Mark V. Rosenker, Acting Chairman
National Transportation Safety Board
Wichita Aero Club Monthly Luncheon Meeting
April 14, 2009
Thank you very much for that gracious introduction, Dave. It is truly a pleasure and privilege to be given the dais at this month’s Wichita Aero Club Monthly Luncheon Meeting.
It’s not often that I am invited to address such an august body of aviation professionals like the membership of the WAC. You represent the leadership of more than 40 companies and organizations of the Wichita aviation community. This is, indeed, a critical year for your industry and for your state, since our economy is so closely tied to the fortunes of major employers like Cessna, Spirit AeroSystems, Hawker Beechcraft, Boeing Integrated Defense Systems, Bombardier Learjet and Airbus North America Engineering, all of whom are facing serious challenges in 2009 and beyond.
I am no stranger to the Air Capital of the World. Since coming to the Board in 2003, I have visited Wichita on numerous occasions to participate in the annual Bombardier Learjet Safety Standown, speak at the annual General Aviation Air Safety Investigator’s Workshop, and to tour the Hawker Beechcraft, Learjet, and Cessna plants. The weather is usually pretty good when I’m here, and the people are downright the friendliest, most down-to-earth in the nation. Wichitans are known for a solid work ethic and a love of county.
And this visit to Wichita is yet another golden opportunity for me, for many reasons. I am utilizing the time to visit Cessna this afternoon, and I plan to visit Hawker Beechcraft and Spirit AeroSystems tomorrow. I also took the opportunity to ensure that the public affairs aspects of our business were address by having the director of our Public Affairs office, Ted Lopatkiewicz, participate in a roundtable discussion earlier this morning with WAC members to discuss the role of NTSB public affairs in the wake of the unfortunate circumstances of an aircraft accident. An ounce of prevention is worth a pound of cure, and that’s why it is so important to prepare for the worst.
As many of you know, the NTSB is a very small, independent, federal agency. We’re about 400 people strong, just more than a quarter 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 regulations, 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 I am here. I have an ulterior motive, an agenda if you will, to reach out as much as I can to enhance safety by speaking at forums like this.
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 across the United States. They are hardworking, dedicated professionals who pride themselves on their work.
Now, Dave’s letter officially inviting me to speak today stated that the WAC was interested in hearing my perspective on, and I quote “the future of the aerospace industry in the state of Kansas.” Additional follow-up conversations with Dave indicated that he wanted me to discuss current safety issues in the general aviation community, recent NTSB activities, and completed investigations.
And he didn’t want me to focus on just general aviation, but also commercial aviation, since there are many WAC members involved in commercial aviation. Dave said you all would also have lot of interest in past accident investigations of large aircraft and related issues, such as crew resource management, video recorders, fatigue and runway safety. The recent Colgan Air accident in Buffalo was also mentioned as a topic of interest, as well as my personal experiences launching to the site of the Steve Fossett accident, and other accidents, as a Board Member.
In all seriousness, there are many critical issues and challenges that face general and commercial aviation these days. Economics, Reputation, and of course, Safety. I’ll talk a little about the first two, and a lot about the third, because that’s my forte. I’ll do my best to impart some insights on a variety of issues in the short time that we have today.
First, the economics of your industry: I don't have to preach to this crowd that a safe and efficient aviation transportation network is essential for the commercial viability, economic health, and security of the nation...not to mention the sheer fun of flying. According to statistics from the General Aviation Manufactures Association (GAMA), general aviation, excluding commercial airlines, directly contributes more than $41 billion annually to the U.S. economy. Over 200,000 aircraft, ranging from two-seat trainers to intercontinental business jets, fly nearly twice the airlines' flight hours, and carry 166 million passengers annually.
Clearly, your industry is an important part of this nation's economy, and I am here today, in part, to reiterate the Safety Board's commitment to making a safe industry even safer.
