Honorable Deborah Hersman, NTSB Board Member

Chairman Deborah A.P. Hersman
National Press Club
Washington, DC – April 21, 2014
"When The Rope Breaks: Why We Protect Against Unlikely Risks"


Thank you Myron [Belkind] for that gracious introduction, and thank you to the very busy people who've taken time out of their day. And I want to thank you for the invitation to come back to National Press Club.

Does anyone remember the Reliable Source before it was remodeled in the 1990s? There were little brass plates that had cool quotes on them all over the walls. Perhaps some of you who are reporters still have one of those brass plates. A lot of them were about an independent press as a check on government -- where I've spent most of my working career.

But I've spent much of it at the National Transportation Safety Board, where independence is critical. Do we investigate, report, and go where the facts lead us? Yes. Is that similar to what you in the press do? I think it is.

But your primary responsibility is to inform the public; Our primary responsibility is to investigate to reduce future risk. So, when do we intersect? When risk becomes news.

Today I want to talk about risks, especially unlikely risks, and why we pay attention to them, and when they become news.

There's a story about a secluded village high on a mountaintop in a prosperous kingdom where life was treasured. The only way to visit this secluded village was to be hoisted up in a rope-drawn basket, accompanied by a village elder.

One day a visitor notices when he gets in the basket that the rope is badly frayed. But he rationalizes that surely such a place would never put at risk their own elders and visitors.

Once the basket is off the ground the wind starts to picks up, the basket's swaying, and he's sure that the rope has just a little too much give to it. And he rationalizes that they must find extra-special rope that has a lot of "give" because of the windy conditions near the village.

Finally, halfway to the top and hundreds of feet from the ground, the rope is squeaking and groaning and he feels that he just has to say something. So he turns to the village elder in the basket next to him and says, "So how often do they replace the rope?"

The elder thinks for a moment and says, "Whenever it breaks, I guess."

So, do you think that that is good governance?

Or perhaps more relevant for the audience here today -- when the rope breaks, would you write the story about it?

I can see your headline now: "Beware: Village of Death!"

But let's make the question a little bit harder. Maybe rope is very expensive, and 10,000 passengers make the trek up in that basket before the rope breaks.

Now should you wait until the rope breaks?

What if the rope costs as much as solid gold. Should you wait until the rope breaks?

Sure, we could add all sorts of different variables. But what if you or someone that you love is the 10,000th visitor?

Or, what if you write the story of the 10,000th visitor? Then that stranger becomes someone that we all know. And the trouble is that by that time, the rope has already broken.

So let me tell you what happens when the rope breaks, in real life.

25 years ago, the NTSB investigated the crash-landing in Sioux City of a United Airlines DC-10, Flight 232. The crew of this airplane did an amazing job in a no-win situation. If anybody here in the room is a Star Trek fan, this was the Kobayashi-Maru of DC-10 simulators.

The flight took off from Denver bound for Chicago, and on the way, the tail mounted engine exploded, severing all of their hydraulics. Although the plane's two wing-mounted engines were still operable, the crew had no control over the very esssential control surfaces of the airplane.

Crew members shuttled back to visually inspect the tail and wings, while others methodically tried to access the control surfaces, to no avail. They kept the plane flying, using the difference in thrust between the two engines.

The captain realized that they would have to perform a crash landing and informed the crew. The crew then had the task of preparing the passengers on that flight for that landing.

But there was no way to prepare the littlest passengers. There were children under two on board and they were permitted to sit on their parents' laps.

So as the passengers and cabin crew waited for the brace signal, that senior flight attendant picked up the microphone and reminded parents to buffer their babies by wrapping them in towels and blankets, and placing them on the floor, and bracing them with their hands and legs.

And that's exactly what two mothers did, Lori Michaelson and Sylvia Tsao.

But the plane's final approach speed was over 240 miles per hour. The right wing caught on the runway; the plane cartwheeled, broke into three pieces, caught on fire, and came to rest in a cornfield.

That crew couldn't control the landing. Nobody could.

Those mothers couldn't hold onto their babies. Nobody could.

Amazingly, 185 people survived that crash. But tragically, 111 did not.

