Opening Remarks of Mark V. Rosenker, Chairman
National Transportation Safety Board
2007 Bombardier Safety Standdown Seminar
October 23, 2007
Thank you very much for that gracious introduction, Rick.
It is truly a pleasure and privilege to be given the pulpit at this year’s Bombardier Safety Standdown. Since its inception 11 years ago, this seminar has proven to be a premier event for disseminating important, non-commercial, non-marketing, safety information for corporate pilots.
While it is common for the NTSB to be asked to participate in some fashion in professional meetings and educational events designed to enhance transportation safety, it’s not often that the NTSB takes a significant role in these external activities. But this seminar has caught our attention over the past few years, and I wanted our agency to be a part of it. The NTSB is pleased to join the FAA as a Federal partner in this safety seminar, that was pioneered and spearheaded by Bombardier, who now counts among its industry co-sponsors, the NBAA led by Ed Bolen.
This seminar represents the fulfillment of a critical element of the Safety Board's mission… to share the knowledge gained from accident investigations to prevent similar accidents from occurring again. Your participation during the next three days may help save lives, and saving lives is the bottom line of our profession. This is why I am proud to have the NTSB become an inaugural partner in this event.THE NTSB
First, I want to provide you with a bit of insight into who we are. The NTSB is a very small, independent, federal agency…we’re talking less than 400 people, with less than half of that number involved with aviation.
There are some FAA regional offices with more people than our entire agency ! And our entire annual budget is about $80 million dollars, which is what NASA spends during the first six seconds of a Space Shuttle launch !
But we have the very specific mission, and Congressional mandate, to investigate transportation accidents, determining their probable cause, and issuing recommendations, to prevent future accidents. Our independence is crucial. We call it the way we see it and we don’t pull any punches. We do not have regulatory authority. We can only issue a safety recommendation to the appropriate organization and then see what happens. Our big stick is that we track these recommendations, and agencies are required to report to Congress those recommendations that they haven’t implemented.
In our 40 years of existence, the NTSB has investigated over 128,000 aviation accidents. We have issued over 4,700 aviation safety recommendations, with an 82 percent acceptance rate.
While some of our recommendations call for our associates at the FAA, like Mr. Sabatini, to “require” things from corporate operators, I firmly believe that regulation is not the only way to improve safety. I believe, and so do my colleagues at the Board, that voluntary action by industry, in partnership with the government, is one of the most effective ways to decrease accidents. That’s another reason why we’ve allowed the NTSB’s name to be included, as a partner, in an effort that is so well symbolized on the “War on Error” patch. Personal discipline, combined with skill and knowledge based training, as you will experience in this seminar, can make a stronger impact on safety than any written regulation.
I am very proud of the hard work of our air safety investigators from our “go-team” at NTSB Headquarters, and also from our regional offices. Regional investigators are the eyes and ears of aviation safety issues across the United States. They are hardworking, dedicated professionals who pride themselves on their work. I brought several of them with me today, and I hope you will go out of your way to seek them out and pick their brains. To you NTSB investigators: Please raise your hand and make yourself known.
Now, let me make it clear that I hope you will meet these investigators ONLY in venues such as this, and NOT during a post-accident interview !
I also hope you all have had an opportunity to use our NTSB web site at www.ntsb.gov. I think it’s one of the most dynamic, user-friendly, and informative government sites around. Through the site, we endeavor to keep aviation safety professionals like you informed. The site contains a detailed video archive of all the public hearings, forums, and final Board Meetings for significant aviation accidents. And you can quickly obtain any and all of our accident reports on corporate aviation accidents by using our query page.
