Thank you Jeff (Mulder) for that kind introduction, and my thanks to AAAE for inviting me to speak today on behalf of the National Transportation Safety Board at its annual awards luncheon.
It is my great honor and privilege to serve as the Chairman of the National Transportation Safety Board. As many of you know, the NTSB was created by Congress to investigate transportation accidents and incidents in order to find out what went wrong and make recommendations to prevent them from happening again. Note that I referred to both accidents and incidents. The Minneapolis overflight and the Boeing 787 lithium-ion battery problem at Logan, for example, were not accidents, as the law defines that term, yet we believe that they were just as informative as accidents regarding how to prevent future mishaps. We are involved in all modes of transportation: from aviation, to rail, to highway, marine and pipeline. Currently, for example, we are receiving considerable attention in Philadelphia because of the recent Amtrak derailment.
We can’t require anyone to follow our recommendations, but it is a testament to the quality of our amazing staff of investigators and analysts that, contrary to the impression the media sometimes gives, more than 80% of our recommendations are acted on favorably.
When I became Acting Chairman of the NTSB last April, I told the staff that I appreciate what an amazing agency it is, but there is always room for improvement. Thus, I told them that I was looking for two things: better collaboration, internally and externally, and continuous improvement from that collaboration. So I really appreciate the opportunity to be with you as part of today’s awards ceremonies because both of your awardees, Mark Brewer and Elaine Roberts, represent exemplary leadership in the aviation and airports community for collaboration and continuous improvement – congratulations to both of you.
Along those lines of collaboration and continuous improvement, I’d like to talk about an issue that AAAE and NTSB are both very interested in, namely, runway safety. The two aspects of runway safety I’d like to talk about are incursions and excursions. Both incursions and excursions are ripe for the application of a process that the aviation industry is using today very successfully – collaboration for continuous improvement through the Commercial Aviation Safety Team, or CAST.
The impetus for CAST was that the fatal accident rate, after declining marvelously for several decades, began to “flatten out” on a “plateau” in the early 1990’s. Meanwhile, the FAA was projecting that commercial aviation volume would double in the next 15-20 years. It didn’t take very advanced math to realize that doubling the volume, but maintaining the same fatal accident rate, meant that the public would see twice as many fatal accidents.
Because the commercial aviation industry is one in which anybody’s accident is everybody’s accident, the prospect of twice as many accidents scared the industry. The public doesn’t say “That accident was on Airline X, but not to worry because I’ll be going on Airline Y.” To the contrary, the public gets worried when they see a German airliner crash in the French Alps. So the industry did something it had never done before – work collaboratively to identify potential safety issues, prioritize them, develop remedies, and evaluate whether the remedies were working – and the result has been a major win-win. The CAST process resulted in a reduction of the stuck, flat U.S. airline fatal accident rate by more than 80 percent in its first ten years. The win-win is that while safety was being improved, productivity was improved as well, contrary to conventional wisdom that improving one usually undermines the other.
The moral of this collaborative win-win success story is very simple: Anyone who is involved in a problem should be involved in developing the solution. The reason that it has been sustainable is that it was a win-win for both productivity and safety; and as much as we safety people hate to say it, a safety improvement program is not generally sustainable if it hurts the bottom line.
I would like to suggest that you, too, can benefit from collaboration and continuous improvement, and that you, too, can see improved safety along with improved productivity, just as the industry has done with CAST. Let’s start with incursions.
The worst accident in aviation history was the runway incursion in Tenerife that resulted in 583 fatalities. Mark Brewer is a great example of the collaboration and continuous improvement that are the hallmark of your association because of his response to a near incursion at his airport.
When Mr. Brewer was the director of Providence Rhode Island’s T.F. Green airport, he experienced a runway incursion near miss. As a result, he offered up his airport surfaces to test new taxiway and runway markings in an effort to improve situational awareness and prevent runway collisions. Well, you know the result. The FAA went forward with mandating the new runway and taxiway markings.
Speaking of collaboration, let’s look at a program that the FAA recently announced – their Runway Incursion Mitigation, or RIM, program, to identify airport risk factors that might contribute to runway incursions.
The objective of RIM is to identify and fix problems, rather than to punish. It is a collaborative activity, including the airlines, pilots, AOPA, airports, the FAA, and others. Unfortunately, the reason for RIM is that since 2010, the rate of A and B incursions, the most severe incursions, has been on the rise, tripling from 6 to 18 per million by 2012, declining to 11 in 2013, and rising again to 14 in 2014. That is particularly troublesome after the rate for A and B incursions declined from 67 per million airport operations in 2000 to 6 per million in 2010, an eleven-fold decrease. This is truly an example of the fact that not having an accident is not necessarily an indicator of safety. Just ask others who enjoyed a long period without any accidents and then saw a turnaround -- the people at Metro North, or Washington Metro.
Previously, the response to runway accidents and incidents was simply to find somebody to blame, usually a pilot, but occasionally an air traffic controller, and punish them. But Identifying problems and fixing them improves safety far more effectively than punishment. As the FAA works to implement its 15-year effort to decrease the rate of incursions, the RIM program will be strongest if everybody who is part of the problem is part of the solution, and that includes you – the airports.
And the non-punitive emphasis of the effort enables feedback from the front lines, such as non-punitive reporting programs that allow pilots, controllers, and others to report, without fear of punishment, problems that they encounter in the system.
Now let’s look at excursions. Although the worst accident in aviation history was an incursion, as I mentioned before, there are many more runway excursions than incursions, and there are many more fatalities from excursions than from incursions.
We are currently investigating the March 2015 incident at New York’s LaGuardia airport, when Delta Airlines flight 1086, a Boeing MD-88, was landing during a snowstorm and exited the left side of the runway and collided into a perimeter fence, with the nose of the aircraft resting on an embankment next to Flushing Bay. All the passengers and crew safely evacuated with either minor or no injuries.
We’ve seen that before. A Southwest Airlines plane landing in Chicago’s Midway airport skidded off the end of the runway, crashing through a perimeter fence and coming to rest on the adjacent city streets. Unfortunately, that accident resulted in fatally injuring a child who was in a car that was hit by the airplane.
What is your role in this? You have many roles. For example, your airports are responsible for keeping the runways clear, and your runway condition reports are used to develop landing distance assessments. These are some of the issues that you and your airline partners are constantly dealing with. And it will take a collaborative effort to address the many facets of these challenges.
Another example of a problem area that we have seen in runway mishap investigations and that involves your role is airport construction projects. They pose a special incursion risk because during construction, normal or construction lights might be inoperative, routes might not be well marked, and interim procedures adopted during the construction project might not be robust. One example involving construction was the tragic wrong-runway accident in Lexington, Kentucky, in 2006.
We need another win-win: more air traffic is good for airports, airlines, and the public. The challenge is how to improve safety at the same time that more flights are departing and arriving, with few new runways being put into service.
Whether it is runway status lights, or perimeter taxiways, or a wholesale infrastructure modernization and reconfiguration effort, you, as airport directors, have an opportunity as never before to lead the way in embracing collaboration and continuous improvement to improve safety and efficiency at your airports and throughout our national airspace system.
Going forward, I hope all of you will continue to reach out: to your colleagues in the airport community, both domestically and internationally, as you are doing in this conference; to your colleagues in the airline and GA community; the leaders in the FAA and Capitol Hill. I hope that you will reach out and be willing to identify and tackle the challenges confronting the industry so that you, too, can enjoy the win-win of improving both safety and productivity.
Once more, thank you for inviting me to speak today, congratulations to today’s awardees, and best wishes to the AAAE in the future.