In the aftermath of the crash, in the burning fuselage, Lori and Mark Michaelson could not find their 11-month-old daughter Sabrina. They had to make a choice no parent should ever have to make: whether to escort their 4- and 6-year old sons out of the aircraft to safety, or to stay, to look for Sabrina.

In the thick smoke, they made their choice. They got their boys out of that airplane safely. Mark ran back to search for Sabrina. He heard her cry -- but only once.

Sylvia Tsao tried to return to the plane to find her son, Evan. But that senior flight attendant who prepared them for the crash landing blocked her path and told her she could not return to the burning aircraft. She said helpers would find the baby.

Sylvia Tsao then looked up at that flight attendant and said, "You told me to put my baby on the floor, and I did, and he's gone."

Ever since then, that Senior Flight Attendant has been on a crusade to ban lap-held children from flights, advocating forcefully on the issue and testifying before Congress.  Journalists -- maybe some in this room -- have drawn attention to the issue, telling the stories of those aboard flight 232.

Ten years earlier, in 1979, the NTSB had already recommended that the FAA research, and issue a rulemaking on, restraint of small children. We recommended restraints for lap-held children after the Sioux City accident, and we have been recommending it ever since.

Some people say the risk is small. I tell them no, a baby is small. We secure laptops and coffee pots. Yet we do not secure our most precious cargo, our children.

Are there other risks the NTSB should also pay attention to? Of course.

How many people die in large airplane crashes? Just a handful, in the last 4 years, in the United States. But 30,000 people die every year on the nation's highways.

Do you think we should back off aviation safety? Most people don't. Most people want those frayed ropes replaced before they break. Not after, but now.

Safety is never just about numbers. 1,500 people died when the Titanic sank. There was room in lifeboats for scarcely half aboard, and, because of ill-defined evacuation procedures, some lifeboats departed half-empty. In response, 100 years ago this year, 13 nations concluded work on the Safety of Life at Sea, or SOLAS.

Then World War I broke out, followed by the Spanish flu pandemic, where tens of millions died. Did we forget the Titanic?  No, because the story had been told in newspapers, art, and poetry. People learned what happened to strangers, and they wept.

Did we forget about SOLAS? Again, no. Today, there are 159 countries that have signed on to that agreement.

Once the rope breaks, you know you can't let it break again. People expect some things from government, and a good, and improving, standard of safety is one of those things. That's because part of who we are transcends statistics and facts: It has to do with how our brains are wired.

So I'd like to ask the journalists in this room to think back to an interaction with your first editor that really sticks with you, and for the rest of us, to think about an interaction with your first boss, that you really remember. Got it? Show of hands:  how many of those memories were good memories? How many of those memories were bad memories?

I saw a lot of hands go up for "bad" and only one for "good." That really helps to prove a point, and that has to do with how we remember things.

The amygdala influences the encoding of episodic memory. Or in layman's terms, bad memories stick. So think about it: Some actors won't read their reviews, because if a review mentions 9 things that are good about them, they'll remember the 10th thing, something bad about them. Companies spend big money trying to help their employees overcome their fear of change, because there's an awful lot of people who say "we tried something different 20 years ago and it didn't work," and they remember that.

We evolved that way to survive. If you're a cave-man, and a saber-tooth tiger ate your friend a mile east of the cave, it's really important to remember not to go to that place that's a mile east of the cave.

We learn by seeing.

So when you raised your hand before in response to my question a set of motor neurons fired -- the neurons that tell your muscles what to do.

When you lowered it another set of motor neurons fired.

But something else happened just now. When you watched me raise my hand and some of your motor neurons fired again -- as if you had raised your hand.

These are called mirror neurons, and they're key to learning and teaching: So if you're teaching a child to tie their shoelaces, you do it first, you show them how to do it, and then they copy you.

Think of how much easier that is for a child to learn to tie a knot all by themselves in a new way.

So this is very helpful for survivability -- if you're teaching someone to throw a spear or build a fire. It's another reason why we've survived.

But there's more. When I scratch my hand, sensory neurons fire in your brain, just because you're watching me.

The only reason you don't feel it in your hand is that you have a combination of types of neurons. But if you numbed your hand so there's no feedback, you would actually feel your hand being scratched.

The Spanish phrase for "I'm sorry" is "Lo siento" -- it means "I feel it." It's not just a colorful phrase. When we see something or hear about suffering, at some level, we feel it. We might override it. In fact, we have a mix of mirror and normal neurons to do just that. But we are hard-wired for empathy.

