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Speeches

Board Meeting: Aircraft Accident Report—Collision with Terrain, Promech Air, Inc., de Havilland DHC‐3, N270PA, Ketchikan, Alaska, June 25, 2015 - Closing Statement
Robert L. Sumwalt
NTSB Boardroom and Conference Center, Washington, DC
4/25/2017

In closing, I would like to recognize the hard work of the NTSB staff in this investigation, and I really would like to  thank my colleagues on the board for their thoughtful consideration.

What I’ve learned from my time on the board that it’s the investigators that get the credit and rightfully so. But it’s a team effort that requires a lot of effort from those not at this table: the chief financial officer, folks that fix computers, administrative professionals.

That said, I’d like to recognize Brice Banning and Shaun Williams of the NTSB’s Alaska office. Brice was the investigator-in-charge, and Shaun stepped up to the role of the Operations group chairman. It’s my understanding, gentlemen, that on-scene, you and others climbed steep mountain terrain, using ropes and harnesses, to retrieve cameras and other objects from the wreckage. I also know that this is your first board meeting, as well as Adam Tucker’s from our Office of Marine Safety. So thank you all for a job well done. We want to thank the Ketchikan Volunteer Rescue Squad for helping our investigators do this work safely. It certainly does take a whole team both inside and outside the agency.

I was struck by what one Promech pilot said in an interview with an investigator. His superior warned that if one pilot turned around and the others made it through, he and that pilot would “have a conversation.”

Now imagine the difference if the message was, “We’re going to have an ongoing conversation about what the flight data are telling us, so we all make the proper decisions, each and every time.”

And this isn’t just some ivory-tower thing that we thought up here. I used to  work in an airline that had the equivalent programs and Member Weener told me once something that he learned – that the data will set you free. And if we have the data, it can set us free, and help us to operate more safely. With these ADSB  air tour operators, they can use the data in a manner to ensure they’re learning about their operation so they can operate more safely.

We learned grim lessons about operational shortcomings that relied on the subjective information of one pilot  with little objective input.

We recommended that the FAA work with the air tour industry in Ketchikan to identify objective measures to help pilots in their decision-making, and we recommended that the FAA publish guidance on best practices for operational control.

As you heard in our deliberations, we recommended that the cruise line industry explores ways that they can mitigate risks associated with real or perceived time pressures to return to the ship.

We reiterated that every Part 135 operator - every charter operator - should operate under effective safety management systems. Effective SMS can be the framework around which operations build an effective safety culture, which was sadly absent in this accident.

Safety must be a core value in any aviation operation, as you heard me say earlier, not just a priority but a core value in any aviation operation. When this board sees an operation in which safety competed with performance and revenue, the reason we see it here at the NTSB is unfortunately because safety lost. Safety must always be set to win. This is not a game.

Before we adjourn, I would like to acknowledge the retirement of our general counsel, David Tochen, who will retire on Friday, May 12.  Dave has worked in federal service for 38 years and he has worked at the Board for nearly six years. David, I would like to thank you for all of your hard work, and I wish you a wonderful retirement. Thank you so much.

The recommendations adopted and reiterated today, if acted upon, will - among other results - help to remove safety from being in competition. Safety has to be set to win.

We stand adjourned.

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