The Honorable Robert L. Sumwalt, III
"From complacency to catastrophe"
Good evening. It's great to be in Georgetown. Thank you so much for inviting me.
Aviation safety has been something that has been of tremendous interest to me for forty years. You see, I got into aviation by accident. When I was seventeen years old, I heard on my car radio that there had been a plane crash on approach to my hometown airport in Columbia. I decided to go see if I could find the crash. As I approached the crash site, I saw the coroner and decided to tuck in close to him. As he walked towards the accident site, I stayed close to him. The law enforcement officers raised the yellow tape for him, and I slipped in with him.
Don't ask me how this happened, but on the way home, I drove by the airport and stopped in a local flight school and signed up for flying lessons. So, yes, I sort of got into aviation by accident.
As I progressed through my pilot certificates and ratings, I continued to think of that accident. I occasionally returned to the accident site. I would try to understand what was going on in the cockpit of that aircraft as they approached Columbia Metro on a low, overcast day. And, while at the University of South Carolina, instead of studying whatever I was supposed to be studying, I would spend countless hours sitting on the floor of the Government Documents Library, reading NTSB accident reports.
So, although I got in to aviation "by accident," so to speak, I truly had a lifetime appreciation of accident investigation and a passion for working to prevent accidents. Beginning in 1974 when I started reading those reports, I had a secret dream that one day, I would be a member of the NTSB. It was a dream that continued throughout my adult life. It was a dream that would likely I would not have fulfilled had it not been for a good friend of mine, Captain Bill Weeks, who came up to me and pointed out that there was a vacancy on the Board and urged me to go for it. That night, we sketched out a plan on the back of a napkin. Today that napkin is framed in my office; exactly one year to the day later was my last day at SCANA. The next day I drove to Washington where I was sworn in as 37th member of the NTSB and vice chairman of the board.
I know you all know the NTSB is the federal agency that investigates plane crashes. And, yes, we certainly do that, but we also investigate accidents involving other modes of transportation, as well – marine, rail, highway, and even pipeline accidents.
Transportation safety is very personal to me. In 1976, my parents survived a fiery plane crash in the Virginia mountains.
In December 1980, I stood in the kitchen as my wife walked in the door and told her that her cousin, Julie Codington, was killed the night before by a drunk driver. We buried her the day after Christmas.
Six weeks later, my wife stood in that same spot in the kitchen as I walked in the door from my first week of airline training. She told me that my closet friend, Joe Nannarello, was killed in a plane crash that afternoon.
In 1994, my brother-in-law was a passenger in the USAir 1016 accident in Charlotte - an accident that claimed 37 lives.
Improving the safety of our transportation system is what the NTSB is all about. We're not in the business of pointing fingers, laying blame, assigning fault, or helping lawyers build their cases. We want to find out what happened so we can prevent it from happening again.
The last time I was in Georgetown was September 2009. I was here because an air ambulance helicopter had crashed just south of the airport. The helicopter and crew were based in Conway and were returning from dropping off a patient at the Medical University of South Carolina. As they approached Georgetown, there were thunderstorms in the area. Our analysis revealed the pilot likely flew into clouds, became spatially disoriented and lost control of the helicopter. The lives of the pilot and two medical crewmembers were lost.
The question I have asked so many times about this accident, and others, is: what causes pilots to make bad decisions about flying when they shouldn't?
I can say it is great to be back here under happier circumstances.
After being involved with investigating dozens and dozens of transportation disasters over the years, I have found there are two closely-related common threads woven throughout many of them – failure of leadership and complacency. It may be a failure of leadership or complacency in the cockpit of an aircraft or bridge of a vessel, or it can involve a failure of leadership or complacency the CEO or board of directors. And, I suspect this applies to life in general, and not just transportation safety.
I had been at NTSB less than a week. It was a few minutes before seven o'clock on a Sunday morning when the phone rang. On the other end of the phone was the NTSB chairman, telling me there had been an airline accident in Lexington, Kentucky, and there were massive casualties. With that, I was off on my first accident as a NTSB board member.
