Good morning! Thank you, Matt, for that kind introduction and thank you to HAI for inviting me to speak. I am honored to be with all of you today. Last week, I was in Wichita, Kansas, and spoke with the aviation safety investigators at GAMA, who deal with the aftermath of aviation accidents. So it is very appropriate that this week, I am here speaking with you -- aviation executive leadership from Fortune-500 companies, who are in positions to really shape safety policy and direction for your companies to help prevent these accidents from occurring in the first place. In a few weeks, I also will be speaking at the NETS (Network of Employers for Traffic Safety) Benchmark Conference – to Fortune 500 professionals, who are responsible for the safety and security of their corporate motor vehicle fleets.
Today I would like to give you a glimpse into the work that my colleagues and I do every day at the National Transportation Safety Board. First, I will give you a brief overview of our NTSB investigative process so you can have exposure to our process under benign conditions and hopefully, this will never amount to anything more than information for you. Then, I am going to briefly discuss corporate aviation safety and NTSB safety recommendations in this area. Finally, what we can do together to move safety forward.
Before I begin, let me say this -- 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.
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, I am doing my best to absorb as much information as I can in order to do 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, attended Heli-Expo, chaired the Board Meeting for the Bedford, Massachusetts accident, served as the member on-scene at the Akron, Ohio accident, and have spoken to HAI (Helicopter Association International), A4A (Airlines For America), ALPA (Air Line Pilots Association, International), ISASI (International Society of Air Safety Investigators), and GAMA (General Aviation Manufacturers Association). I also have talked with dozens of investigators and other aviation experts. But I am always striving 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.
The NTSB Investigative Process
The NTSB is an independent federal agency dedicated to transportation safety. We are charged by Congress with investigating every civil aviation accident in the United States. Historically, the public is most familiar with our investigations of airplane crashes - but we also investigate major transportation accidents in rail, marine, and highways, as well as pipeline and hazardous material disasters.
We are independent of all other federal agencies and we have 5 independent Board Members nominated by the President and confirmed by the Senate. Since our creation in 1926, our agency has one simple but noble purpose: to prevent transportation-related deaths and injuries. At the NTSB, we are on call 24-hours a day, 365 days a year to investigate accidents, assist the families of victims, and develop factual records and safety recommendations to make our transportation system safer. Currently there are 4 Members on the Board (one spot is vacant) so Board Members like myself are “on call” every 4 weeks, ready to launch as part of a Go Team, in case a major transportation disaster occurs. In fact, I am on the Go Team now!
Unlike many government agencies, the NTSB does not have regulatory authority and we have no financial incentives to promote our safety recommendations. We fiercely protect our values of independence, credibility, and transparency because these are the values that define our agency. We are independent so we do not report to anyone and we can make recommendations to anyone, such as the U.S. Department of Transportation, state governments, associations, and private companies, but our purpose is to advance safety, not to lay blame. We maintain our credibility by conducting very thorough investigations that touch on every single aspect of an accident from engineering to human performance to weather. We value scientific and investigative rigor because our credibility lies in our reports and recommendations. As for transparency, our work and deliberations and votes are all done in public, in webcast meetings in compliance with the Government in the Sunshine Act. As you can see if you ever watch our accident investigations and other board meetings, we sometimes do not agree – but that is the beauty and strength of the NTSB, we debate publicly not for any political gain, but in order to come to the best resolution for the sake of safety.
During the on-scene phase of our investigations, if a Board Member travels to an accident scene, we serve as the on-scene spokesperson to the family members and press. The NTSB also will send an investigator-in-charge (or IIC) who leads the investigation. The NTSB offers party status to those companies, government agencies, and associations that have employees, activities, or equipment involved in the accident. We offer party status to those organizations because they provide the technical expertise and relevant information supporting the development of the best possible factual record. Parties may not release information about the investigation to the media or anyone outside the investigation without approval of the IIC. In our organizational meeting on scene, we establish parties to the investigation. At the meeting, we will form investigative groups in subject areas such as: Operations, Air Traffic Control, Weather, Survival Factors, and Human Performance. Each group is generally headed by an NTSB group chairman who is a seasoned investigator. We also try to complete our on-scene work as quickly as possible – generally within 7-10 days. At the conclusion of the on-scene process, each group will prepare field notes summarizing the on-scene factual work.
Once we leave the scene, our investigation continues with the assistance of our party members. Each group prepares group chairman factual reports. In certain high visibility cases, where we need more information, we may hold an investigative hearing. The party participation in our process ends at the technical review of factual information and group chairman reports.
During our final report development, the NTSB may issue a Board Accident Report after a public meeting or may issue a brief report. The board report contains analysis of factual information, conclusions, recommendations, and a probable cause determination. As an agency subject to the Government in the Sunshine Act, the Board Meeting will be open to the public.
Corporate Aviation Safety
I would like to spend a little time sharing with you my first, and very positive, experience with the aviation safety office at NTSB as it relates to corporate aviation safety. Last September, I had the privilege of chairing the board meeting of the fatal overrun accident that occurred in Bedford, Massachusetts. 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 had 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 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 am sure you have observed in some of your accident investigations.
The Bedford accident, like so many accidents that we investigate across all the modes, was preventable. It could have been avoided by following established procedures. Our 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. The accident also highlighted the importance of having a robust safety management system (SMS) and of routinely reviewing flight operational quality assurance data to help identify problem areas before they turn into devastating accidents. 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 prevent deaths and injuries across all modes of transportation.
So how can we work together? Yes, I am asking for your help.
Every year, the NTSB releases our “Most Wanted List” of transportation priorities. For over 25 years, the NTSB has chosen ten issues – covering all modes of transportation - that represent safety challenges; challenges which have a strong chance of being advanced if given some good hard pushes by the NTSB and colleagues like you. Each Board Member is assigned 2 to 3 issue areas, but we all work on all ten of them. This year, 7 of the ten issue areas we selected relate to aviation safety. I want to focus on one issue here today – expanding the use of recorders.
Recorders is one of my 3 Most Wanted List Issues this year. So I would 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. 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 video images with a view of the cockpit environment.
This past June, the NTSB met in a sunshine meeting to hear about the accident involving an Embraer 500 (also called a Phenom 100) aerodynamic stall and loss of control during approach 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 critical information to determine the sequence of events in order to identify actions needed 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 must be validated. People often wonder why it takes so long or why we do not release the raw data in the name of transparency, but I know that all of you 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 same luxury as the media, who often include the disclaimer “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.
All of you in this room are aviation experts and industry leaders and, as a result, you are 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, and wouldn’t you want to know what happened when there is a crash? With your help, 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 to prevent accidents from happening again. Safety is not glamorous and sometimes it is not 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.
As a public health professional, I am so proud of the work we do at NTSB and I am 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 because we have the same goal: to 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 today. Thank you.