According to GAMA, 2008 year-end worldwide shipments of general aviation airplanes decreased for the first time in five years. Despite a positive year for revenue … $24 billion dollars … which was attributed mostly to aircraft order backlog, the industry is feeling a significant impact from the slowing worldwide economy. I know that many companies in Wichita have been forced to significantly reduce their work force to compensate for the weakness in orders. Your industry is severely challenged in the current economic climate, and I know you are focused on planning for a stronger future. The world's economy depends upon a robust air transportation system and general aviation and airline travel is absolutely a vital component of that global system. It is this for this reason that I believe aviation will soon fly out of the turbulence that surround it today. You just need to cinch up your lap belts and shoulder harnesses, maintain your pitch attitude and airspeed, and ride out the storm.
In the reputation category, I am fully aware that your industry has gotten a black eye recently from the press, public and congress regarding the use of business aircraft in corporate America. My view on this is best articulated in my strong agreement with the letter from the National Air Transportation Association to the President last month, which stated, and I quote: “All that is needed is an understanding in Washington that it's not fair for private aviation to become a political punching bag in some perverse populist version of class warfare in the skies. It's time to stop the populist demonizing. It's time, instead, to support, if only with words, an outstanding American success story.”
The letter went on to say that corporate executives, who are the captains of industry, and who hold the keys to getting us out of these tough economic times, need more flexibility, more speed, more security, more availability, more communications, better schedules, and more control than the airlines have to offer. Every minute of these people’s day is critical. Every minute needs to be utilized increasing sales, making investments, evaluating major projects, building morale, expanding plants, exploring new markets, improving safety, attracting investors, and saving their company. It’s tough to do these things when you are waiting in a metal detector line at the airport, or waiting to board an airplane operating on a schedule and a routing that’s not convenient.
Everyone in this room knows the benefits of business aviation, but many outside this room don’t get it, so I would advise that you increase your “outreach” to the public, and Washington DC, to heal that black eye.
Finally, the first two aspects that I just mentioned can be greatly affected by the third challenge, safety, which is where the Safety Board comes in.
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. Despite explosive growth in business aviation over the past few years, NTSB data reveal that corporate jets flown by professional crews under part 91 have accident rates that are comparable to the very low rates of 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 give your industry a black eye in the white hot media spotlight. It’s just good business to be safe.
Let me provide more insights regarding aviation accidents. While the overall aviation safety record in the United States is among the best in the world, the 2008 accident statistics reveal a mixed picture. We are particularly concerned with the spike in fatalities in on-demand “Part 135” air charter operations, which include air medical, air taxi and air tour flights. These flights logged over 3.6 million flight hours and had 56 accidents, killing 66 people -- the highest number of fatalities since 2000. There were 43 fatalities in this category one year before. There's a lot of room for improvement in this area, and, as evidenced by our recent public hearing on emergency medical service helicopter accidents, and our Most Wanted List of Safety Improvements that I will discuss in a bit, we continue to do everything we can to identify the safety issues involved, and to advocate for the adoption of our recommendations that will make the skies safer.
In general aviation, there were 1,559 accidents, 275 of which involved fatalities, killing a total of 495 - one fewer than the previous year.
The number of accidents involving the major airlines was 28 in both 2008 and 2007. The airlines carried 753 million passengers on over 10.8 million flights without a single passenger fatality. Unfortunately, that string of success ended in calendar year 2009, with the recent Dash 8 accident in Buffalo.
Two months ago, Continental Connection flight 3407 a Dash 8-Q400, crashed on top of a house during an instrument approach to runway 23 at the Buffalo-Niagara International Airport. The 4 crew members and 45 passengers were fatally injured. There was one ground fatality.
A preliminary examination of the airplane systems has revealed no indication of pre-impact system failures or anomalies. The airplane maintenance records have been reviewed and no significant findings have been identified at this time. Examination of the flight data recorder, and preliminary evaluation of airplane performance models, shows that some ice accumulation was likely present on the airplane prior to the initial upset event, but that the airplane continued to respond as expected to flight control inputs throughout the accident flight. Preliminary airplane performance modeling and simulation efforts indicate that icing had a minimal impact on the stall speed of the airplane.
