Thanks to the Aero Club for inviting me to speak. It was an honor when you invited me the first time, and it’s even more of an honor to be invited again, despite the fact that I am no longer NTSB Chairman, but a mere mortal Member. Being NTSB Chairman has been one of the most challenging, exciting, and gratifying experiences of my career.
As we celebrate the NTSB’s 50th anniversary, my best wishes to Acting Chairman Robert Sumwalt, as well as to the next NTSB Chairman, yet to be named, for many more years of working with all of you in the aviation community and others to continue improving transportation safety.
The NTSB is populated with world-class experts who are passionate about what they do, and they do it very well. I would like to be able to take credit for that, but the simple fact is that I inherited the best workforce on the planet. Although the NTSB is one of the world’s best accident investigation agencies, there’s always room for improvement, so when I became Chairman, I told our staff that I was excited to work with such a world-renowned agency, but I wanted to encourage two ideas to make it even better – more effective collaboration and continuous improvement.
The staff took that ball and ran with it. What a thrill it has been to watch their creativity in action. Today I would like to discuss some of their accomplishments in those two areas, as well as some future opportunities and challenges.
Before doing that, I would like to describe briefly what we do, for those of you who may not already know. Congress created the NTSB to investigate transportation accidents, in all modes of transportation, in order to determine the probable cause of the accidents and to make recommendations to prevent them from happening again. Our primary product is recommendations. We are not a regulator, and we cannot require anyone to implement our recommendations. Nonetheless, contrary to popular belief, more than 80% of our recommendations are responded to favorably. That high acceptance rate has undoubtedly contributed to improving transportation safety, and it is a major tribute to the quality of the work by our staff. What’s not to like when they do all the work and I get all the credit?
Why do I believe so strongly in the power of collaboration? I believe in collaboration because all of you in the commercial aviation community created the collaborative program called CAST, the Commercial Aviation Safety Team, and it has been an amazing success story.
CAST was created because the commercial aviation fatal accident rate had been declining commendably for decades, largely because of new technologies such as jet engines, simulators, and automation. The marginal improvements from the new technologies decreased over time until, in the early 1990’s, the accident rate was flattening onto a plateau. Meanwhile, the FAA was projecting that the volume of commercial flying would double in the next 15-20 years. It didn’t require advanced math for the industry to realize that a stuck, flat accident rate times double the volume meant that the public would see twice as many aviation accidents in 15-20 years. That was an unacceptable outcome.
Thus, the challenge was how to improve the safety of the complex commercial aviation system – a system of subsystems that are coupled together such that changes in one subsystem could have effects in the other subsystems. The FAA Administrator at the time, David Hinson, knew that the answer was not more regulations or a “bigger stick” for the regulator. He, along with Ed Soliday, who was then with United Airlines, knew that one way to improve the safety of this complex system was collaboration. Thus, they proposed that airlines, manufacturers, pilots, air traffic controllers, airports, and the regulator work together to do four things – identify potential safety issues; prioritize those issues, because they would identify more issues than there were resources to address; develop remedies for the prioritized issues; and evaluate whether the remedies were accomplishing the desired results without creating any unintended consequences.
Because the participants had differing and sometimes competing interests, getting them to collaborate was a major challenge. Moreover, it’s human nature that the prospective participants believed that they were each doing fine but the other prospective participants needed to “get their act together.” How often has it been said that, “I don’t need to go the marriage counselor . . . you’re the one who’s got the problem, so you should go to the marriage counselor!” Nonetheless, Messrs. Hinson and Soliday managed to convince these participants, with their differing and sometimes competing interests, that if they participated in this voluntary collaboration, in their enlightened self-interest, they would make the entire system better and everyone would win.
The result has been an amazing success. The stuck, flat fatality rate, which many safety experts thought was already very good and not likely to improve much, was reduced by more than 80% in less than ten years. Moreover, contrary to conventional wisdom that improving safety generally hurts productivity and vice versa, the CAST process improved both safety and productivity. This is crucial, because as much as safety professionals hate to admit it, a safety program that hurts the bottom line is probably not sustainable.
If that weren’t enough, a major challenge of making changes to complex systems is unintended consequences, yet CAST has generated very few unintended consequences. Last but not least, the process occurred without generating any new regulations. The system was already heavily regulated, and as David Hinson correctly predicted, what was needed was not more regulations, but figuring out how to make a complex system work better.
In short, CAST has demonstrated that collaborative improvement is not just an abstract notion – it really works. That’s why I’m such a fan of collaboration. The moral of the story is very simple – everyone who is involved in a problem should be involved in developing the solution.
