Thanks for your
excellent remarks, David (Coleal), and thanks for inviting me to speak today on
behalf of the NTSB. My thanks also for inviting Board Member Robert Sumwalt,
who will present in the general session tomorrow at 8:00.
It’s an honor to
share the keynote remarks with you, David, with John Duncan from the FAA, and
with Ed Bolen of the National Business Aviation Association (NBAA).
At the NTSB we
investigate accidents, determine the probable cause, and make recommendations
to prevent recurrences. We can’t require anybody to follow our recommendations,
but it’s a testament to our staff’s thorough, knowledge-based investigations
that more than 4 out of 5 times, the recipients of our recommendations respond
positively to what we recommend.
I am particularly
honored that Standdown organizers have arranged for so many presentations to address
issues on the 2015 NTSB Most Wanted List - including disconnecting from distractions,
strengthening procedural compliance, fitness for duty and preventing loss of
control in flight. So let me touch briefly on where we are on those issues.
“Disconnect from deadly distractions” is on our
Most Wanted List because distractions are taking lives across all of the transportation
modes. That’s why earlier this year we held a multi-modal roundtable discussion
on the issue. One of the major sources
of distraction is portable electronic devices, such as cellphones. Many people assume they can multi-task – for
example, talking or texting on a cellphone while driving – but our accident
investigation experience has abundantly demonstrated that multitasking leads to
accidents, injuries, and deaths.
Another issue that
this Standdown will address from our Most Wanted List is procedural
compliance. Tony Kern will discuss this
issue in his session later this morning, “The Will is More Important Than The
We pilots have one
big advantage, if we embrace it: We have carefully crafted checklists to help
to ensure procedural compliance. Most of
the time we remember all of the items on our checklists. But checklists exist
because most of the time is not good enough; the items on a checklist must be
done every time.
Compliance with procedures
prevents all sorts of errors – including the obvious diversions of attention
that are most easily classified as distraction. But because procedures are
created, among other reasons, to positively reinforce focus on the most safety-critical
tasks at the most appropriate times, compliance with those procedures can also
help defeat subtle, everyday distractions.
For example, we
recently investigated the crash during a rejected takeoff of a Gulfstream G-IV
in Bedford, Massachusetts. I recused myself from the investigation and decision
because my son is an aeronautical engineer at Gulfstream, but now that the
report has been completed, I am free to talk about it.
The pilots failed to remove
their gust lock, which was an item on their Before Starting Engines checklist,
so their controls were largely immobilized. They also skipped a routine flight control
check on their After Starting Engines checklist that would have revealed their error,
and our investigators discovered that they also failed to do a complete flight
control check prior to 173 of their previous 175 takeoffs. What amazing
behavior by well-trained pilots who had a combined total of almost 30,000
hours. Using and following the checklist
could have changed the outcome.
The pilots began their
takeoff roll with the gust lock still engaged, ignored several warnings that
something was badly amiss with the controls and the throttles, reached takeoff
speed, and then realized the lock was still on. They overran the runway and
crashed into a ravine, resulting not only in their own deaths but also in the
deaths of the plane’s flight attendant and four passengers.
We made a number of
recommendations that emphasized best practices for checklist execution and reemphasized
the importance of procedural compliance. We also issued a safety alert, titled,
Locks: Overlooking the Obvious/Use Checklists to Prevent Procedural Omissions.”
What were those
pilots doing, when they should have used the checklist and removed the gust
lock, and when they should have checked to ensure that the controls were free
and correct? We will never know, but we
know that complying with checklist procedures could have prevented this tragic
Other presentations in
this Standdown that address issues from our Most Wanted List include Pat
Daily’s session, also later this morning, “Unfit for Duty”; a session tomorrow by NTSB’s own Loren Groff
and Dr. Mary Pat McKay, “Understanding Substance Impairment and Reducing your
Risk of Flying while Impaired”; and BJ Ransbury’s session, “Loss of Control in
Flight – Hazardous Mental Attitudes.”
On the subject of Loss
of Control, I should mention that the NTSB will hold a Loss of Control forum next
week, on October 14. Go to NTSB.gov/LOCforum
to find out more or to send us your questions.
These issue areas all point to the attention of the pilot being
somewhere other than where it should be at a critical moment. Our accident
investigation experience has revealed that there’s an element of distraction to
most of them.
When we talk about
distraction, we often focus on the obvious culprits, such as idle chatter in
the cockpit and inappropriate use of portable electronic devices.
But NTSB human performance
investigator Bill Bramble recently observed, in a presentation to the
Transportation Research Board, that the science of distraction can be more
subtle. It can also involve sub-optimal prioritization of tasks.
The one ironclad fact,
as I noted earlier, is that multitasking is a myth. We can change channels, but
we can only watch one at a time. We shift conscious attention sequentially from
one task to another.
So Dr. Bramble talked
about how we choose: essential vs. non-essential activities; high priority vs.
low priority activities; and finally high priority vs. other high priority activities.
How do we reduce the danger
First we remove the
obvious – the non-essential tasks. Then we train, so that, as second nature, we
put high-priority tasks ahead of low-priority tasks. And finally, we develop
expertise so that, when workload is highest, we can choose most effectively between
competing high-priority tasks.
So thank you for
attending the Standdown, and thanks also for focusing on some of our Most
Wanted issues and for inviting us to share with you what we have learned from our
accident investigations regarding those issues.
I hope that you will take maximum advantage of the great learning
opportunities that lie ahead, that you will put new lessons that you learn into
practice, and that those new lessons will help you become safer and more
proficient operators and pilots.
Thank you – and may
you have a productive and informative Standdown!