Thank you very much. It is truly an honor and a privilege to be here today.
I would like to begin by thanking President Obama, first for nominating me to be a Member of the NTSB, and then for appointing me to be Vice Chairman. I also want to thank all of you who took time from your busy schedules to come here today to share this very special and wonderful occasion with me. Friends from all aspects of my life have come to join me today.
Some friends, such as Delabian Rice-Thurston, Marlene Zinn-Connors, Herman Mitchell, and Claude Johnson, are from Denver, my home town. People are here from several of the industries I have worked in, such as Dr. David van Stralen, who works in health care and came from California. I have also worked with Amy Hultman and Chief Billy Goldfeder, who are here today, to help them develop a near-miss reporting system for firefighters that is similar to the one in aviation. Chief Goldfeder has the distinction of having taught my daughter Brooke, then age five, how to launch a piece of bread across the table on a fork . . . so much for all those years of “don’t play at the dinner table, Brooke.”
I have also worked with many people who are here today in various transportation safety endeavors. Ed Soliday has come from Indiana. He is the godfather of aviation safety. He pushed many rocks uphill to pursue safety ideas that were not popular at that time, but that everyone is doing now. It is truly amazing how much the progress he made benefits not only US aviation but world aviation.
On a more sentimental note, my great uncle, James Herman Banning – the first African-American to receive a US pilot’s license, in 1926 – is surely looking down from above to see this wonderful event. And to add some historic irony, today is the 106th anniversary of the Wright brothers’ first flight.
I also would like to thank NTSB Chairman Deborah Hersman, former NTSB Chairman Jim Hall and Mr. Bill Broadwater for their very kind remarks, and Antion Downs for being the Master of Ceremonies today. Please give them a round of applause.
Many people have asked me why it is so exciting and gratifying to be at the NTSB, where our job is to investigate and help fix things that have gone wrong. That is a very good question. Another question people have often asked was why I went all the way through engineering school only to become an attorney. The answer to that question is easy – Perry Mason.
As a child, when I watched Perry Mason every Saturday, I noticed with considerable interest that he made a boat-load of money – I remember from one episode that he charged $75 an hour. I see in the latest issue of the Washingtonian magazine, the title on the cover is “Why attorneys make so much money, “ so I guess it’s still true. Also, he drove a Ford hard-top convertible. For a gadget geek like me, watching the top disappear into the trunk was really cool. And if all that weren’t enough, he never lost a case! So that made it easy – I wanted to be an attorney. Along with Perry Mason every Saturday I also watched Gunsmoke, Wanted Dead or Alive, and Palladin, but somehow, being a US Marshal, a bounty hunter, or a hired gun did not appeal to me as much as driving a Ford hard-top convertible; so that decision was easy.
The tougher question is why being here is so gratifying. There are two reasons, both of which have already been touched upon today by previous speakers – the mission and the people. I am very familiar with both the mission and the people because I was an NTSB Member before, from 1990-1993.
In terms of the mission, I remember reading a book in elementary school about accident investigations. Those investigations were absolutely amazing to me. One that I particularly remember was about the deHavilland Comet, the first jet airliner in commercial service. For starters, investigators had a major challenge because many of the airplanes were departing from London, so many of them disappeared over the ocean. When they finally found enough pieces of an airplane to reconstruct it, they discovered that the problem came from the windows being square. As engineers know, stresses concentrate in sharp corners. So the repeated pressurization, depressurization, expansion, and contraction, over and over again with each flight, finally caused one of the square window corners to crack, causing the airplane to decompress explosively. It was so amazing to me that they were able to put those gazillion pieces together and figure out the cause of the accidents. And that is why airliners to this day have rounded corners on the windows and doors.
Then there are the many other tangible results from what this Agency does. When I was growing up, my parents would put my two older brothers and me, and about 200 of our favorite comic books, on the train every summer to send us from Denver to Salina, Kansas, to spend a couple of weeks with our grandparents. I really loved riding on the train. I remember that the train windows were about so thick. There was no way for passengers to get out if they had to, or for emergency workers to get in if they had to. Today, emergency windows on trains are well marked – on the inside, throughout the train, so passengers can easily get out, as well as on the outside, so rescue workers can easily get in.
Also, the luggage rack used to be very long and uninterrupted, so if the train stopped very suddenly, the bags on the rack could become heavy and dangerous projectiles. Today’s luggage racks have frequent vertical partitions that contain the bags to keep them from hurting people. Another improvement comes from the robustness of the couplers that hold the train cars together. The couplers are very robust because safety experts realized out that coupled train cars are much less likely to roll over, and if the cars don’t roll over, the passengers are much less likely to be injured. All of those things came from recommendations from this Agency. That is why I am so intrigued by the mission of this Agency, because the benefits of our work are so abundantly apparent, not only for the traveling public but for the public in general.