The reason I mention the web site is because I simply do not have time this morning to list all the many lessons learned from the past few years of corporate jet and turboprop accidents, so I offer the web site as a valuable tool for your safety tool kit. However, I would like to mention a few recent accidents that could have been prevented if pilots and mechanics would have practiced what will be preached here over the next three days.PROFESSIONALISM
In October of 2004, a Bombardier CL-600 operated by Pinnacle Airlines crashed on a Part 91 repositioning flight. The NTSB determined the probable cause of the accident to be, in part: “the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover…”
The following week, a Jetstream turboprop, doing business as a scheduled Part 121 flight, crashed on approach into Kirksville, Missouri. This CFIT accident claimed 13 lives. The Probable Cause statement cited the pilots’ unprofessional behavior during the flight.
Three months ago, the Safety Board deliberated on the 2006 Comair regional jet accident in Lexington, Kentucky, in which the crew took off from the wrong runway, killing 49 people. We concluded that non-adherence to FARs, company procedures, and checklist discipline, set the stage for the accident.
We have had an extraordinary safety record in corporate aviation the past few years. And the people in this room can certainly be proud to share some of the credit for this. But, my colleagues on the Board and I are disturbed that all three of these accidents – and several others in business aviation during this same time period – have all involved a less than professional approach to airmanship.
Don’t confuse getting paid to fly with being a professional pilot. Professionalism has absolutely nothing to do with the size of a paycheck or the size of your airplane. Professionalism in a mindset that includes hallmarks such as precise checklist usage, precise callouts, precise compliance with SOPs and regulations, including sterile cockpit compliance.
Quite simply, professionalism means doing the right things, even when no one is watching. Captain Gene Cernan and Dr. Tony Kern will talk more about professionalism later this morning.
By the way, in spite of all the cues that the Comair crew had when taxiing for takeoff, we recommended that allPart 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. I mention this because even with all the information provided to pilots via cockpit displays publications, and air traffic controllers, the final line of defense is YOU, the pilot !
Other accidents that we’ve investigated highlight deficiencies with TRAINING, which is a topic to be addressed by Captain Donna Murdock this afternoon. Two years ago, a Cessna Citation 560, operated for Circuit City Store executives, crashed near Pueblo, Colorado, while on an instrument approach. The two pilots and six passengers on board were killed. The flight was operating under Part 91. The NTSB determined that the probable cause was the flight crew’s failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover.
From that accident, we recommended that the FAA (1) require that operational training in the Cessna 560 airplane emphasize the airplane flight manual requirements that pilots increase the airspeed and operate the deice boots during approaches when ice is present on the wings; and (2) that the FAA require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management
These recommendations are indicative of the Safety Board’s concern that TRAINING DEFICIENCIES in corporate flight departments can lead to tragic circumstances.
You can design, build, buy, and fly the most advanced wiz-bang, go-fast, airplanes, but if you’re not adequately trained on using the hardware, all those advancements mean little. I hope this seminar will convince you that enhancing efforts on training is one of the most effective ways for corporate flight departments to protect themselves and their passengers.PREFLIGHT PREPARATION
Many times, the initiation of the chain of events that lead to corporate aviation accidents begins before the aircraft even leaves the ground. INADEQUATE PREFLIGHT PREPARATION can lead to an unhappy ending, and our files are too full with these types of accidents. For example, in February 2005, a Challenger CL-600 ran off the departure end of runway 6 at Teterboro Airport at a ground speed of about 110 knots; through an airport perimeter fence; across a six-lane highway; and into a parking lot before impacting a building. The two pilots were seriously injured. The cabin aide, eight passengers, and one person in the building received minor injuries. The accident flight was an on-demand Part 135 passenger charter flight . The probable cause was the pilots’ failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with the center of gravity well forward of the forward takeoff limit, which prevented the airplane from rotating at the intended rotation speed.
