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Speeches

Remarks at the Annual Bombardier Safety Standdown
Christopher A. Hart
Wichita, KS
10/6/2015

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 Wings.”

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,

“Flight Control 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 accident.

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 of distraction?

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!