Opening Remarks of Mark V. Rosenker, Chairman
National Transportation Safety Board
Before The
2008
Bombardier Safety Standdown Seminar
Kansas City, Missouri
October 21, 2008


It is truly a pleasure and privilege to once again be a part of this year’s Bombardier Safety Standdown.   Since its inception, this seminar has grown in size and stature to become a premier event for disseminating important safety information for pilots, mechanics, and managers of business jets and turboprops. 

While the Standdown has been going strong for a dozen years now, this marks the second year that the NTSB has been an official partner in this important event.  As I indicated last year at this event, it is very common for the NTSB to be asked to participate in some fashion in professional meetings and educational events designed to enhance transportation safety; however, it is very rare 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 continue with the FAA as a Federal partner in this safety seminar.

This event 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 be a partner in this event.

As some of you know, the NTSB is a very small, independent, federal agency.  We’re  about 400 people strong, with less than half of that number involved with aviation. But we have the very specific mission, and Congressional mandate, to investigate transportation accidents, determine their probable cause, and issue 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 leverage the quality of our investigation, the strength of our argument, and the credibility of our viewpoints to try to accomplish change. Our big stick is that we track these recommendations, and publicize the quality and timeliness of agency responses.

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 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.  They 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 is the portal by which 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 business jet and turboprop accidents, so I offer the web site as a valuable tool for your safety tool kit. 

I have good news and not-so-good news to report to you today regarding aviation safety.  The good news is that aviation deaths decreased from 784 to 545 over the past two calendar years. Nearly 90% of aviation fatalities occurred in general aviation accidents (491), but they still represented a significant decrease from the previous year (703).

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.

For the weeks and months immediately following last year’s Standdown, I was pleased to see that there were no turbine-powered business fatal airplane accidents, and I was hopeful to come to you today and report that. But unfortunately, we did have several.  In fact, during the past 3 months, there have been three fatal accidents involving your community, killing a total of 22 people, including all the flightcrew.  All of these accidents occurred during takeoff or immediately thereafter.
On July 31, of this year, a business jet was destroyed when it impacted terrain during an attempted go-around from runway three-zero at the Owatonna Regional Airport in Minnesota.  The pilot, co-pilot, and six passengers sustained fatal injuries. The flightcrew touched down on the runway, but then attempted to take off from it again, and that’s when the accident happened.  The Part 135 flight originated from Atlantic City, carrying a group of people involved in the building of New York City’s new Freedom Tower.  The Safety Board’s investigation continues to focus on what effect the weather, runway condition, aircraft systems, and the flightcrew’s knowledge of those systems, may have had on the accident.

Three weeks later, on August 22, a twin-engine turboprop impacted hilly terrain shortly after takeoff from the Canyonlands Field Airport in Moab, Utah. The commercial pilot and all nine of his passengers were killed. The airplane was destroyed during a post-impact fire. Visual meteorological conditions prevailed for the cross-country flight that was destined for the airport in Cedar City, Utah.  The purpose of the Part 91 business flight was to transport medical personnel back to their base of operation in Cedar City. The personnel had flown to Moab earlier in the day to work in a clinic.  An examination of the wreckage did not reveal any obvious signs of preimpact mechanical malfunctions, and there were no reported distress calls from the pilot.

And then, one month ago, on September 19, another business jet, operating as a Part 135 flight, overran runway 11 while departing Columbia, South Carolina, enroute to Van Nuys, California. The 2 crewmembers and 2 of the 4 passengers were fatally injured, and the other 2 passengers suffered serious injuries. The aircraft was destroyed by an extensive post-crash fire. Weather was reported as clear with light winds.  Tire debris and portions of airplane components were found along the 8,600 foot runway. According to witnesses and initial information, the beginning of the takeoff roll appeared normal, then sparks were observed as the airplane traveled along the runway. The airplane continued beyond the runway threshold, through the approximately 1,000 foot runway safety area and impacted airport lighting, navigation facilities, perimeter fence and concrete marker posts. The airplane then crossed a roadway, and came to rest on an embankment on the far side of the road.

All three of these accidents are what our investigators initially call “head scratchers”.  The pilots were very experienced. While it will be difficult and time-consuming, I’m confident that we will determine the “probable” cause of these accidents, and disseminate the detailed findings of them for you all to learn from this time next year. 

Aside from the findings and recommendations issued from individual accidents, the  Safety Board also takes a holistic view of accident trends and why they continue to occur.  This view gives rise to the NTSB’s Most Wanted List of Transportation Safety Improvements, which the Board updates each year.  This is the agency’s high priority hit list of what we believe to be the most critical changes needed to reduce transportation accidents and save lives.  There are 15 items on this list that deal with all modes of transportation, six of them in the aviation mode.  Of those six, three of them are especially applicable to you.  They are the following:

  1. Improving Runway Safety by requiring Require landing distance assessment with an adequate safety margin for every landing, and to give immediate warnings of probable collisions/incursions directly to flight crews in the cockpit.
  2. Improving Crew Resource Management by requiring on-demand air taxi flight crews to receive crew resource management training.
  3. Reducing Accidents Caused by Human Fatigue by setting work hour limits for flight crews, aviation mechanics and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements. 

I am very pleased to see that all three of these items will be covered in some fashion during the next three days.

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. So, when accidents do happen, they attract a lot of public attention because they are rare, and also because they typically involve a large loss of life. Accidents involving your type of aircraft operations 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 turbine-powered business 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 will continue to be found in seminars like this.

I don’t want to cut into any more of your valuable training time, so 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. 

Please continue to join me in 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.

 

 


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