Just one look at the pictures on CNN pretty much would tell what had happened – the pilots inexplicably attempted to take off on the wrong runway – one that was too short for the performance of the aircraft. They ran off the runway, became slightly airborne, struck trees and the aircraft exploded into a fireball. Forty-nine of the fifty occupants perished. The only survivor was the copilot.
The crew had not flown together before this morning. I listened to the cockpit voice recorder, and from my years of being in airline cockpits, it immediately sounded to me as if they captain was trying to appear as a very confident, relaxed airman, as he talked to the copilot while preflighting the cockpit.
"I'm easy, buddy," he told the copilot. He abdicated his responsibility for calling for the checklists, instead instructing the copilot to do them "at your leisure." The captain set an over-relaxed tone in the cockpit. In short, it was a failure of leadership.
The Board basically determined was that – among other things – the pilots didn't have their heads in the game. They were over-relaxed and missed very basic things; they were complacent.
And, from listening to the cockpit voice recorder – from the beginning of the CVR until the very end when they realized they had made a critical mistake – I can tell you they went from complacency to catastrophe in seconds.
We've also seen failure of leadership with company CEOs and even boards of directors.
For example, in June 2009, a Washington, DC, subway ran into the back of a stopped train. The speed at collision was between 44 and 49 MPH. There were nine fatalities and scores of injuries. We determined there was a technical failure that allowed the accident to happen. But, we didn't stop the investigation there; we wanted to understand the underlying conditions that could have led to the crash.
We found that a few years earlier, the Washington transit agency had a near miss under very similar circumstances. After that event, they established procedures to ensure safety – but, those procedures were never inculcated into their way of doing business. Basically, no one knew the procedures existed. Our investigation determined that if those procedures had been used, this 2009 accident would have never occurred.
But, our investigation went further than that. We found the transit agency's board of directors had not been providing oversight over the operations or maintenance of the subway system. When they got briefings from staff on safety, the things they looked at were things like slips, trips, and falls; escalator injuries; and, crimes in the subway stations.
I chaired the board of inquiry for this accident and we put the chairman of their board of directors on the witness stand. He continued to say they were a policy board; I think he made references to that nine times. He made no reference to their being an "oversight board."
When you're on a board of directors, you have a responsibility to provide oversight.
The transit agency's staff had prepared a PowerPoint presentation that was supposed to have been presented to the Board three days after the accident. Ironically, the presentation boasted of the excellent safety record of the agency. The board was complacent. They went from complacency to catastrophe in moments.
Failure of leadership and complacency - they can kill you, literally and figuratively.
I'll close on this note with a story about an aquarium. The aquarium had a tank of barracuda. As you can imagine, the fish would swim the inside perimeter of the tank all day, day after day. One day researchers at the aquarium bisected the tank by placing a glass partition in it. After bumping their noses on it a few times, the fish soon realized they couldn't swim into the other section of the tank.
After the fish got accustomed to the fact that they couldn't swim into the other section, the researchers removed the glass partition.
What do you think the fish did?
They continued to swim right up to the point where the glass had been, but instead of continuing forward, they made their usual 90 degree turn and continued to swim their usual circuit. In essence, there was an artificial barrier – they perceived the barrier to be there, although it really wasn't there. Their perception of the barrier prevented them from going where they could have gone.
I know had placed an artificial barrier in my life: a lifelong dream was to be on the NTSB, but I had tons of reasons – artificial barriers – that were preventing me from accomplishing – even trying – to reach my goal. Then a friend approached me and told me there was an opening on the Board and it was time for me to go for it. He and I sketched out a plan to achieve my goal on the back of a napkin.
And just as I had placed an artificial barrier in my life, I suspect many of you have done the same. Oftentimes that barrier is fear of failure. Perhaps you've always wanted to write that novel that has been in your head for years, but the fear of failure has held you back. Perhaps you have thought of leaving the comfort and security of your job and then starting your own business. Perhaps you've always felt you could make a difference by running for public office. You have placed artificial barriers in your life, just as those fish in the aquarium, and those barriers have prevented you from reaching your dreams.
If you have placed artificial barriers in your lives, I urge you to remove them. It may start tonight on the back of a napkin.
So, gentlemen of the Winyah Indigo Society, I raise a toast to you. Thank you, safe travels, and may God bless America!