The flight recorder data indicates that the stick shaker activated at 130 knots, which is consistent with the de-ice system being engaged. The data further indicate that when the stick shaker activated, there was a 25-pound pull force on the control column, followed by an up elevator deflection and increase in pitch, angle of attack, and Gs. The data indicate a likely separation of the airflow over the wing and ensuing roll two seconds after the stick shaker activated while the aircraft was slowing through 125 knots and while at a flight load of 1.42 Gs.
The tragedy of flight 3407 is the deadliest transportation accident in the U.S. in more than 7 years. The circumstances of the crash have raised several issues that go well beyond the widely discussed matter of airframe icing, and we will explore these issues in our investigative public hearing one month from today at our Board Room in Washington DC. The hearing will cover a wide range of safety issues including: icing effect on the airplane’s performance, cold weather operations, sterile cockpit rules, crew experience, fatigue management, and stall recovery training.
Another public hearing that we are planning is for the accident involving US Airways flight 1549, which ditched into the Hudson River on January 15. Thankfully, no one was killed in what many refer to as the “Miracle on the Hudson”, but there are still safety concerns that we need to explore. Hazards to aircraft due to water fowl is one of those concerns. We know that the Airbus A320 experienced a dual-engine failure after an encounter with Canadian Geese, also known as Branta Canadensis for you bird nerds.
This accident came on the heels of a 5-fatal Cessna Citation 500 jet that struck birds and was destroyed upon impact with terrain following a loss of control shortly after takeoff from the Wiley Post Airport in Oklahoma City about one year ago, and the crash of a helicopter in Louisiana three months ago, which killed 8 of the 9 oil industry workers on board.
In the Oklahoma City case, which our staff has completed and will be presenting to the Board soon, an analysis by the Smithsonian Institution’s Feather Identification Laboratory revealed that the recovered splatter residue were identified as the remains of an American White Pelican. This species, known as Pelecanus erythrorhynchos, is common in central Oklahoma from March to May and ranges in weight from 10 to 30 pounds. This bird has a beak-to-tail length of 5 feet, and a wingspan of up to 9 feet! That’s a big bird!
In the Louisiana helicopter crash, the same laboratory identified bird remains on the damaged windscreen area, and the engine inlet filters, as a Hawk, perhaps a Red-tailed Hawk, or Buteo jamaicensis for you bird watchers.
According to USDA researchers, the risks to aviation posed by bird populations have increased in the last few decades due to a number of factors, including an increase in air traffic volume. Also, although populations of bird species in general have declined, the populations of nearly all of the large bird species (those greater than 8 pounds) in North America have increased significantly in the past 30 years.
Now I don’t want to be an alarmist, but, in my view, something has got to be done about this. What would the industry do if suddenly there occurred a phenomenon in which thousands of 20 pound rocks would suddenly appear in the sky and float around? How would the aviation industry react to this? Would structures and windscreens and engines be beefed up? Would airspeeds need to be decreased, or flight paths altered?
We have tentatively scheduled the public hearing for the Hudson River accident for June 9 and 10 in Washington DC. The issues we plan to cover will include certification standards for bird strikes, and mitigation of bird hazards to aircraft.
As one of five Board Members at the Safety Board, one of my responsibilities is to launch with the go-team to be the spokesperson for the investigations. I rotate this duty with the other board members. I’d like to give you a personal perspective on a couple of launches that I have been called upon to join.
This past October, I received a call about midnight with the news that they had just found the wreckage of the airplane flown by famous aviator, and, to some of you, a colleague, Steve Fossett. It had been 13 months since he disappeared after departing from the Flying M ranch in a friend’s Bellanca Super Decathlon.
According to the pilot's wife, the purpose of the flight was pleasure; she characterized it as "a Sunday drive."
