Good evening! Thank you, Ron, for that very kind introduction and thank you, Frank and your members for inviting me to speak to you this evening. It is a pleasure to be here with the Mid-Atlantic Regional Chapter of ISASI along with your international colleagues. Each of you is a champion for aviation safety in your own country and around the world. It is an honor to be addressing you this evening.
I love airplanes but, unlike all of you, I am no aviation expert. My training is in injury prevention, public health, and safety with a focus on transportation. But I am lucky that at the NTSB, where I have been for almost exactly a year now, I get to meet people like you and I get to work every day with knowledgeable and respected experts in aviation safety. I know you know many of the good people at the NTSB - people like Frank Hilldrup, Dana Schulze, John DeLisi, Luke, Todd, and, of course, my three fellow Board members, not to mention former NTSB experts like Tom, Jeff, and many others who are here today.
I know this group, unlike some of the groups that I have opportunity to address, is very familiar with the NTSB, our operations, and our functions. So while I don’t need to tell you about the NTSB, I would like to tell you that I have great admiration and respect for the training and skill that you have to have to fly aircraft and, equally important, the training and skill you have in ensuring that those who fly or are passengers in aircraft are as safe as possible through your accident investigations. And, as you know, at the NTSB, our sole mission is to save lives and prevent injuries, so we very much appreciate your help in making transportation safer.
Tonight, I’m not going to give you a recitation of what the Board does or what accidents we are investigating but rather, I hope to give you my observations on the NTSB after my first year at the Board. First, since I am new to this group, I would like to explain how I, a public health scientist, ended up at the National TRANSPORTATION Safety Board.
When I started my training in public health, I was drawn to the specific topic of injury prevention – quite a neglected area in a field where infectious diseases or cancer are often considered the hot topics. A school friend is now one of the world’s top Ebola researchers, but I got just as excited about investigating injuries as she did investigating disease outbreaks! And funny thing is that, although our work is so different, both of us ended up helping people in some of the most remote parts of the world. Public health is about prevention and I was drawn to injury prevention because I saw that this was an area where we could investigate to answer the question “Why?” Why did older people break their hips more often in certain facilities and why were kids killed in car crashes? We could find out why and then scientifically test solutions – solutions that were sometimes basic engineering such as energy absorbent flooring or sometimes behavioral such as ensuring children were properly restrained – and these solutions could prevent injuries and deaths from happening again. I thought - what a great field! This focus on prevention is, I think, perhaps not so different from the reasons each of you is so dedicated to your investigations – you want to find out what happened in order to make aviation safer.
I was very surprised and honored when I was nominated to the NTSB. After working at the CDC and other places, I was enjoying my work for a philanthropy that focused on making transportation safety an international priority. I worked with governments and civil society in dozens of countries around the world on infrastructure, laws, manufacturing, and other aspects of safety. One day, I was about to go into a meeting at the United Nations to discuss the importance of making transportation safety part of the sustainable development goals when I got my first call from the White House – that call turned out to be the possibility of a dream job in transportation safety. That first call was just the start of a very long process that included interviews, FBI investigations, the White House nomination, and an intimidating Senate confirmation hearing. Even though I had been tapped as a potential nominee, I knew that no public health professional had ever been chosen to serve on the NTSB. But even then I felt that many public health values – justice, equality, access – seemed a natural fit with transportation safety. Despite the change in leadership of the Senate, after about 6 months, I was confirmed by the Senate and then soon after, appointed Vice Chairman by the President.
We are fortunate at the NTSB because Congress mandated our mission to be a noble one – to be an independent agency charged with investigating transportation accidents, determine their probable causes, and make recommendations to prevent their recurrence. Our sole purpose is to save lives and prevent injuries by advancing transportation safety. We do not have regulatory authority and we have no financial incentives to promote our recommendations. As a result, we fiercely protect our values of independence, credibility, and transparency. These are the values which define our agency perhaps because they also are what keep our agency functioning and relevant.
You often hear us speak of our independence and that is because we are an independent agency that is headed by 5 independent Board Members. As for transparency, our work, deliberations, and votes are all conducted in the public eye as part of the Government in the Sunshine Act.
Although Board Members, like myself, are not political in the traditional sense, we are nominated by a certain party and, by law, NTSB is bipartisan since no more than 3 of the 5 board members can be nominated by the same party – but we never let that get in the way of safety. This philosophy of collegiality for the sake of a good cause is strong among the current NTSB Board Members. We still disagree with each other – and we often do, sometimes vocally, which is one of the great privileges and responsibilities of being independent Board Members of an independent agency. I feel very lucky to be able to say, after working closely with the other 3 current members that, for these Board Members and certainly for myself, our disagreements are not for any political gain or gamesmanship, but simply for the sake of keeping our transportation systems safe.
You may or may not be familiar with the fact that our statute requires (quote) “At least 3 members shall be appointed on the basis of technical qualification, professional standing, and demonstrated knowledge in accident reconstruction, safety engineering, human factors, transportation safety, or transportation regulation.” Unlike some past Boards, we are fortunate that all 4 of our current Board members have this type of technical and professional expertise. As this group well knows, Chairman Hart, Member Sumwalt, and Member Weener all are recognized experts in various areas of aviation safety. And now you know that my expertise is in public health and the science of injury prevention, as it relates to surface transportation, and more specifically, highway transportation. During my graduate and post-graduate studies as well as during my career, I have conducted research into highway vehicle occupant protection, especially in the area of seat belts.
