the Board obtain additional expertise and provides stakeholders a window into the investigation. Allowing them to see early, and firsthand, the evidence they may need to take corrective action, such as in April 2011 when the fuselage on a Southwest Airlines 737 ruptured. The plane diverted and landed safely in Yuma.
Our investigators found a 9-inch by 5-foot hole. Next, our lab's close examination of the skin found fatigue cracks emanating from rivet holes. Within days, the FAA issued an emergency airworthiness directive requiring lap-joint inspections. These inspections revealed cracks in several airplanes, which were immediately removed from service and repaired.
Safety was served.
I mentioned the importance of identifying and understanding emerging safety issues, which can be a challenge with the growing complexity of aircraft, engines, components, systems, and more.
That's why, on January 7, when we learned about a lithium-ion battery fire on a JAL 787 at Boston Logan we immediately sent an investigator to take a look. Fire on an aircraft is never a good thing. And, the 787 is a new airplane, with, as Boeing describes it, "a suite of new technologies and revolutionary design."
We needed to know more. Was the battery fire a ball or a strike? We couldn't know unless we checked it out.
On January 11, the FAA announced it would conduct a comprehensive review of the 787’s critical systems, including their design, manufacture and assembly. At the same time, the FAA voiced its confidence in the 787's safety.
Then, less than a week later, on January 16, as we were tearing down the JAL battery, an ANA 787 performed an emergency landing after the pilots received warnings about smoke and a fault in the battery system. We sent an investigator to Japan to serve as an accredited representative on the JTSB's investigation.
ANA and JAL grounded their 787s.
The next day, the FAA issued an emergency airworthiness directive for 787s to cease further flight.
The FAA grounds a U.S. fleet.
The first time a U.S. aviation authority grounded a fleet was after a fatal Lockheed Constellation crash in 1946. The second grounding came 33 years later, after the 1979 Chicago DC-10 crash that killed 275 people.
This year, 34 years after the FAA grounded the DC 10, we see only the third commercial grounding in U.S. history.
This is big. And the pressure was, and is, intense to get to the root of the problem.
Two incidents in two weeks on two operators' aircraft.
Is it a ball or a strike?
In today's global aviation environment, with so much at stake, it's crucial to conduct a thorough, objective, and, yes, independent investigation.
We sent investigators to the battery manufacturer in Japan. We sent investigators to the battery integrator in France. We sent investigators to the battery charger manufacturer in Arizona. We sent multiple teams to meet with Boeing in Seattle. And, we brought in outside battery experts.
In April, we held a forum on lithium-ion battery technology and then an investigative hearing on the 787 battery fire, which brought more experts and more light to bear.
We released an interim factual report in March and we plan to release the final report before the end of the year.
But, here's what strikes me about the 787 battery story - which is still to be fully told - it is sign of how risk intolerant we have become. As air travel becomes safer and safer, the tolerance for risk, for failure, is reduced.
Look at the biggest difference between this FAA grounding and the last one in 1979.
No one died.
We live in a different era now. We've seen 52 straight months without a fatal U.S. commercial accident.
There are higher standards today. And greater expectations. Much greater.
Yet, the absence of accidents does not equal safety. Safely defying gravity thousands of times each day requires constant vigilance. That's because risk remains and always will. What the aviation community has done is learn and apply effective ways to mitigate many of the risks that we've identified.
And, there's no credit from the public for past achievements. Airlines are only as good as their last flight. What happens today is a given and continued improvement is expected to safely defy gravity tomorrow.
The consequences of failure can be dramatic. Yes, loss of life and injuries, but also loss of business and hard-earned public confidence.
But, there are no "miracles" in modern aviation. The remarkable safety record is the result of a lot of hard work by a lot of players. With the reduced tolerance for risk and the public's high expectations, every player, every team, must come to the field with their A-game: ready to play and ready to respect the calls, whether they are balls or strikes.