National Transportation Safety Board
Air Line Pilots Association, International
2007 Air Safety & Security Forum
August 8, 2007
It is great to be back at this event – one that I have attended for 16 out of the past 17 years. Perhaps like an unlucky penny, I just keep turning up. I guess you just can’t get rid of me. Terry, you even changed hotels and I still didn’t get the hint.
I am glad to see this forum combining safety and security. Although the methods for assuring safety and security can be vastly different, to the flying public, safety and security are synonymous.
When I last stood before you two years ago, you honored me with ALPA’s highest award for an ALPA air safety representative. Today I am honored to stand before you as a representative of the NTSB.
Someone recently asked, “Hey, now that you’re on the other side, do you look at things any differently?”
Well, let me assure you that I am not on the other side. The moral compass that guided me when doing ALPA safety work is the same one that guides me today as a NTSB Board Member.
My commitment and dedication to safety is unchanged.
I call it the way that I see it – even if it means taking unpopular positions. I like to keep in mind what American diplomat and politician Adlai Stevenson once said, “All progress has resulted from people who took unpopular positions.”
I’m interested in progress. So today I may say things that may be unpopular to some, but I am saying these things not to be critical, but rather, to inspire progress.
I strongly believe in safety culture and I have been critical of organizations that, in my opinion, failed to establish such a culture. In fact, if I was speaking today to a group of airline management, I would emphasize that safety must start of the top of an organization. But, just as it is incumbent on senior management to establish and maintain a safety culture, it’s also up to people on the front lines to carry out their responsibilities with precision and professionalism.
Let me acknowledge that the vast majority of airline flights in the US and Canada are conducted with high degrees of professionalism.
That said, the NTSB, of course, looks at flights that don’t work out too well. So, I will discuss a few of those.
I flew my last airline trip in September of three years ago. In those three years, we have had four fatal air carrier accidents in the US. The Safety Board has not yet determined the Probable Cause for one of these, but for the remaining three, we have some disturbing evidence of behavior that is unbecoming of the airline piloting profession.
In October of 2004, Pinnacle Airlines flight 3701 crashed on a repositioning flight. 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…”
I’d like to believe the conduct on that flight was very much an aberration, but nevertheless, we can’t deny that it happened on that evening.
The following week, Corporate Airlines, doing business as American Connection crashed on approach into Kirksville, Missouri. This CFIT accident claimed 13 lives. The Safety Board concluded the following: “The pilots’ nonessential conversation below 10,000 feet MSL was contrary to established sterile cockpit regulations and reflected a demeanor and cockpit environment that fostered deviation from established standard procedures, crew resource management disciplines, division of duties, and professionalism, reducing the margin of safety well below acceptable limits during the accident approach and likely contributing to the pilots’ degraded performance.”
The Probable Cause statement contained these poignant words: “The pilots’ unprofessional behavior during the flight…”
As you know, two weeks ago the Safety Board deliberated the Comair 5191 accident. We concluded that non-adherence to FARs, company procedures and checklist discipline set the stage for the accident. Specifically, we said that the crew’s noncompliance with SOPs, including the captain’s abbreviated taxi briefing and both pilots’ non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors.
I listened to the CVR several times, and to be honest, what I heard was two guys that were trying very hard to be relaxed and easy-going. They were trying to get along well and be friendly. But, I believe their cockpit demeanor was too comfortable.
I recognize that it is important to be comfortable in the cockpit. FAA guidance on CRM states that that the tone in the cockpit should be “friendly, relaxed, and supportive.” But it also points out that the crew must ensure that cockpit discipline is maintained, crew vigilance is not reduced and critical items are not missed.
And on this flight, critical items were missed.
Many years ago, former NTSB Board Member John Lauber, put this in perspective: “There is a fine line separating a relaxed and easy atmosphere in a cockpit from a lax one where distractions can result in critical failures. Professionalism may be described as knowing the difference between the two.”
And that’s what we are talking about here – Professionalism.
We have had an extraordinary safety record in 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.
Put bluntly, professionals don’t intentionally violate Federal Regulations. And remember, the sterile cockpit is a regulation, not just a good operating practice.