Collaboration is in the NTSB’s DNA because the fact-finding portion of our investigation process relies heavily on the “parties” to the process – e.g., in a major airline crash, the airline, the manufacturer, the pilots, the air traffic controllers, and the FAA – so the fact finding is inherently collaborative. Outside of the investigation process, however, the NTSB has considered its independence to be so important – to ensure that our investigations are objective and unbiased – that we have avoided collaboration. But I believe that we can collaborate without undermining our independence.
Examples of our increasing collaboration include our participation in the CAST process as a source of information to help inform CAST decisions. In addition, thanks to Peggy Gilligan and John Hickey for inviting us to participate, as information sources, in various FAA activities. We are also “learning to dance” with ASIAS. Our well known transparency, which helps ensure that our decisions and recommendations are based upon the facts from our investigations rather than politics, was a concern for ASIAS. Their concern was that any information they gave us would be available to the public. Experience has shown them that, for several reasons, the information they give us is in good hands.
First, the law requires us to protect from public disclosure any information about safety or security that is voluntarily provided to us, and information from ASIAS is voluntary. Protecting information is not new to us because we have a longstanding record of maintaining the confidentiality of proprietary information that we receive in our investigations. Moreover, we realize the value of ASIAS information, and we would not want to “kill the goose that laid the golden egg.” We are developing a good relationship with ASIAS, fostered by our mutual trust and self-interest.
In addition, we are working very well with our international partners in accidents to which ICAO Annex 13 applies. Our international relationships are so good, in fact, that we are often invited by foreign governments to help with investigations even when Annex 13 does not give us the right to be there. Our process is so respected that we have also been invited by foreign governments to help them develop NTSB-type processes.
We also have excellent collaborative relationships outside of aviation. For example, after the cargo ship El Faro sank near the Bahamas in a hurricane in 2015, our collaboration with the Coast Guard, the Navy, the Woods Hole Oceanographic Institute, and the University of Rhode Island enabled us to find the ship and retrieve its voyage data recorder from 15,000 feet of water. We have very good relationships with state and local police around the country, and their help – starting with being first responders at crash sites and protecting the sites until we arrive – has been essential to our accident investigation work in all modes of transportation, including aviation.
Before I leave the issue of collaboration, I would like to mention an emerging collaboration opportunity regarding automation in cars. Most of our motor vehicle crash investigations have involved large vehicles such as commercial trucks, motor coaches, and school buses, usually with professional drivers who have commercial drivers’ licenses. When the first fatal crash of a Tesla operating in an automated mode occurred last May in Florida, however, our staff was eager to investigate it, and I was happy to let them do so. For decades we have investigated accidents involving problems with automation, mostly in aviation, and we can bring those lessons learned to the process of automating our cars.
I have already seen the auto industry make some mistakes regarding automation that were made in aviation automation decades ago. When aviation began automating, they often automated whenever the technology enabled it. When experience demonstrated that automating because it was possible did not necessarily make the human/machine system safer or better, they evolved to “human-centric” automation. Today, many automated features in our cars are included because of the technological capability, but human factors issues are often not adequately considered. We can help them avoid the same mistakes that were made in aviation.
Now I would like to discuss continuous improvement. The NTSB is already considered to be among the best accident investigation agencies in the world, and one way for us to avoid the complacency that can accompany improved safety is by continuously improving. I am pleased to note that while I was Chairman, we improved in three ways -- the types of investigations that we do; the methods we use to investigate; and how we use our investigation results to continue improving safety.
Regarding the types of investigations that we do, our investigation of the Virgin Galactic space launch accident that occurred in 2014 was a first for us. The FAA was also on a learning curve because their statutory mandate regarding commercial space is very different from their mandate regarding commercial aviation. Virgin Galactic had never dealt with our investigation process, so they were also on a learning curve. Kudos to our staff because, anticipating this new experience, they had already attended previous space launch accidents as observers, and they handled the Virgin Galactic investigation masterfully.
I already mentioned that we are investigating the first fatal crash last year of a Tesla that was operating in an automated mode. The investigation is still underway, and our staff is aggressively pursuing it as the auto industry forges new frontiers in automation.
There is a connection between the Tesla accident and the next investigation I would like to discuss – our investigation of the SpaceX launch accident last year. As you know, Tesla is an Elon Musk enterprise, and so is SpaceX. Even as we were investigating his Tesla crash, he invited us to help with the SpaceX accident, which we would not otherwise have done. What an amazing vote of confidence regarding our investigation processes and capabilities to be invited by someone whose accident we were currently investigating. Again, the credit for that goes to our amazing staff.