After the wreckage was discovered, radar tracks identified during the original search were reviewed. A radar track beginning about the time of the accident showed a target flying southbound following the crest of the Sierra Nevada Mountains. The track started about 35 miles south-southwest of the departure airport and ended about 1 mile northwest of the accident site. Early in the original search, this track was eliminated as a possibility, as its time did not agree with the time of a witness sighting that was believed to be accurate. The witness sighting was that of a Flying M employee who observed the airplane approximately 9 miles south of the departure airstrip. Regardless, the California Wing of the CAP reported that the area where the wreckage was located had been searched once by air during the original search. I can tell you that given the features of the terrain at the accident, it would be very difficult to spot that wreckage.
The wreckage was discovered about 1/2 mile from the location where hikers had found personal effects. The examination of the accident site revealed that the airplane collided with terrain while maneuvering in remote mountainous terrain approximately 8 miles west-northwest of Mammoth Lakes, California, and 65 miles south of the departure airport. The wreckage was located at an elevation of approximately 10,000 feet.
The accident site was located about 300 feet below the crest of a ridge that was oriented northwest/southeast. The steep terrain was sparsely forested with Ponderosa pines averaging 40 to 60 feet tall. Numerous boulders and rock outcrops surrounded by grassy areas covered the ground. Now I’m not a young man, and it was not easy for me to hike to the site with our team, but I managed. It took awhile, but I managed.
The airplane was severely fragmented and a severe post crash fire burned most of the structure and surrounding vegetation. The first evidence of ground contact was a boulder with paint transfers on it consistent with the left main wheel and the belly of the airplane. Wreckage was distributed upslope from this point in a debris field measuring approximately 350 feet long. All of the cockpit instruments, and the airplane’s ELT were destroyed.
DNA testing recovered skeletal fragments determined that they were from the pilot. The cause of death was determined to be multiple traumatic injuries.
Meteorological data indicate that about the time of the accident, downdrafts existed in the accident area of approximately 400 feet per minute.
We released the factual report on this investigation on our web site, and a probable cause will be issued soon.
Three weeks ago, I launched with a go-team to another accident site, and it was one of the most tragic accidents that I have ever been involved with. Like the other members of our go-team that stand call on a roster, I got a phone call late on a Sunday afternoon, and I was told that an airplane full of children had crashed short of the runway at the airport in Butte, Montana. At that time, we didn’t even know what type of airplane it was, or whether it was a scheduled commuter plane, or business jet, or some other aircraft. As the minutes ticked by, and as we received updates from the local authorities, we learned that the airplane was a single-engine turboprop owned by several doctors, and piloted by a very experienced pilot.
The airplane impacted a cemetery west of the landing runway at the airport. Seven adults and seven children, all under the age of 10, we were eventually told, were traveling to Bozeman, Montana, to meet other family members and friends for a ski vacation.
Whenever we get the initial call on these types of accidents, we conference in with regional investigators on the ground, senior NTSB managers, and specialists with the go-team. A decision is made, based on the available information we have, whether or not to launch a team, and to determine the size of the team. Frequently, the FAA assists us by flying our team in one of their jets, either a Gulfstream G-4, or a Cessna Citation, from their hangar at the Ronald Reagan Washington National Airport. For this Montana accident, based on the number of fatalities, the complexity of the aircraft, the mysterious circumstances, and the press attention, we decided to launch somewhat of a “partial” go-team with combined assets from our regional offices and headquarters.
After arriving in Butte very late in the evening, I got a few hours of sleep, and then visited the accident site at first light. I addressed the media soon thereafter, and our investigator-in-charge held an organizational meeting to round up all of the expertise from the aircraft and engine manufacturers, and the FAA. During the on-site phase of the investigation, we learned that the pilot filed an instrument flight plan from Oroville, California to Bozeman, Montana, with Butte as the alternate. As the airplane was cruising about 25,000 feet, the pilot contacted Air Traffic Control and requested to change his destination to Butte. He gave no reason for the diversion. And to divert to Butte really would not save him that much time, and did not appear to be for weather-related reasons. The pilot had never been to Butte, which is a much smaller airport than his usual destination of Bozeman. Answering why he diverted may hold the key to this accident.