Two years later, a Citation jet departed controlled flight and impacted terrain while attempting to land back at the Van Nuys Airport in California. The Part 91 positioning flight was enroute to pick up paying passengers, and the two professional pilots on board were killed. Witnesses reported that, during the preflight, the copilot loaded bags into the left front baggage compartment, but they did not see him latch or lock it. A few minutes later, the airplane was started up, taxied out, and took off. Witnesses at the end of the runway said that the baggage door was open, as the airplane was climbing about 200 feet above the ground, and they said it was “slow”. One of the pilots radioed that they wanted to return to land at the Van Nuys Airport. The witnesses observed the airplane turn slightly left, descend, turn steeply to the right, and impact the ground. Examination of the front left baggage door indicated that the key mechanism was in the unlocked position. While this investigation is not yet completed yet, the co-pilot’s preflight actions will surely be addressed.
If some of you are cutting corners on your preflight preparation out of complacency, or to please your passengers, then you are playing with fire.FATIGUE
I am also pleased to see that you have Dr. Mark Rosekind back this year to preach to you tomorrow about the importance of fatigue countermeasures. We are very familiar with Dr. Rosekind, as he is one of the instructors at our NTSB Training Center for our “Investigating Human Fatigue Factors” course. He and I both know that one of the items on the NTSB’s Most Wanted List is to reduce accidents and incidents caused by human fatigue, and our objective is to push for working hour limits for flight crews, and aviation mechanics, based on fatigue research, circadian rhythms, and sleep and rest requirements.
An example of what can happen if a pilot is fatigued occurred on a flight that departed from here in Wichita on February 17, 2004, on a air ambulance positioning flight en route to Dodge City. The airplane was a Beech Kingair, and the pilot had been awake for 21 hours. Radar data indicated that the airplane initiated a gradual, straight-line descent toward the Dodge City Regional Airport, but flew past the airport before descending into the ground. No communications from the airplane were made during this descent. The pilot, flight nurse, and flight paramedic were killed. The NTSB determined that the probable cause was the pilot’s failure to maintain clearance with terrain due to pilot’s lack of sleep.
I can stand at this podium for hours and recount other cases of corporate aircraft accidents that took the lives of a professional golfer, family members of a television executive, a NASCAR racing team, a college basketball team, and even a U.S. senator. And, of course, these accidents also killed people who are in the same profession as all of you. I can go on and on about our “Most Wanted List” of safety issues that address runway incursions, the need for cockpit resource management for Part 135 operators, and fatigue involving pilots and mechanics. But I don’t want to cut into your valuable training time.
Carl Dinwiddie, our esteemed director of the NTSB’s Chicago Regional Office will provide you with more detailed case studies later this morning. One of Carl’s case studies pertains to a business jet accident in Missouri caused by maintenance errors. How well maintenance is handled in corporate flight departments is equally as important as the quality of the pilots, and I am very pleased to see that this year’s Safety Standdown includes the issue of maintenance.CONCLUSION
Despite explosive growth in business aviation, NTSB data reveal that corporate jets flown by professional crews under part 91 have accident rates that are comparable to scheduled air carriers. Accidents rates for on-demand Part 135 charters are a bit higher. Professional aviation is one of the safest modes of transportation. Some flight departments, however, operate aircraft on a shoestring budget, with inadequately experienced or trained crews, or shoddy maintenance practices. These types of operations, unfortunately, are typically the ones that garner the NTSB’s attention. They also give your industry a black eye in the white hot media spotlight. There is always room for improvement.
It seems that even though the airplanes that you all fly and maintain have gotten more advanced over the years, and even though the requirements for the certification of the hardware have gotten more stringent over the years, the biggest killer of corporate airplanes continues to be HUMAN FAILURE, not unlike other forms of transportation.
Why ? What can we do to mitigate this ? What if the redundancy in the system breaks down and we have to rely on our own skill sets to keep us alive ?
I’m hoping that some answers to those questions can be found in seminars like this.
Finally, let me leave you with the thought that I mentioned at the beginning of these remarks: I believe that what you take away from the next three days of this seminar may help save your life, and the lives of your passengers.
As long as I am leading this agency, I am committed to supporting the War on Error. We are partners in this effort, and I look forward to working with you on making our safe skies even safer.
Good luck, good learning, and thank you for inviting me to be with you today.