We are also increasingly investigating incidents and other events, not just accidents. Well-known examples include the Minneapolis overflight in 2009 and the lithium-ion battery event in a Boeing 787 at Logan Airport in 2014. The overflight and the battery event could have been much more serious, and the fact that they were not legally “accidents” does not reduce the need for us to find out what went wrong so that we can try to prevent those problems from happening again. My objective is for operators to appreciate the value that we add and to want us to investigate, as Elon Musk and several foreign governments have done, rather than to dread our coming, and I look forward to our doing more of the same.
Regarding how we investigate, our investigation of the sinking of the El Faro that I mentioned earlier was our first deepwater retrieval of a voyage data recorder. Also new is that we have begun using a drone in our investigations because it gives us quality information that is not otherwise available, such as pictures from various perspectives, and photogrammetry - stitching the photos into a geographically accurate 3-D digital map or model that will enable us to extract information about the accident even after the actual debris field has been removed.
We are also benefitting from an increasing number of video sources. Onboard outward facing cameras have been providing a wealth of investigation information for years, and the Virgin Galactic investigation and some of our recent general aviation accident investigations are showing the value of onboard inward facing cameras. We are also getting increasing information from passenger cameras. Our investigation of a Part 135 sightseeing accident that occurred in Alaska that we will be considering in a public meeting tomorrow was aided by video taken by passengers.
Another increasing source of information that has proven to be quite valuable to our investigations is video from witnesses. In our investigation of a Boeing 747 cargo plane take-off accident in Bagram, Afghanistan, in 2013, for example, information from the flight data recorder and cockpit voice recorder stopped when the aircraft rotated to take off, but the take off and crash were captured by a dashcam on a passing truck. When a tractor-trailer truck hit and collapsed the superstructure of the Skagit River Bridge in Washington State in 2013, the event was caught on a nearby surveillance camera. We may not know about these video sources unless they are voluntarily provided to us by the public, and we take the public’s willingness to give it to us as a vote of confidence in what we do.
Our engineering lab has shown an amazing capability to get information from a variety of other sources that contain valuable information, such as antilock brake chips, airbag chips, and engine control modules. Many of these sources are nonvolatile – they don’t lose their information even if power is lost – and we are learning how to capture the information even if the chips are damaged, thanks in large measure to excellent cooperation from the electronics manufacturers. Also thanks to cooperation from manufacturers, we are improving our ability to download electronics at the accident site, rather than having to return them to our lab, and that greatly improves the efficiency and effectiveness of our investigations. In addition, as many of you know, we have recommended ways to get better information from aircraft that are lost at sea.
Our investigations are only as good as our ability to get the information out to the industry so that they can use it to prevent accidents, so we are exploring better ways to do that. We have been issuing safety alerts for decades, and we are exploring the efficacy of issuing video safety alerts. Similarly, we are exploring better ways to report about our accident investigations. Our first effort in that regard was our video companion to our written report on the Birmingham UPS accident, and that has been highly praised. Stay tuned as we continue down that path.
Before I leave this topic, I would like to mention another new direction that we have taken regarding the outputs of our investigations. In our investigation of the accidents on WMATA, our local Metro, we took the unprecedented step of recommending that the Federal Railroad Administration should oversee WMATA rather than the Federal Transit Administration. As we increasingly consider the big picture in determining how best to prevent accidents, that is the first time we have recommended which federal government agency should exercise oversight.
What about future challenges? One of our challenges arises from the fact that most of the transportation modes are becoming safer, which is obviously good; and as they become safer, proposed new safety regulations face more daunting cost-benefit challenges in the regulatory process. When we recommend that a regulatory agency “require” something, that’s NTSB-speak for “promulgate a regulation.” As new regulations become less likely, our challenge is exploring how to continue making safety improvements other than with new regulations.
We are exploring a variety of alternatives, including sending recommendations to manufacturers rather than to regulators; sending recommendations to trade associations to get their assistance; and with respect to cars, exploring better ways to educate consumers so that they will want safety technologies, in an effort to get the market to drive safety improvements. Stay tuned as we figure out how best to address these issues.
In conclusion, kudos to all of you for your amazing CAST collaboration success story. I am confident that you will continue to collaborate to resolve major emerging issues such as drones, commercial space, the shortage of airline pilots, and the future of air traffic control. I am also optimistic that the NTSB is improving to become even more effective in the future. I am honored to have had the opportunity to move it that way, and being invited to investigate, as I mentioned earlier, tells us how respected we are and that we are moving in the right direction. With indicia like that, I am confident that NTSB’s progress in these regards will continue after I leave the Board.
Thanks again for inviting me to speak, and I would be happy to take any questions.