Good afternoon. I want to thank the board of the Aviation Law and Insurance Symposium for inviting me to participate in this panel discussion.
Before I get started, earlier this week, I saw that there’s now an app to tell you the chances of dying in a plane crash. By one measure, you could go sixty-six thousand years before being involved in an aviation crash. But who in their right mind wants to fly every day for sixty-six thousand years?
As I was preparing for this panel, it dawned on me that I took my second flying lesson exactly 41 years ago today. So, I thought I’d compare the number of NTSB investigations conducted for the five years after I started flying with the number conducted in the five years after I stopped flying (which, incidentally, is still my greatest contribution to aviation safety).
Between the years of 1974 and 1978, the NTSB produced 72 “blue cover” accident reports – an average 14 per year. Between the years of 2006 and 2010, it produced 25 – an average of 5 per year. Two of those investigations involved fatal airline crashes, compared to the dozens of fatal airline crashes of the mid-to-late 1970’s.
In this brave new world of accident investigation, what are we doing at the NTSB – sitting around drinking coffee all day? Well, we are doing plenty of that, but we’re still very much in the accident investigation business. Just last year:
• We wrapped up an investigation into the 2013 Boeing 787 lithium-ion battery fire in Boston;
• We conducted an investigation of the Asiana Airlines Flight 214 crash on approach in San Francisco;
• We produced a report in the fatal crash of UPS cargo Flight 1354 on approach to Birmingham–Shuttlesworth International Airport;
• We determined the probable cause of the March 30, 2013, crash of an Alaska Department of Public Safety helicopter on a search-and-rescue mission; and,
• We launched a Go Team to investigate the midair breakup of Virgin Galactic’s SpaceShipTwo vehicle over the Mojave Desert on Halloween.
Focusing on general aviation (GA), we’re pleased that we’re seeing a positive trend: last year there were 1,264 GA crashes, 257 of which were fatal. This is compared to the 1,800+GA crashes in 2000, 345 of which were fatal. We want to do what we can, though, to bring that number of GA fatalities to zero.
Although our enabling legislation says that the NTSB is an accident investigation agency, we are trying to be more proactive in mining safety data and issuing safety recommendations, in order to avoid accidents before they happen. In the past eight and a half years since I’ve been a Board Member, the NTSB has conducted:
• A study of experimental and amateur-built aircraft (EAB): While about 10% of the United States GA fleet are EAB aircraft, they comprise 15% of all GA accidents – and 21% of fatal GA accidents;
• A study of potentially impairing drug use in fatal aviation accidents – including illicit, prescription, and over-the-counter drugs: In 1990, less than 10% of pilots involved in fatal crashes had potentially impairing drugs in their system; in 2011, that percentage was 40%;
• A study of safety of parachute operations;
• A study of aircraft used in agricultural operations;
• A study of airbags in GA aircraft;
• A study of glass cockpit technology in light aircraft; and,
• A study of parasailing operations.
We put helicopter emergency medical services (HEMS) operations under the microscope in 2008 – the most deadly year for the industry, with 29 fatalities – and issued over 40 recommendations to improve its safety record.
Just last week, the Board issued eight new safety recommendations in the field of flight locator technologies.
Another thing we are doing is putting the spotlight on areas in which we see a need for additional safety focus, and adding these areas to our Most Wanted List of Transportation Safety Improvements. For this year’s list – announced just two weeks ago – we have highlighted two aviation-specific items.
One of these items is “Enhance Public Helicopter Safety.” During the past decade, there have been over 130 crashes of helicopters operated by federal, state, and local government agencies. These crashes have resulted in more than 50 fatalities; roughly two-thirds of them have involved helicopters involved in law enforcement operations. Just yesterday, NTSB’s Sean Dalton and I had the opportunity to visit the aviation unit of the Seminole County Sheriff’s Department in Sanford, and see first-hand the mission challenges in this sector of aviation.
For the other aviation-specific item, see if you can connect these dots. In the summer of 2013, how many air carrier hull losses did we have in the U.S.? The answer is three: Asiana Flight 214 in San Francisco; Southwest Flight 345 at LaGuardia; and, UPS Flight 1354 at Birmingham – all within a 5 ½ week timespan. Seven months after the UPS crash, there was another air carrier hull loss – a rejected takeoff by US Airways Flight 1702 at Philadelphia.
Between these four accidents, we could be sitting here today talking about the loss of 608 lives, rather than five fatalities that unfortunately did occur. “There, but for the grace of God, go we.”
And what was the common thread woven through these four accidents? It was procedural non-compliance. Over the past ten years, in fact, the NTSB has investigated more than a dozen high-profile crashes in which procedural non-compliance was an issue. We’ve seen air carriers landing at the wrong airports, landing on taxiways, and attempting to depart on closed runways. These are the direct result of a lack of procedural non-compliance such as lack of sterile cockpit discipline, continuing unstabilized approaches, and a lack of standard callouts.
Data from the LOSA Collaborative has shown that flight crewmembers who intentionally deviated from SOPs were three times more likely to commit other types of errors, mismanage more errors, and find themselves in more undesired aircraft situations compared with those flight crewmembers who did not intentionally deviate from procedures.
For these reasons, we have placed the issue of “Strengthen Procedural Compliance” on our 2015 Most Wanted List.
We look forward to working with air carriers, aviation enthusiasts and safety advocates alike to advance these issues over the next year.
Thank you again for the invitation to speak to you today, and I hope we don’t have to meet professionally. Safe travels to you all.