As much as I am excited by the mission, though, my biggest reason for wanting to come back to NTSB is the people. As you have already heard from previous speakers today, we are blessed with an amazing staff, and many who were here when I left in 1993 are still here. They are highly talented people who could earn more elsewhere, but they stayed because they love their jobs so much. They are great detectives. When they worked through the recent Metro crash, I was so amazed when they showed me how they figured it out – a “parasitic oscillation” in the electronics, along with a few other links in the chain, caused the stopped train to be electronically invisible, both on the dispatcher’s screen and to the proximity warning devices of the approaching train behind it, so the electronic systems in the approaching train didn’t know that the stopped train was there. That was truly amazing to me.
And even though they are such great detectives, and even though they love to find out the answer, one way they have really gained my respect is that they are willing to admit when they aren’t able to figure out what caused an accident. One example is the Boeing 737 that crashed in Colorado Springs in the early 1990’s. I gained great respect for them to see that, as much as they endeavor to come up with the answer, they are willing to admit when they do not have enough evidence to say what caused the accident.
Another incident involved a Boeing 747 that lost a cargo door while departing from Honolulu, and then managed, fortunately, to return safely to Honolulu. Investigators could not initially find the cargo door because it was on the ocean floor, under 15,000 feet of water. Based on the physical evidence around the missing door, we reached our probable cause determination. Amazingly, the Navy later not only found the door, but retrieved it from 15,000 feet, and that gave us the physical evidence of the door. Once the investigators had the door, they changed the probable cause. My respect for NTSB staff, for admitting when they don’t know, and for admitting if they made a mistake, is enormous. They are why the NTSB is the world’s gold standard in terms of accident investigation, and that is the number one reason why I love being here.
In addition to that, the Members have been fabulous. The Members I worked with before were great – John Hammerschmidt, who is in the audience today; Carl Vogt, who was Chairman; Susan Coughlin; and John Lauber. John Lauber was widely known as the person who moved safety experts away from the theory that “pilot error” was the end of inquiry. Since then, Dan Marino, recently retired from ICAO, is widely noted for saying that “pilot error” is not the end of inquiry but the beginning of the inquiry – why would a proud, highly trained professional make a mistake that could hurt him or herself. This change in thinking, away from the concept that accidents are just caused by the individuals “up front” – caused us to look beyond, into the corporate culture and the many interactions of the system around the individual players, rather than focusing only on the pilot and pilot errors. It was a privilege to work with that Board.
Working with the Board today is equally exciting, under the leadership of Chairman Hersman. I have had the pleasure of working with Member Sumwalt over the years in relation to the proactive information programs I have been developing at the FAA. The Member of the Board who is now waiting for the Senate confirmation vote, Mark Rosenkind, is a fatigue scientist, and I have worked with him over the years on the Board of Directors of the National Sleep Foundation. As we know, fatigue is an issue that affects all transportation modes because transportation is a 24/7 endeavor. We already have fatigue expertise in the staff, but it will be great to have a fatigue specialist as a Member. The Chairman probably knows who the fifth Member may be, too, but if she told me, she’d have to shoot me, so I’m happy to wait to find out who that is. All told, I am looking forward to being on a very exciting Board this time as well.
Having said that, I am looking at some differences in the way we did it in those days and the way we are doing it now. Whenever a mishap occurred back in those days, our staff would go out to do their usual detailed and exhaustive investigation and identify the links in the chain of the mishap. The managers of the companies involved in the mishap, as well as the regulators, were often surprised by what we found – they would often say that they had no idea that these things were happening every day in their airline or railroad, and the regulators would say the same thing. The worker bees on the front lines usually knew about the problems in the system because they lived them and breathed them every day – but more often than not, there was a failure to communicate between the front line and the management or the regulator, so when our reports came out, they were surprised by what we found.
Now things have changed quite a bit, and these changes are forcing us to re-think how we can continue to play our role most effectively to continue to improve transportation safety. There are two major changes.
The first change is that information technology has advanced tremendously. IT advances over the years are enabling us to collect and analyze information as never before in order to be proactive. Your Blackberry has more capability than computers that used to fill this room. These advances allow us to collect information about things that are happening every day so that we can spot precursors of things that could go wrong and then fix them before they actually do go wrong and hurt somebody. So our ability to collect and use information more proactively has been enhanced enormously.
The second change, that is perhaps even more amazing, is the concept of what I call “System Think.” Our transportation systems involve complex interactions between many parts. In aviation, for example, those complex interactions are between airlines, manufacturers, pilots, controllers, labor, management, and the regulator. Given these interactions, what we usually see these days is that the most challenging safety issues are not simple “stovepipe” issues, like an “airport” issue, or an “airplane” issue. Instead, safety issues more typically involve interactions between the parts of the system. Thus, in order to effectively address these complex issues, System Think must address the system interactions.
The commercial aviation industry made history by bringing all of these system players to the table to work collaboratively. To the best of my knowledge, that has never happened in any industry before or since. Bringing all the players to the table to work together is a major accomplishment.
First, the regulators are created to regulate and enforce, so by definition nobody likes them or wants them at the table. No big surprise there. But guess what – the operators and the manufacturers don’t like each other, either. If there is a mishap, they will be blaming each other in the ensuing lawsuits. We are now receiving the party submissions regarding the accident in Buffalo that we are investigating, and you may have noticed in the media in the last week or so that in most of those submissions, the parties are blaming everyone else. In this finger-pointing environment, getting all these players to come to the party to dance together was a huge accomplishment . . . and one of the people who deserves the credit for that is, once again, Ed Soliday, who is here today in the audience. He managed to get all of those players to realize that they had a common goal – improving safety – and he managed to get them to come to the table, in their enlightened self-interest, to work together in pursuit of that goal.
