Good Morning. My name is Debbie Hersman and it is my privilege to serve as the Chairman of the National Transportation Safety Board. I would like to take a moment to introduce my colleagues: Vice Chairman Chris Hart, and Board Member Robert Sumwalt.
Welcome to the boardroom of the National Transportation Safety Board. Today, the Safety Board begins its three-day forum on Professionalism in Aviation. Thank you for joining us.
Many of you are familiar with the National Transportation Safety Board convening an open meeting, or what we refer to as a sunshine meeting, to consider the findings and probable causes of transportation accidents. Today, we are convening for a different purpose, but one that is also devoted to promoting safety in our air transportation system.
Over the past several decades, advances in technology along with the dedication of airline pilots, flight crews, technicians and other professionals have made American aviation remarkably safe.
At any given moment, there about 5,000 planes in flight above the United States alone. That’s nearly 45,000 arrivals every day – resulting in millions of flights every year. Yet less than five one-thousandths of one percent of those flights experience any sort of accident.
So with very small exception, this is an industry with a level of professionalism and safety for which they can rightly be very proud.
But the American people rightly demand not 99-plus percent safety, they demand 100% safety. So on the rare occasions when an accident occurs, we must all work together to investigate and learn from it.
Among that very small number of accidents – and even smaller number of fatal accidents – was Colgan Air Flight 3407. In February 2009, Flight 3407 crashed five miles short of the runway at Buffalo-Niagara International Airport, killing all 49 people on board and one person on the ground.
I want to recognize the Colgan Air family members who are joining us today. They have been strong advocates for change in our commercial aviation industry. Because of their work with the Congress, both the Senate and House have moved aviation safety bills that include a number of provisions that deal with pilot training, fatigue and other issues. The Colgan family group, and others who came before them, are the tireless champions of many of the safety issues we will be discussing over the next few days. You are also the visible reminder of why raising the bar on aviation safety is so important. Thank you for joining us.
While the Colgan Air accident investigation was the impetus for this forum, many of the issues raised in that accident investigation were not new to the Safety Board. In fact, we have seen a number of similar issues raised in other accident and incident investigations.
Previously, the NTSB cited concerns with professionalism in aviation when it concluded in one accident investigation that “during the descent, until about 2 minutes and 30 seconds prior to the sound of impact, the flightcrew engaged in conversations not pertinent to the operation of the aircraft … The Safety Board believes that these conversations were distractive and reflected a casual mood and lax cockpit atmosphere, which continued throughout the remainder of the approach and which contributed to the accident. The overall lack of cockpit discipline was manifested in a number of respects … where the flightcrew failed to adhere to recommended or required procedures.”
That accident occurred 35 years ago and involved the crash of an Eastern Air Lines plane in Charlotte, N.C., in which 72 of the 82 passengers and crew died.
Well, over the last 35 years, the industry has made some significant strides in improving the operational safety and reliability of our aviation system. Airplanes and their operations have become more sophisticated, and crew training has developed to incorporate human-centered concepts such as crew resource management and human factors training. Also, through programs like ASAP, FOQA and LOSA, the industry is using systematic methods and approaches to identify safety hazards. Even here at the Safety Board, in order to mitigate the consequences of human error, we have issued safety recommendations to improve training and procedures, and address the constant changes in technology and automation.
Unfortunately, since I came to the Safety Board in 2004, we have seen accidents and incidents that are tragic reminders that more needs to be done to improve aviation safety, especially when it comes to discipline, distractions and deviations. As we have learned through our accident investigations, when flight crews and controllers deviate from standard operating procedures and established best practices, the consequences can be tragic.
For example, the probable cause of a 2004 fatal accident involving Pinnacle Airlines was “… the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover.”
In the 2006 fatal wrong runway takeoff accident in Lexington, KY, involving Comair, it was “The flight crew’s noncompliance with standard operating procedures [which]… most likely created an atmosphere in the cockpit that enabled the crew’s errors.” Contributing to the probable cause was “the flight crew’s non-pertinent conversation during taxi, which resulted in a loss of positional awareness.”
An engine fire on an American Airlines MD-80 in 2007 involved a crew engaged in non-pertinent discussion during taxi and after landing “indicating that a casual atmosphere existed in the cockpit.” This casual atmosphere “before takeoff affected and set a precedent for the pilots’ responses to the situations in flight and after landing, eroding the margins of safety provided by the SOPs and checklists, and increased the risk to passengers and crews.”
You will recall that the Colgan Air crew violated the sterile cockpit rule as they approached Buffalo. As a result, the flight crew’s failure to adhere to sterile cockpit procedures and the captain’s failure to effectively manage the flight contributed to the accident.
And most recently, Northwest Flight 188 overflew its destination airport because the pilots, using their laptops, became distracted by conversation unrelated to the operations of the aircraft.
These accidents and incidents illustrate the consequences when pilots fail to demonstrate the precision and discipline expected of them—when they don’t follow SOPs, when first officers don’t challenge a captain’s deviations, and when crews behave unprofessionally in the cockpit.
And this breakdown in performance isn’t limited to the flight deck. We have seen similar degradations in performance in the control tower as well.
In the Comair accident, the controller wasn’t monitoring the aircraft as it attempted to takeoff on the wrong runway, and instead, was performing a lower-priority administrative task.
In 2008, when a helicopter and aircraft collided in midair over the Hudson River, the tower controller was on the phone for about 2 minutes after he cleared the accident airplane for takeoff, talking about things unrelated to his work.
And, again in the Northwest flight 188 incident, the plane’s radio was not on the correct frequency, and while it should have been promptly identified as NORDO, because air traffic controllers weren’t following established procedures, it went unrecognized for nearly 30 minutes.
