Mark V. Rosenker, Acting Chairman
National Transportation Safety Board
April 5, 2006
Thank you very much for that gracious introduction. It is truly a pleasure and a privilege to be given the opportunity to kick off this second day of the 2006 World and Regional Airline Training Conference and Tradeshow.
Since its inception in 1967, the National Transportation Safety Board has been mandated by Congress to investigate transportation accidents, including every U.S. civil aviation accident, to determine the probable cause and issue safety recommendations for accident prevention. The Safety Board has issued more than 12,000 safety recommendations, and I'm proud to say that more than 83 percent of them have been adopted by government, manufacturers and operators, not only within the aviation community, but also within the transportation industry as a whole.
This is a crowd that clearly recognizes that a safe and efficient aviation transportation system is essential for the commercial viability, economic health, and security of the nation. Yet, last month, the Safety Board released statistics for 2005 showed an overall increase in civil aviation accidents for both scheduled airline and general aviation operations. The statistics indicate we all need to maintain a strong focus on safety in all segments of aviation, and I am here today to reiterate the Safety Board's commitment to making a safe industry even safer. One good way to do this is to improve TRAINING...something that all of you have gathered here this week to learn about.
If there is one thing that I would like you to take away from my remarks today, it is that your participation in this conference will help save lives !
There have been numerous tragic major airline accidents throughout the years in which inadequate training in the areas of flight crew procedures, cabin crew operations, and maintenance actions was causal or contributory. Fortunately, major aviation accidents involving fatalities are becoming a rare event in the United States, but there is still much work to be done, both in this country and throughout the world. Some recent accidents provide excellent lessons about how inadequate training can lead to needless death and injuries. An overview of these recent investigations, as well as accidents from the early days of jet aviation, tell a compelling story of why government and industry must remain vigilant of the importance of good training in accident prevention, whether it be training for pilots, mechanics, or flight attendants.
MAJOR AIRLINE PILOT TRAINING
This overview of accidents begins with one that occurred on March 30, 1967, just two days before the birth of the NTSB. It provided one of the most vivid examples of how training can save lives. You see, before April 1, 1967, aviation accidents were investigated by a branch of the U.S. Civil Aeronautics Board, or CAB. The CAB's "go-team" of investigators launched on a fatal accident in which a Delta Air Lines DC-8 crashed into a hotel during a training flight near New Orleans, Louisiana. The flight was to provide training to a pilot in how to handle a loss of power to two of the four engines. When the CAB go-team returned to Washington DC after completing their on-site documentation, the came home to a new agency called the NTSB. This investigation and hearing focused on the emerging use of simulators for flight training. As all of you know, there are no injuries or deaths when you crash a simulator, and this major accident, which was one of the first ones ever to be completed by the NTSB, was a seminal event that drove the industry in a new direction.
We've come a long way since that accident 39 years ago, but advances in technologies have created new challenges. While training for advanced flight management systems appears to take a bigger slice out of minimum training requirements, teaching basic airmanship skills must remain a core competency of the training curriculum. In an age when aircraft are getting larger and aircraft systems are getting more complex, and in an age when flight crews have been reduced by one-third, a fundamental tenant of any training program must be to ensure that flight crews master all normal, abnormal, and emergency aspects of flight operations. That is but one of many of your challenges as training professionals.
In emergency situations, particularly when the automation of modern aircraft fails, the pilots have to rely upon their basic airmanship skills and effective crew resource management to fly the aircraft. One of the best examples of this was the DC-10 crash in Sioux City, Iowa in 1989. Although the number 2 engine failure caused the loss of the three hydraulic systems which powered the airplane's flight controls, the aircrew, by working together as a cohesive team, were able to bring the aircraft into Sioux City for a crash landing. Although this was a great tragedy, 185 people survived a situation for which no pilots had ever been trained.
One area of basic airmanship skills that should continue to be emphasized during flight training is stall recognition and recovery.
