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Remarks “The Everyday Effects of Disaster: Before, During, and After a Transportation Accident” to the General Aviation Air Safety Investigators (GA-ASI) Workshop, Wichita, Kansas
T. Bella Dinh-Zarr, PhD, MPH
Wichita, Kansas

Good morning!  Thank you, Lauren, for that kind introduction and thank you to GAMA (General Aviation Manufacturers Association) for inviting me to speak.  I am honored to be with all of you here at GA-ASI this week.  It is an honor because you are the people who always are ready before a transportation disaster occurs, ready to leave at a moment’s notice.  You are the people doing the careful investigative work at the scene during the aftermath of a transportation disaster.

In addition, it is your work that helps shape the recommendations and policies to prevent future disasters.  The title of my talk today is “The Everyday Effects of Disaster:  Before, During, and After a Transportation Accident” and it is in recognition of your work before, during, and after a transportation accident.  I am reminded of your work on a daily basis because almost every day, when my phone buzzes, it is the NTSB Response Operations Center (our ROC) texting out notice of another GA accident.  But I also think of your work, because each of you helps prevent GA accidents and therefore you help to save lives every day.

I love airplanes, but unlike all of you, I am not an aviation expert.  My training is in injury prevention, public health, and safety, with a focus on transportation.  But I am lucky, because at the NTSB, I get to work every day with knowledgeable and respected experts in aviation safety.  I know you already may know them, and you heard some of their excellent presentations yesterday and will hear more today, but I would like to ask all of my colleagues from NTSB to stand up for a moment so that everyone here knows who they are.  These are some of the good men and women of the NTSB.

They come from diverse professional backgrounds and they are the people who do the work and are the face of the NTSB -- for your companies, at accident scenes, and for the public.  Their job, like yours, is a tough one and they rarely get any public recognition.  But recognition is not why they – or I am sure you – do the work you do.  You do it, in part, because it is lifesaving work.  In addition, although this is my first GA-ASI meeting, I see one trait that you all have in common – and that is the persistent desire to know “why?,”  “what?,” and “how?”  Why did this plane crash?  What exactly happened?  How can we prevent it from happening again?

I know this group, unlike some of the groups that I have the opportunity to address, is very familiar with the NTSB, our operations, and our functions. So while I do not 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 conduct aviation investigations; 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.  In addition, 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.

So today, I am 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.

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 most often considered the hot topics.  Injury prevention was interesting to me because there were different ways of intervening – by looking at the person, the machine, and the environment – to prevent the injury.

An old school classmate is now one of the world’s top Ebola researchers, but I would get just as excited about investigating injuries as she did investigating disease outbreaks!  The funny thing is that, although our work is so different, both of us ended up working with people in some of the most remote parts of the world.  She worked on Ebola outbreaks and I worked on the rising number of people dying on the roads in developing countries.

Public health is about prevention and I was drawn to injury prevention because I saw this was an area where – like all of you - we could investigate to answer the questions of “why’ and “what” and “how”.    Why were kids dying in sub-Saharan Africa on their way to school?  What exactly happened?  And how can we prevent these deaths from happening again?   This focus on prevention is, I think, perhaps not so different from the reasons each of you is 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.  One of the reasons it is a dream job is because I get to work with smart, dedicated people like you and learn about how things work, how they are made, and how people interact with them. A job where people are usually happy to answer my many questions.  What a great job!

That first call was just the start of a very long process that included interviews, FBI investigations, the White House nomination, and a slightly 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 – scientific rigor, prevention, collaboration – seemed a natural fit with transportation safety.  Despite the change in leadership of the Senate, after approximately six 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.  As you know, at the NTSB, our sole mission is to save lives and prevent injuries.  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 are also 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 also is headed by independent Board Members.  We do not report to anyone so we can make recommendations to anyone.  We conduct rigorous investigations, with the technical help of party members such as yourselves, but independently perform the analyses so our credibility is preserved.  In addition, we are transparent, because all of our activities are conducted in the public eye.  But transparency does not mean that we are careless with the information we share.  Our credibility lies in ensuring the information we provide is the most accurate information possible.  As you can see, our independence, credibility, and transparency are intertwined.