Although I’m not an aviation expert by any stretch of the imagination, I have learned during my time at the NTSB that the laws of physics do not change depending on whether you are in an aircraft or a motor vehicle. In fact, just last week, I hosted an Occupant Protection Workshop with some of the top automotive biomechanics and crashworthiness experts in the world. Yet also present at the meeting on oblique impact and off-axis crash testing were experts from the FAA’s CAMI as well as crash test researchers for the FAA whom I know from the Medical College of Wisconsin. Because the complex interactions in oblique impact crashes have some similarities, especially now with some business and first class seats set at 45 degree angles, we were all there to learn from each other (and commiserate on the high cost of good crash test dummies!).
A great deal of the safety knowledge I have garnered during two decades in highway safety can be translated into the worlds of aviation, rail, and marine safety as well. In fact, in my first year at NTSB, I have launched with the NTSB go-team on two rail accidents, one marine accident, and an aviation accident – everything except highway!
At the NTSB, we hold public board meetings usually once or twice a month to hear investigative reports and vote on them. Although we have no regulatory authority, our good reputation has enabled us to make and pursue adoption of recommendations for the benefit of safety. We have issued over 14,000 safety recommendations to more than 2,500 recipients and about 80% have been adopted. And although we have a good track record of having our recommendations adopted, we do not give up on targets that are not achieved. Some take years or even decades to pass, especially if they must pass in all 50 states in the United States.
I would like to spend a little time sharing with you my first, and very positive, experience with the aviation safety office at NTSB. In September of last year, I was privileged to Chair a Board meeting involving a Gulfstream G-IV accident. It is rare for anyone except the Chairman to lead a meeting and added to that challenge was that this accident was also my very first aviation board meeting. Just as our NTSB investigators are the consummate professionals and experts on scene and throughout the process of our accident investigations, so too were they the consummate professionals in ensuring I was prepared with the technical knowledge I needed to chair the Board meeting.
For those of you unfamiliar with the accident – the accident involved a fatal runway overrun during a rejected takeoff at Hanscom Field in Bedford, Massachusetts, on May 31, 2014. The privately owned and operated business jet rolled beyond the paved overrun area and subsequently crashed into a ravine, where a post-impact fire ensued. Tragically, the two pilots, the flight attendant, and all four passengers on board died.
Much of our investigation centered on the gust lock. As a non-aviator, I quickly learned the importance of the gust lock in preventing wind gusts from moving the airplane’s flight control surfaces and damaging them when the aircraft is parked. But when this flight crew prepared for takeoff, the gust lock remained engaged. As our investigators examined the data about this accident flight, they found that the flight crew routinely neglected performing complete flight control checks.
During my preparations for the Board meeting, I remember going to the FAA’s Hanger at DCA and sitting in the left seat of the FAA’s Gulfstream G-IV. Even as a novice, I was able to feel the difference in flight controls with and without the gust lock engaged when I performed a flight control check. I felt a little better about taking the time of the good people at Hangar 6 when I learned that even an experienced pilot like Member Sumwalt also went to sit in the Gulfstream as part of his meeting preparations! I reviewed the pre-flight checklist with the FAA pilots, which included a step to check the flight controls. The accident investigation raised important issues about patterns of procedural non-compliance – issues that we have seen throughout many accident investigations at NTSB and that I’m sure you have observed in some of your accident investigations.
The Bedford accident, like so many accidents that NTSB investigates across all the modes, was preventable. It could have been avoided by following established procedures. The Board’s investigation brought to light the critical need to follow checklists to prevent procedural omissions such as failing to remove flight control locks and the need to perform flight control checks before every takeoff. As a public health professional – a profession where prevention is the watch word - I am honored to be part of an agency that can make safety recommendations to truly prevent deaths and injuries across all modes of transportation.
That is why I feel privileged to be with you here today and to help support your efforts - in any way I can - to improve aviation safety. While we only have one standalone aviation issue on the NTSB’s “Most Wanted List of Transportation Improvements” this year – preventing loss of control in flight – aviation safety remains a priority for us and in fact, is a key part of most of our top 10 safety advocacy areas, such as Occupant Protection, Fatigue, Recorders, Distraction, Medical Fitness for Duty, and Impairment. With the help of Shannon Bennett, my Special Assistant, who also happens to be Lt. Colonel in the Air Force, and the good people in our Aviation Safety Office, I am doing my best to absorb as much information as I can in order to do the best job I can at the NTSB. So I am here to learn – to learn from you and to learn about you. I hope you won’t hesitate to come talk with me or to get in touch, so I can learn more about what you are doing and what safety issues are important to you.
As a public health professional, I’m so proud of the work we do at NTSB and I’m proud of the fact that we always bring humanity and compassion to what we do. Because of our detailed investigations, it may seem that our work is largely technical or mechanical, but like you, I never forget that the purpose of our work is to serve people – those injured and killed in the accidents we investigate with the goal of preventing future injuries and deaths.
A former Chairman from the 90’s used to describe NTSB’s mission and goals by paraphrasing Thomas Jefferson’s quote: "The care of human life and happiness…is the first and only legitimate object of good government." I agree.
In closing, I would like thank you for the key role each of you play in aviation safety. Many of you have dedicated your lives to aviation safety, which has a positive impact on people’s lives every day around the globe, as my colleagues and I at the NTSB can personally attest. Here’s wishing you many more years of service to making aviation ever safer. It has been an honor to be with you this evening. Thank you.