Opening Remarks by
National Transportation Safety Board
Airline Dispatchers Federation Safety Symposium
October 15, 2007
Thank you for inviting me this morning. I really am delighted to speak to this group today because as an airline pilot for nearly 24 years, I feel as if I was a customer of yours. And appreciate you, I do! Three years ago, I departed the comfort of the left seat of a major air carrier and went to run a small flight department for a Fortune 500 company. To be honest, when I got there, I literally didn’t even know how to file a flight plan. It was quite a culture shock to leave an environment where a licensed dispatcher looked after my flight planning needs and kept a watchful eye on my flight, and then going to one where I was left to be on my own.
There were lot of things I was willing to give up when I left the airline, but a good dispatcher wasn’t one of them!
Two weeks ago, news stories publicized a 70 percent decrease in commercial aviation fatalities in the past decade. It didn’t happen by itself. It has taken a concerted effort on the part of everyone – and you can take pride that your efforts are part why commercial aviation is safer.
Years ago, I started collecting stamps. But, I have a very unusual collection. You see, I collect airmail from the 1920’s and early 30’s, and what makes this collection unusual is that this airmail often didn’t make it to its destination because it was in a plane crash.
Back in these early airmail days, pilots were out there on their own to fend for themselves. There was not a system like we have now where the captain and the dispatcher must agree that a flight can be safety conducted. As a result, pilots often launched into poor weather conditions - conditions that sometimes exceeded their capabilities.
Today, we have a network of licensed dispatchers who have access to vast amounts of information – dedicated professionals who share responsibility for each and every commercial Part 121 flight.
And I firmly believe this is yet another thread in the fabric that we have woven to make our commercial aviation system much safer.
You are part of that fabric. I often refer to aviation as a series of layers of defense and certainly, airline dispatchers are an important layer of defense. You are the eyes and ears of flights. You have access to real-time weather information that pilots may not necessarily have.
This morning I would like to exemplify just how important the role of the dispatcher is in strategic weather avoidance and in the prevention of weather-related accidents. I’d like to highlight the benefits of shared information between the pilot and the dispatcher, and the important role that dispatchers can take in preventing accidents, through proactive sharing of this information.
I have had long-standing interest in the work that you do. I actually got started as a safety advocate because I saw the need to improve weather information for pilots. This was back in the mid to late 1980’s and early 90’s – before the Internet and all of these fancy graphical uplink products available today.
Basically, I felt then, and still believe that since the captain and the dispatcher have joint responsibility for the flight, to the extent possible, both parties should have the same information. You have Aircraft Situation Displays (ASDs) that display graphic weather information. The technology exists now for pilots to also have similar graphical weather information and I’d like to see it employed on a more widespread basis.
As you know, airborne weather radar really isn’t too effective for seeing convective weather more than a few hundred miles in front of the aircraft. You, on the other hand, have the advantage of seeing the big picture. Therefore, pilots find is very helpful if you can help them to strategically avoid the weather by changing their route of flight. For example, when flying from LAX to CLT, I didn’t really care if I went over Texas or Nebraska. True, a pilot is interested in operating that flight as efficiently as he/she can, and yes, they are interested in on-time performance, but if they can meet those goals and be routed around the weather, instead of through it, that would be their preference. And, it will give the passengers a better ride, also.
Recently the Safety Board has investigated accidents that involved the failure of ATC to provide convective weather information in a timely fashion. Case in point is the April 2006 accident that claimed famed aviator Scott Crossfield. Three weeks ago the Safety Board released the final report of that accident. While we did cite the pilots’ failure to obtain updated en route weather information, which resulted in his continued instrument flight into a widespread area of severe convective activity, we also cited the air traffic controller’s failure to provide adverse weather assistance. As you know, the flight flew into an extreme thunderstorm and suffered loss of control and subsequent in-flight breakup.
Of course, that was a Part 91 flight, but my point is that ATC cannot always be relied upon for weather avoidance information. As a result of this accident and three other similar fatal accidents we issued a Safety Alert SA-11, “Thunderstorm Encounters,” which speaks to in-flight encounters with severe weather and ATC’s role in these accidents. I would encourage each of you to read this Safety Alert and use it in your recurrent training. These accidents should underscore and leverage the importance of your role as an aircraft dispatcher for assistance with weather avoidance.
As it relates to airlines, weather accounts for approximately 29 percent of Part 121 accidents. Of those, turbulence accounts for about three-quarters of those. While not typically high visibility events, injures to flight attendants and passengers continue due to turbulence. While many of those events are classified as clear air turbulence (CAT) events, many are related to convection or “Convectively Induced Turbulence (CIT)”. Flight planning and flight following is critical in reducing these events.
I’m certainly not a meteorologist, but I do predict that we will eventually get rid of this Indian Summer that has been newsworthy as of late. Before we know it, we will be right smack in the middle of winter. With that, we will turn our worries to weather concerns such as ground deicing and anti-icing, in-flight icing, and runway contamination.