The process, called CAST, for Commercial Aviation Safety Team, brings manufacturers, operators, regulators, labor, and management together. Everyone is at the table, so they accomplish System Think not by relying upon a very smart person who understands the system, but instead by having all parts of the system sitting at the table and working together to identify problems and come up with solutions. CAST has been so successful that it won the Collier Trophy last year.
When those two advances are taken together, i.e., when the System Think process is fueled by the information that is created from the information technology advances, the results can be very powerful. In fact, the combination has been so powerful in aviation that it resulted in a 65% reduction in the fatal accident rate in only ten years, from 1997 to 2007. A 65% reduction is amazing enough by itself, but what is even more amazing is that in 1997, US commercial aviation was already considered very safe. That is why so many industries have been coming to aviation to find out how they manage their risks so well.
These advances will affect how we do business at the NTSB. First of all, when our reports come out, management and the regulators are no longer surprised because they have their own information processes that bring them information about what is happening in their systems every day. Not only that, but because this information helps them determine more accurately what is going wrong and what needs to be fixed, they may already have identified and fixed the problems by the time our report comes out. Their quicker response is obviously great for the safety of the system, but it necessitates a major re-think on our part about what role we want to play to continue contributing most effectively to improving safety.
What are our long-term opportunities? Just as the celluloid film industry had to re-think its business plan when we started taking pictures with electrons, and just as the mainframe computer industry had to re-think its business plan when the populace started having PCs with more capability than computers that used to fill this room, we need to re-examine our business plan and re-think what role we will play. In the long term, transportation industries are evolving from primarily forensic, which is what we have historically been, to diagnostic and even prognostic. Thus, we need to get smarter about how we can play the most effective role in this evolving environment. That’s a huge long-term challenge and opportunity we have, and I am excited to be here to play a role in it.
We also have some exciting opportunities in the shorter term. For example, when I worked at FAA in the past few years, many industries came to FAA to ask how the aviation community manages risk as well as it does. That includes industries such as nuclear power, chemical manufacturing, petroleum refining, and even the finance industry, the banks.
Amongst all those industries, the 900-pound gorilla is health care. It’s the 900-pound gorilla because about 10 years ago, the Institute of Medicine released a report that estimated that there were nearly 100,000 deaths per year – almost 2,000 every week – in US hospitals due to medical mistakes. That’s really scary. The healthcare industry also came to the FAA to see if aviation’s safety management processes might work for them. As a result, I have been talking in conferences in all of these industries about of aviation safety, noting that although one size does not necessarily fit all, other industries might nonetheless learn from what worked for aviation and what did not. It has been a very productive endeavor because not only do the other industries benefit, but every time I speak to another industry, I learn more about how we can do it better in our industry. I see enormous opportunities to exchange information with other industries, and I am pleased to say that Member Sumwalt has been already doing that. I have been to at least two multi-industry conferences that he either organized or enabled by allowing the use of NTSB facilities, conferences that provided valuable opportunities for various industries to exchange notes and learn from each other about how best to use limited safety improvement resources without duplicating each other.
Another short-term opportunity is a huge issue, and it is still in the conceptual phase for me. As I have spoken in various industries, I have seen that they are getting smarter about using information technology advances to generate information, to learn about things that could go wrong so that they can fix them, proactively, before they cause harm. As they get better at this, they are identifying many more things that could go wrong than they have resources to fix – big time! So now they are facing the challenge of what to fix first, and what to put on the back burner. This is a huge challenge, and I think the NTSB has an enormous opportunity to bring experts together from academia, various industries, and several countries to develop a prioritization process that is not only robust, objective, and repeatable, but also flexible enough to respond to the changing environments in which these industries operate.
The NTSB is not in the business of telling anybody what their priorities should be. But I do think we have an enormous opportunity to bring experts together to develop a prioritization process that is generically applicable across industries because it is in our bailiwick to help improve safety. If people can improve safety more efficiently and effectively by prioritizing their resources better, then we all win. I think that is a huge opportunity, and I look forward to helping this Agency pursue it.
As they say, safety is a journey, not a destination, and I look forward to working with all of you in that journey. Before I close, I would like to thank all of those who organized this ceremony and helped to make it as successful as it is – Harkey Mayo, my Special Assistant; He Ning, who unfortunately could not be here today; Reshan Blackwell; Stephanie Matonek; Tarrence Thresh; Mary Jones; Towanna Price; Lola Ward; and Barbara Zimmerman, as well as many others whom you see with the usher badges. I would like to thank all of them for all they did, and I would like to ask you to give them a round of applause.
Once again I would like to thank President Obama for showing confidence in me by putting me here. I would also like to thank my family, my son and daughter, who are the best son and daughter a parent could ever want, and thank my wife and best friend, LeeAnn for her support in helping me to be here.
Thank you very much. Happy Holidays, and God Bless.