On December 22, 1996, a DC-8 operated by a cargo airline impacted mountainous terrain in Narrows, Virginia while on a post-maintenance check flight. Three flight crewmembers and three maintenance technicians on board lost their lives. The Safety Board determined that the flight crew, neither of whom had actually handled the controls in an actual stall in a DC-8, failed to recognize they were in a stall and made improper control inputs during a stall recovery attempt. The Board issued recommendations to require manufacturers and operators of flight simulators improve the fidelity of simulators in order to reproduce the stall characteristics of airplanes, and also to add training for recovery from stalls with pitch attitudes at or below the horizon to the special events training program. Safety recommendations were also issued to require air carriers establish appropriate flight crew training and qualification requirements in their training manuals for non-routine operations, such as functional evaluation flights.
Other Safety Board investigations have unfortunately revealed deficiencies in pilot training programs. In fact, the second deadliest aviation accident in U.S. history was, in part, caused by deficiencies in the Airbus A300 pilot training program. On November 12, 2001, an Airbus A300 crashed into a residential area of Belle Harbor, New York, shortly after takeoff from JFK Airport. All 260 people aboard the airplane and 5 people on the ground were killed.
The airplane crashed because its vertical stabilizer separated as a result of overstress due to high aerodynamic loads created by the first officer's unnecessary and excessive rudder pedal inputs after the aircraft encountered wake turbulence. The Safety Board determined that pilots generally had little exposure to, and therefore may not have fully understood, the effect of large rudder pedal inputs in normal flight, or the mechanism by which rudder deflections induce roll on a transport-category airplane. In addition, the airline's training program may have reinforced the first officer's tendency to respond aggressively to wake turbulence. The training encouraged the use of full rudder pedal inputs and misrepresented the airplane's actual response to large rudder inputs. Finally, the airline's A300 pilots were not well trained regarding the airplane's reduction in rudder pedal travel with increasing airspeed. Safety recommendations were made to address all of these training issues.
REGIONAL & COMMUTER PILOT TRAINING
Partly based on the tragic aftermath of accidents, and the Safety Board recommendations that followed, there have been significant changes over the years to improve regional and commuter aviation safety. One of these changes occurred in the mid-1990's and involved the alignment of commuter airline regulations with the more stringent safety standards that applied to large air carriers. This included aligning pilot training with the more rigid standards.
Regional Airlines can certainly benefit from aviation training, as evidenced by a recent non-fatal accident in Puerto Rico. On May 9, 2004, a commuter airline flight involving an ATR 42, skipped once, bounced hard twice, and then crashed at San Juan, Puerto Rico. The captain was seriously injured and the first officer, 2 flight attendants, and 16 of the 22 passengers received minor injuries.
The Safety Board determined that the probable cause was the captain's failure to execute proper techniques to recover from the bounced landings and his subsequent failure to execute a go-around. The airline did not have standardized guidance, training or procedures regarding bounced landing recovery and the company did not teach its pilots bounced landing recovery techniques. The Safety Board determined that pilot performance would be improved if additional guidance and training in bounced landing recovery techniques were available, and we issued safety recommendations to the FAA to require air carriers to incorporate bounced landing recovery techniques in their flight manuals, and to teach those techniques during initial and recurrent training.
CABIN CREW TRAINING
Cabin Crew Training is also critical to ensure the safety of our traveling public. Flight attendants perform vital crewmember functions, and like pilots, are also charged with ensuring safety of the aircraft and passengers during flight. Several accidents and incidents have highlighted the importance of training flight attendants to handle situations that they may encounter during flight.
The Board issued its first recommendation about flight attendant training in 1968 and has continued to evaluate flight attendant training and procedures during its accident, incident, and special investigations. In a 1992 special investigation report on flight attendant procedures and training, the Board acknowledged that: "There were many examples of flight attendants who performed well, even heroically, during life-threatening emergencies and who were responsible for preventing and/or minimizing injuries to passengers." However, the Board also found examples of flight attendants who were not adequately prepared to handle emergency situations.