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.”  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.   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 worked on highway vehicle occupant protection research, the effects of aging on mobility, and policies related to infrastructure, vehicles, and human behavior.

Although Board Members, like myself and Member Weener, 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 politics get in the way of safety.  This philosophy of collegiality for the sake of a good cause is strong among the current Board Members.  We still disagree with each other, and we sometimes do, vocally, but this is one of the great privileges and responsibilities of being independent Board Members of an independent safety agency.

Much of the safety knowledge I have garnered during more than 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 – every transportation mode except highway!

As the newest Board Member at the NTSB, I have been trying to learn everything I can about aviation.  With the help of Shannon Bennett, my Special Assistant, who also happens to be a Lt. Colonel in the Air Force Reserves, and the experts in our Aviation Safety Office, and Research and Engineering Office, I am doing my best to absorb as much information as I can in order to carry out the best job I can as a Board member.

I have had the privilege of being at the NTSB for a year and a half now and what an amazing year and a half it has been.  I have toured ATC centers, visited several aircraft manufacturers of different sizes (thank you Textron for yesterday’s tour), attended the Heli-Expo, chaired the Board Meeting for the Bedford, Massachusetts accident, was the member on-scene at the Akron, Ohio accident, and I have talked with dozens of investigators and other aviation experts.  But I am here to learn more.  To learn from you and to learn about you.  I hope you will not hesitate to come talk with me so I can learn more about what you do and what safety issues are important to you.

I would like to spend a little time sharing with you my first, and very positive, experience with the aviation safety office at NTSB.  Last September, not long after I arrived at the NTSB, I had the privilege of chairing the board meeting of the fatal overrun accident that occurred in Bedford, Massachusetts.  You heard all about the technical details of this accident from Tom Huff of Gulfstream yesterday, but what you may not know is that it is very rare for anyone except the Chairman to lead a meeting and added to that challenge was that this accident was my first aviation board meeting ever – and I was chairing it!  But just as our NTSB investigators are the consummate professionals on scene and throughout the investigation, so too were they the consummate professionals in ensuring that I was prepared with the technical knowledge I needed to chair the meeting.

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 – habitual non-compliance - issues that we have seen throughout many accident investigations at NTSB and that I am sure you have observed in some of your accident investigations.

The Bedford accident, like so many accidents that NTSB investigates across all the transportation 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.  As Member Weener mentioned, 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 the majority of our top 10 safety advocacy areas

Member Weener briefly touched on the issue of recorders.  Recorders is one of my 3 Most Wanted List Issues this year.  So I would also like to talk about CVDRs (cockpit voice and flight data recorders) since recorders, like investigators, are the “unsung heroes” of safety and they provide information before, during, and after an accident.  No one understands the importance of recorders better than investigators, such as you.

When we released the NTSB’s Most Wanted List this year, we said that no single tool has helped the NTSB determine what went wrong more than recorders.  That is why NTSB recommends that all existing turbine-powered, non-experimental, non-restricted category aircraft contain or be retrofitted with a crash-resistant flight recorder system that records cockpit audio and images with a view of the cockpit environment.  On a more basic level, GA accidents are usually single pilot yet involve a complex system.  When that pilot dies, and even when the pilot survives, important data is lost without a recorder.

This past June, the NTSB met in a sunshine meeting to hear about the accident involving an Embraer 500 (or Phenom 100) aerodynamic stall and loss of control in Gaithersburg, Maryland.  This investigation further highlighted the importance of recorders.  Embraer’s decision to install a CVDR in this fleet ensured that our investigators had the critical information they needed to determine the sequence of events in order to identify actions to prevent a similar accident in the future.