Initial reports from ground witnesses indicate that the airplane was flying approximately 300 feet above ground level as it approached the airport. Shortly thereafter, the airplane's nose pitched to a nose-low attitude and it impacted the ground. This accident will be a challenge to solve. We have human performance specialists analyzing the pilot’s background, and his voice captured on recorded air traffic transmissions. Our examination of what was left of the airplane did not reveal any obvious pre-impact malfunctions. Unfortunately, the airplane had no flight recorders, nor was it required to, which brings me to my next topic.
As you know, GA airplanes are not required to have a flight data recorder, and certain types of turbine aircraft are required to only have a cockpit voice recorder. The rationale for this has been that these types of recorders are simply too costly, too complex, and too heavy. Well, advanced in technology have been very helpful in this regard. Government and industry representatives have been participating since 2007 in a working group to develop a specification for lightweight flight recorders. Both the NTSB and the FAA are members of this working group. When finalized this summer, this standard is expected to address recent improvements in technology by establishing the minimum performance requirements for flight recorder systems that could be used on board smaller aircraft. This specification targets a more affordable flight recorder option for smaller aircraft than traditional CVRs or FDRs and addresses the recording of audio, image, and parametric information.
Both Bell Helicopter and American Eurocopter have developed prototype lightweight recorders that contain internal global positioning system receivers and inertial sensing electronics. They are about the size of a couple of packs of cigarettes, and very affordable. Although these recorders are not being designed to meet the crashworthy requirements stipulated in the FAA’s current technical standard order for CVRs and FDRs, they would have a level of crash protection that meets many of the industry criteria for reliability and survivability. The companies also expected to make kits available for retrofitting older helicopters with the recorders. If recorder systems that captured cockpit audio, images, and parametric data had been installed on the Butte accident airplane, the recorders would have enabled us to quickly determine information about the accident scenario, including precise locations, altitudes, headings, airspeeds, and pilot actions. We have made recommendations about flight recorders to the FAA for many years. The issue has been on our Most Wanted List for many years, and, now, with the recent advent of these lightweight, inexpensive image recorders, we want these items installed on aircraft, to help us solve accidents and make recommendations to prevent future ones.
Another issue that the Safety Board has long been concerned about is the effect of human fatigue in transportation and the consequences of fatigue on those who perform critical functions in all modes of transportation. Fatigue in transportation presents unnecessary risks to the traveling public, and can impair a person behind the control yoke much like alcohol or other drugs. The Safety Board continues to advocate setting work hour limits based on fatigue research, circadian rhythms, and sleep rest requirements that will reduce unnecessary risk to the traveling public.
An example of what can happen if a pilot is fatigued occurred on a flight that departed from here in Wichita, five years ago in February 2004, on an 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.
Since 1972, the NTSB has issued over 100 fatigue related recommendations in all modes of transportation. Human fatigue and hours-of-service are issues that have been on the NTSB's Most Wanted List of safety improvements the Board believes will have the greatest impact on transportation safety.
And speaking of our Most Wanted List, I want to mention what the list means, and which items on the list pertain to your industry. 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. The first three are ones we touched upon somewhat. They are:
The remained items are:
I 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.
Dave….I can stand up here all day and talk about more accidents, more recommendations, our on-going special investigations into the use of Airbags in GA aircraft, Advanced Cockpits, Human Fatigue, and Special Light Sport Aircraft, but I don’t think you’ve got dinner set up in here. So, I’ll close by saying that the Safety Board is “the little agency that could” if you will allow the metaphor. But we at the Board have always realized that no one organization can do this work alone, and that aviation safety has always been, and must always be, a team effort between the Board, FAA, and the industry that you represent. Today, I am proud to stand among the best and brightest of representatives of all these organizations.
Good luck, and thank you for inviting me to be with you today.