A series of accident and incidents caused by in-flight fires raised new concerns at the Safety Board about crewmember training for fighting in-flight fires. In September 1999, a MD-88 experienced an in flight electrical fire and made an emergency landing in Kentucky. After locating the source of the smoke, the flight attendant asked the captain's permission to use the Halon extinguisher on the fire, which delayed an immediate fire fighting response. About one year later, a DC-9 experienced an in-flight electrical fire and made an emergency landing in North Carolina. The investigation revealed that neither flight attendant attempted to locate the source of the smoke in the cabin or to use any of the firefighting equipment available to them. It was also noted that the airline's flight attendant training program did not include any drill involving hidden fires. A third accident near Washington DC occurred in November 2000 when a DC-9 was struck by lightning and experienced an in-flight fire that began shortly after take off. One of the flight attendants was able to successfully extinguish the fire by cutting a hole in the ceiling panel and discharging fire extinguisher agent.
Based on these three accidents, and other accidents and incidents involving in-flight fires, the Safety Board determined that, as a result of limited training, crewmembers may fail to take immediate and aggressive action to locate and fight fires. Further, the Board determined that crewmember knowledge about Halon was inadequate. Additionally, the training programs did not adequately prepare crewmembers to fight the type of hidden in-flight fires that are most likely to occur in airplanes. The Safety Board issued five safety recommendations to the FAA in January 2002 regarding improved crewmember training for fighting in-flight fires.
Maintenance training is also a very critical tenant of aviation safety. As more sophisticated and complex aircraft enter the fleet, it is more important than ever for the mechanics to be technically trained and qualified. The quality of the aviation maintenance professional has a direct impact on aviation safety. Too often, aircraft accidents have major contributing factors such as poor maintenance work practices, inadequate training, supervision, or oversight, as well as insufficient quality assurance. Maintenance accidents continue to occur. Constant vigilance to improve maintenance practices, oversight and training is essential to reduce the number of aviation accidents attributable to maintenance.
The importance of maintenance training to aviation safety can be highlighted in several recent Safety Board accident investigations.
A little over 3 years ago, a Beech 1900D crashed shortly after takeoff in Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed. It was determined that the airplane's flight control system had been mis-rigged during routine maintenance and rendered the airplane uncontrollable. The Safety Board's investigation revealed that the inspector and mechanic performing the flight control rigging did not diligently follow the rigging procedure as written, and they missed a critical step that would have likely detected the misrig condition, thus preventing the accident. In addition, the airline did not have maintenance training policies and procedures in place to ensure that each of its maintenance stations had an effective on-the-job training program. Further, they did not ensure that the maintenance training was conducted and documented in accordance with the company's maintenance training program. Numerous recommendations related to maintenance training were issued by the Board.
Another maintenance related accident involved the crash of a MD-83 in the Pacific Ocean off the coast of California in January 2000. Eighty-eight people lost their lives, and the Board's investigation determined that the MD-83 lost pitch control as a result of a failure of the horizontal stabilizer jackscrew. The investigation found that maintenance issues contributed to the accident, particularly inadequate lubrication of the jackscrew, procedural variability with the periodic endplay check, and use of a non-conforming tool for the endplay checks. The Board recommended requiring maintenance personnel and QA inspectors involved with the lubrication and inspection of the pitch trim system of DC-9, MD-80 and Boeing 717 series aircraft undergo specialized training.
As my summary of these accidents indicates, the role that pilots, cabin crew, and mechanics play is critical to aviation safety and accident prevention, and the great work that you do in these areas has a tremendous influence on the prevention of airline accidents and injuries.
We need to always seek ways to make the aviation industry safer, whether through improvements in training curriculum, flight simulators, or training devices, and by embracing new technology in the aviation training industry. The aviation industry is constantly pushing the envelope of technology, and we must make sure that we update our training requirements and approaches to keep up with the technology.
Remember....your efforts in this regard will help prevent accident save lives!
Thank you for the invitation to talk to you this morning.