I can tell you that it is extremely disheartening to listen to a CVR where joking, laughing, off-hand comments and sterile cockpit violations are heard right before the crash. Even more difficult, though, is having a Board Meeting where the pilot’s widow is sitting amongst the other accident victims’ families as we explain how her husband’s casual attitude led to the crash.
So, what is my point?
Management expert Peter Drucker: “The best way to predict the future is to create it.”
If you don’t like what you see when you look into your safety crystal ball, create a new future.
You are the leaders of airline safety. And as best selling author John Maxwell says, “Leadership is about influence. Nothing more, nothing less.”
As aviation leaders, I suggest that you not only have the ability to influence safety, but you have the obligation to do so, as well.
So, next time you ride jump seat or fly a trip, when you see someone violating the sterile cockpit or being a little loose with callouts or checklist items, what are you going to do? Are you going to let it go, or are you going to say something about it?
If you let it go, you are providing tacit approval, which reinforces this undesirable behavior. Once I asked a First Officer to read the checklist instead of doing it from memory. He retorted that he had flown with several Check Airmen who didn’t say anything about it, so it must be okay. In your position as aviation leaders, if you accept anything less than standard, you send a message to others that it is okay to perform to a lower standard.
I can tell you from personal experience that speaking up and saying something about these SOP deviations is hard. It’s unpopular. But, remember: “All progress has resulted from people who took unpopular positions.”
While we are talking about professionalism, 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.
When you presented me the coveted ALPA Air Safety Award, I assume you did so for a reason. I never intended to receive it and I am flattered that you thought I deserved it.
I’m the same person that I was two years ago. Only now, I’m the messenger. There is a message here and I’d prefer that you don’t shoot the messenger.
There is no excuse for violating the sterile cockpit. Period. It is a violation of CARs and FARs.
I look at procedures as layers of defense that can trap our errors. If we don’t follow procedures, we are effectively putting holes in these layers of defense. I don’t know about you, but I’d prefer that my safety net not have holes in it.
One danger of routinely deviating from standards is that we “normalize” the deviation. This “normalization of deviance,” is problematic because crewmembers can view this new way of doing business as the norm. We get so used to it that the crew can eventually fail to see their actions as being deviations.
LOSA data from nearly 6,000 line observations reveal that crews that intentionally deviate by not following SOPs are about three times more likely to commit additional errors with consequential results. What does consequential mean? Well, I think the three accidents that we mentioned earlier are vivid examples of consequential.
I’m sort of sorry to admit this to myself, let alone an audience of airline pilots, but I’ve basically gone from being an airline pilot to being an airline passenger. I’ve racked up over 150,000 passenger miles in the past year. I’ve spent way too much time in the back of airplanes these days.
But, one thing this has done for me is that I now what it’s like to be an airline passenger. I can tell you that the people sitting in the back of your airplane aren’t interested in the fact that your pension has been cut, they don’t care how much your pay cut is, they really don’t care about how the seniority list merger may pan out. (And by the way, I experienced each of these when I was an airline pilot).
All that matters to the people sitting in the back of your airplane is that you get them safely to their destination.
That’s what they’ve paid for — they rightfully deserve and expect that each and every flight will be conducted with utmost precision and professionalism.
The forefathers of ALPA had the right idea when, 51 years ago, they created the ALPA Code of Ethics and Cannons.
The first sentence of that document says:
“An Air Line Pilot will keep uppermost in his mind that the safety, comfort, and well-being of the passengers who entrust their lives to him are his first and greatest responsibility.”
Safety, security, and professionalism – they all go hand-in-hand and they all directly relate to this statement. If you don’t have all three – safety, security and professionalism, then, in my opinion, you are not upholding your responsibilities as an Air Line Pilot.
Leaders influence others. Whether you are a line pilot, check airman, VP of Flight Operations, or air safety representative, I challenge you to go out and influence professional behavior on the line.
Insist on it. Accept nothing less.
Having been an ALPA air safety representative for many years, I know you are up to the challenge.
Thank you very much.