The evidence is clear that when pilots and controllers drift away from their training, procedures and best practices, safety margins erode and inadvertent errors go uncorrected. Things are happening in industry that have lead us to this point—errors and practices that warrant closer scrutiny. That is why we are here.
Our purpose today in convening this three day forum is different than the more traditional Safety Board meeting you may be used to seeing. Today we are not considering an accident report and making probable cause findings on what went wrong. Rather, we are here today to focus on what can and does go right, and to understand how we can collaborate to develop and reinforce professionalism in the workforce.
While the sheer numbers of operations daily, involving professionals in the air and on the ground, demonstrates that a majority of pilots and controllers carefully perform their jobs with precision, pride and professionalism, the consequences of failure in aviation can be so severe that everyone needs to be guardians of high standards. The costs of doing otherwise are too great.
This forum on Professionalism in Aviation brings together participants from across the aviation community – from industry, labor, academia, and government – to examine the challenges that pilots and controllers face today, the best practices already in use to address these challenges, and other ideas for improving professionalism and increasing passenger safety.
In fact, this forum has drawn interest and participation from the international community as well. In particular, I want to extend a warm welcome to the Director General of Civil Aviation for the Republic of Lebanon, Dr. Hamdi Chaouk. Dr. Chaouk and I met a few weeks ago at the ICAO high level safety conference, and he mentioned his interest in a number of the issues we are considering in this forum. Just as we are seeking ways to raise the bar on standards here in the U.S., our colleagues like Dr. Chaouk are doing the same around the world. We have much to learn and share with one another, and I am delighted that he is with us today.
We recognize that there are many industry professionals whose work, day-in and day-out, reflects the highest level of professionalism. We welcome this opportunity to learn from them about what works and about what changes we can make, individually and collectively, to raise the safety bar.
We all know the saying: the more things change, the more they stay the same. While today’s technologies and safety standards are unprecedented, many of the issues we will address at this forum are as old as flight itself.
In fact, as far back as 1934, President Franklin Roosevelt wrote that “Public safety calls for pilots of high character and great skill…therefore, the law should provide for a method to fix maximum flying hours, minimum pay, and a system for retirement or annuity benefits.”
Just months later, he signed into law the Air Mail Act of 1934, instituting the first statutory standards for pilot professionalism.
The sweep of nearly eight decades has seen unimagined advancements in flight safety. Today, FDR’s standard of “high character and great skill” is met by almost every pilot that enters the cockpit.
But we can do better; indeed, we must do better to ensure that the industry’s professional standards meet that standard as well. I am confident that this forum will prove enlightening and educating for all of us.
Any study on professionalism involves multiple stakeholders, and each plays a role in developing and ensuring professionalism. Over the next 3 days, we will hear from many of these stakeholders – individuals who represent pilots and controllers, the companies and organizations that they work for, the professional associations, and the regulator.
In today’s panels, we will focus on the development of professionalism – that is, how pilots and air traffic controllers are selected, screened and trained.
Tomorrow morning we will continue with pilot training, before shifting focus to the methods and techniques for ensuring professionalism. As part of that discussion, we will explore the shared responsibility that companies and associations have in reinforcing professional standards in pilots and controllers. We will also discuss the important role of the captain – who is uniquely positioned at the front line in ensuring professionalism.
Finally, on Thursday, we will discuss effective pilot-controller communications and methods for ensuring excellence through data and information sharing. We will then close with a look at the role of the regulator.
It bears repeating that our overall focus is not to revisit previous accidents and incidents. Rather, we want to make this forum forward-looking – by narrowing the discussion to best practices and areas where we can make improvements.
The forum will be conducted en banc, meaning all Members of the Board will participate. The more than 45 panelists may offer presentations and will engage in discussions with the Members of the Board, along with a panel of NTSB staff from the Offices of Aviation Safety and Research and Engineering. We appreciate all of our panelists who have voluntarily made themselves available to participate in this event.
Now, a few housekeeping items. We welcome the public to the forum and invite you to watch either in person or via webcast on the NTSB’s web site.
Copies of the agenda are available in the lobby outside our Boardroom. The agenda, along with the biographical information of invited participants, is also posted on the NTSB’s website.
Because we have such a full agenda, we appreciate your cooperation in helping us keep on schedule, and ask that panelists respect time limits and keep discussions focused on the subject at hand, rather than slip into topics covered by other panels.
We recognize that not all stakeholders are represented in person at this forum. Because it was not possible to accommodate everyone who wanted to participate as a panelist, those individuals and organizations who wish to submit written comments may do so until June 3. Details on submitting written comments are available on the NTSB’s website.
As a reminder, please silence your cell phones and familiarize yourself with the emergency exits available to you in the front and the back of the room.
Finally, before we begin with our keynote address, I want to take a moment to personally thank the NTSB staff for their tremendous effort in organizing and preparing for this forum. This forum is a collaborative effort that involved many at the Board and to everyone involved, thank you.
Particularly, I would like to acknowledge the technical staff who spearheaded this effort and whose hard work and dedication made this forum possible – Dr. Evan Byrne, Captain Roger Cox, and Dan Bartlett of the Office of Aviation Safety and Dr. Vern Ellingstad and Erin Gormley from the Office of Research and Engineering. Undertakings of this scope do not simply happen – they are the end product of many months of long hours and meticulous preparation and planning, including administrative, technical, and press support which has been provided by Eunice Bellinger, Antion Downs, Rochelle Hall, Jason Fedok, Christine Fortin, Greg Pereira, Rob Turner, Brian Dennis, and Terry Williams.
It has been said that professionalism is not the job you do, but how you do your job. I extend our appreciation to the staff that proposed this forum and have executed it with the high standards of professionalism that we have come to depend on.
Dr. Byrne, would you please introduce the keynote speaker?
View the page for the Forum here