Southwest Airlines flight 1248 at Chicago’s Midway in December 2005, Shuttle America flight 6448 at Cleveland, OH in February 2007, and Pinnacle Airlines flight 4712 at Traverse City, MI in April 2007, are all recent examples of overrun accidents that occurred in winter conditions with contaminated runways. In all three of these cases, moderate to heavy snowfall resulted in rapidly deteriorating field conditions and braking action, which made for a challenging operating environment.
The role of dispatch in obtaining field conditions and braking action reports is critical, as well as continuing to monitor wind components and snowfall rates. Dispatchers have better weather and access to information than pilots may have in the cockpit, and your flight following and alerts can be critical in deciding if a safe operation is possible.
I’d like to briefly discus Southwest at Midway since just two weeks ago the Board deliberated that accident. As you know the B737-700 overran the end of Runway 31C and struck a car where it claimed the life of a 6 year-old boy. As that flight neared neared Chicago’s Midway, the pilots received mixed braking action reports for the landing runway. They used an on-board laptop performance computer (OPC) to calculate expected landing distance. Observing OPC indications that they would stop before the end of the runway with either fair or poor braking action, they decided that they could safely land at Midway.
However, the accident pilots were not aware that stopping margins displayed by the OPC for poor runway conditions were in some cases based on a lower tailwind component than that which was presented. Also, the accident pilots were not aware that the stopping margins computed by the OPC incorporated the use of thrust reversers for their model aircraft, the 737-700, which resulted in more favorable stopping margins. Therefore, the Safety Board concluded in the report that had the pilots known this information, the pilots might have elected to divert to another airport.
As you know, the Safety Board determined that the probable cause of this accident was “the pilot's failure to use available reverse thrust in a timely manner to safely slow or stop the airplane after landing. This failure occurred because the pilots' first experience and lack of familiarity with the airplane's autobrake system distracted them from thrust reverser usage during the challenging landing situation.”
Contributing to the accident were Southwest Airlines' failure to provide its pilots with clear and consistent guidance and training regarding company policies and procedures related to arrival landing distance calculations; programming and design of its on board performance computer, which did not present critical assumption information despite inconsistent tailwind and reverse thrust assessment methods; plan to implement new autobrake procedures without a familiarization period; and failure to include a margin of safety in the arrival assessment to account for operational uncertainties. Also contributing to the accident was the pilot's failure to divert to another airport given the reports that included poor braking action and a tailwind component greater than 5 knots.
Our report did not find any wrongdoing on the part of the dispatcher, but there were dispatch-related factors that may interest you. I mention them not to imply any dispatch culpability, but rather to illustrate the potential role that Dispatch can have in preventing accidents:
Having been a pilot for many years, I can say from experience that sometimes the captain may be looking for a reason to make a different decision. Sometimes all it may take is you to point-out something that will help his/her make the right decision.
I realize there is a “disconnect” between braking action reports reported to ATC, and information actually provided to dispatchers. In my personal opinion, this is a loophole that should be corrected. I can’t help wondering about the outcome if dispatch had been given more updated braking action reports. If he had been given such information, then he would have been in a better position to provide accurate information to flightcrews planning to land at Midway that night.
“Attention Captain: Tailwind component on Runway 31C is 8 knots. Braking Action is fair to poor. Under our company procedures, with mixed reports, we must use the most restrictive category. With poor braking action, our maximum allowable tailwind component is 5 knots. Both of your alternates still look good. Please advise your intentions.”
Hopefully this illustrates my belief that dispatch is a very important layer of defense in preventing accidents. You have the power to affect the course.
I recall a number of times while I was flying the line where dispatch provided me with information that significantly and positively affected the outcome of my flights.
At the entrance to the NTSB’s Training Center, we have a plaque that says: “From tragedy we draw knowledge to improve the safety of us all.” In the Southwest accident, like all others, we have sought to draw knowledge to prevent future accidents. In completing the Southwest Midway investigation, we issued the following recommendations to the FAA:
These recommendations should go a long way towards reducing the likelihood of an overrun during inclement weather, and improving training and guidelines for dispatchers and pilots alike.
As I spoke earlier regarding my conviction that pilots be afforded the same information as dispatchers, I feel equally strong that dispatchers should be provided with the same information and training as pilots. This shared information and training will allow both parties to participate in the decision-making process in an educated manner.
I know the theme of this symposium centers on Next Generation ATC. I believe new technology can offer some great things for moving traffic, and it is exciting to see how things may change. But, with change, we must ensure that we properly manage the change. We must ensure that we continue to leverage the important role of the dispatcher. Even with better weather products and better technology, we must keep dispatchers in the loop.
I know that ADF’s mission is to advance aviation safety and efficiency by enhancing the professional standards of individual dispatchers and the organizations within which they exercise operational control.
I applaud your efforts to come together to improve your profession and I challenge you to continue your efforts. For it is by working together that we are making commercial aviation safer.
I realize that unlike my former profession where I stood at the doorway to greet my passengers as they deplaned, the traveling public never sees your face. But, whether they realize it or not, your face is always present in helping ensure the safety of each and every airline flight they take.
Thank you for all you have done to ensure the safety of the air transportation system. Keep up the great work and thank you very much for your attention!