By the way, if you want more on mirror neurons check out V.S. Ramachandran's Ted Talks on it. I've borrowed from him shamelessly.

So what do mirror neurons have to do with replacing the rope?

We know that bad things stick with people, and we know that we empathize. So we have to replace the rope. And, we know there are some risks that we can't personally control. That means that sometimes we have to cooperate to replace the rope. But fortunately, we're wired to do just that.

We form societies to teach each other where the predators live, and eventually we rid the area of predators. We band together against enemy tribes. And we teach each other where to find food so we don't starve.

This contrasts with theories of social Darwinism -- the idea that some people are weeded out and the few that remain get all the goodies.

Nobody wants that rope to break, so that the other, safer villages get more visitors, visitors to the bad mountaintop village die, and the village is cut off from the kingdom and withers away. Because that person in the basket could be you or someone you love.  In fact, part of your brain thinks it is you.

So you demand they replace the rope.

25 years ago United flight 232 crashed in Sioux City. Last year Asiana flight 214 crashed in San Francisco with more than 300 people aboard.  The plane struck a seawall short of the runway, pirouetted, and came to rest thousands of feet down the runway.

Only three people died, not 111 -- in part because the two crashes were different, but in part because of safety advances since 1989.  These were the first 3 fatalities in the United States in more than 4 years of commercial aviation. Ninety-nine percent of the passengers on board Asiana 214 survived that crash, and I know you've all seen the footage of it.

But do you think that that statistic comforts the families of the three people who were lost?

For them, this crash was the ultimate tragedy. This Summer NTSB expects to issue its final report on the crash, in hopes of preventing more tragedies.  Because the next life lost could be yours, it could be mine, or it could be any of ours.

Our brains tell us so.

I began telling you about two mothers, Sylvia Tsao and Lori Michaelson, who could not hold their babies in place in 1989.

But there is more to the Michaelsons' story, because there was another passenger on this crash, whose name was Jerry Schemmel. He heard little Sabrina's cries, and he felt around in the overhead bin -- which by this time was on the floor, because the plane was upside-down -- he felt toward her, grabbed a leg, and he pulled her into his arms.  Outside the airplane, he handed Sabrina to a woman in the cornfield, who eventually reunited her with the Michaelsons.

Later, the Michaelsons were able to thank Jerry Schemmel for doing the right thing, doing what his human empathy impelled him to do -- for acting in that selfless way when others were in need of assistance.

But like so many heroes, when Jerry Schemmel was interviewed, he said,

"I'm not a hero, because you would have done the same thing."

But there was no hero for Evan Tsao, and there's somebody who's never forgotten that. The senior flight attendant that day was Jan Brown. I'm honored to share the stage with Jan today, and she came from Chicago to join us.

Within a month of arriving at the NTSB as a new Board Member, I got a call from Jan, imploring me not to remove the issue of child passenger safety in aviation from our Most Wanted List.

Jan always mentions Evan every time she talks about this issue, saying, "This year, Evan would have been 16," and I think, maybe getting his driver's license. "This year, Evan would have been 18." Maybe leaving home for college for the first time.

Well Jan, this year, Evan would have been 27. And maybe if circumstances had been different, he'd be a reporter, covering some other speaker, here today.

So that's why you protect against tail events -- and why people want to write, and read, and watch, the stories of tail events.

Because we're wired to do it. Because it could have been us -- and to some of our neurons, it was us. Because – as Karen [Eckert] and all the families know - making sure that the rope gets replaced is the right thing to do.

We wouldn't accept cars without seat-belts today. We wouldn't accept airliners without evacuation slides. Yesterday's tragic lessons are today's safety wish list - and tomorrow's unacceptable risks.

In the 10 years since I started working with the NTSB, I've seen more news segments that talk about proactive solutions - people replacing the rope before it breaks. Reporting on the disaster is covering your beat. Preventing it gets you a Pulitzer.

We have a whole list of frayed ropes called our Most Wanted List - Occupant Protection is one of the 10 issues on that List. You get to decide what is news.

Because when society is assigned the job of preventing tragedies, it is forever judged by its ability to do so.

As it should be.

Thank you very much.