I think it also is important to mention that the raw data from CVDRs must not only be converted from zeros and ones to engineering units using the correct conversion algorithms, but those results also must be validated, and that takes time.

People often wonder why it takes so long for us to get information from data recorders, or why we do not release the raw data right away in the name of transparency, but – in addition to the risk of losing data if a recorder is opened up or powered up at the scene – I know that all of you, as investigators, understand that data can be misinterpreted and misunderstood if we do not FIRST ensure that it is clean and properly validated.  We do not have the luxury of the media who often include the disclaimer in their stories “This is breaking news so initial reports may have inaccuracies.”  Once we release data or information, it is used for life and death decisions and that is why we are so careful at the NTSB.  We always work as fast as we can, but we are not looking for the fast answer, we are looking for the right answer.  We are as eager as you to know what happened.

Related to this point on data, I know that the NTSB received a lot of criticism over the past year, perhaps even from some of you, for using preliminary 2014 flight hour data to run our calculations on accident rates, in order to meet early demand for this information.  When the actual 2014 final flight hour data turned out to be quite different, our preliminary accident rates looked high.  This year we decided to wait until we received the final flight hour data to calculate the 2015 rates.  So I know you will understand, our calculations may take a bit longer while we wait for final data, but we want them to be accurate for you.

All of you in this room do the real investigative work and, as a result, you are the most effective champions and spokespeople for safety.  People will listen when you talk about lifesaving, injury-preventing, real safety improvements.  People know that you know about safety first-hand.  People may think that recorders with voice, video, and data are too expensive to have in every aircraft, but the aviation industry invests billions of dollars in R&D, so wouldn’t you want to know what happened when there is a crash?

People may think video is an invasion of privacy, but you know it can provide invaluable data.  Even without other data, we have software (as you also may have) that can read the needle positions on the instrument panel and calculate information, such as altitude.

With your help, with you – as accident investigators - championing the importance of CVDRs, I think people will listen and I know we will have a much greater chance of having the information we need from recorders, in every accident, in order to prevent similar accidents from happening again.

Safety is not glamorous, and sometimes it isn’t fun to be the ones always thinking of the worst case scenario.  But this is what all of us do best.  We think of the worst case scenario and THEN we think of how we can prevent it from happening.  Millions of people across the country, and indeed, around the world, are safer because of that.

I am very proud of the work we do at the NTSB and I am proud that we also always bring 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 try never to forget that the purpose of our work is to serve people – the families and friends of people, who have been injured and killed in the accidents with the goal of preventing future deaths and injuries.

This week not only features the GA-ASI meeting, it also includes the meeting of the United Nations General Assembly (also called the “UNGA”).  In my old job, this week I would be in New York at the United Nations Headquarters attending the UNGA working on making transportation safety part of the Sustainable Development Goals.  In my old job, perhaps sometimes like our work now, I sometimes had to remind myself that the work we did was to save real lives and it was not just dry words, on paper, in a report.

But I have to say, one of the best things someone did for me once was to show me a sheet of paper, but this was a page covered with the school photos of about 10 kids in Vietnam, a country where the motorcycle acts as the family car.  He then told me that those were the faces of the kids who were in serious motorcycle accidents with their families this summer, but they did not die or have traumatic brain injuries because they had a helmet supplied by the nonprofit helmet factory that my program had funded.  He told me that these were the children I helped to save that year.  More than all the data, that made a lasting impression on me.

It is unlikely that you will ever know the names or see the faces of the people that YOU save from dying or being seriously injured, but I hope you will remember that there are hundreds and thousands of people out there whom you have saved with your work.

GA-ASI is a special place because you all represent a unique confluence of the latest knowledge about aviation accidents and how to best investigate them.  Thank you for having me here with you this week and, most of all, thank you for the work you do before, during, and after a transportation disaster, work that has a lifesaving effect every day on aviation safety, in our country and around the world.