Good afternoon! Thank you for that kind introduction and thank you to Laura, the DC Ninety-Nines (99s), and the organizers of this meeting of 99s for inviting me to speak. I am honored to be here with all of you today. During the past few weeks, I have been in Wichita, Kansas, speaking with the aviation safety investigators at GAMA (General Aviation Manufacturers Association). I have been in Alexandria, Virginia, at the Chief Pilots’ Roundtable, speaking with chief pilots from various Fortune 500 companies. I also have been just a couple miles away in Laytonsville, Maryland, accompanying one of our NTSB regional aviation investigators on a general aviation investigation into a fatal crash of a Cessna 172P just after takeoff from Davis Airport. So it is very appropriate that this weekend, I am here speaking with you – women pilots dedicated to the advancement of aviation.
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 (NTSB). First, I will give you a brief overview of our NTSB investigative process. Then, I am going to briefly discuss aviation safety and NTSB safety recommendations in this area. Finally, I will discuss what we can do together to move forward the safety needle.
Before, I begin, let me say this -- I love airplanes, but unlike all of you, I am not a pilot. In fact, I am not specifically an aviation expert. My training is in injury prevention, public health, and safety, with a focus on transportation. But as my colleagues and friends, who are pilots, know, I have great respect for the skill, dedication, and training it takes to be a pilot. I read on your website that, first and foremost, you are women, who love to fly. So I am happy to be here with you because I am a woman who loves to make flying as safe as possible. I am lucky, because at the NTSB, I get to work every day with knowledgeable and respected experts in aviation safety to do just that.
While in recent weeks the news has focused primarily about NTSB related to the Hoboken, NJ, train accident, for which I happened to also be the NTSB Board Member on duty, and while we always take safety in every mode of transportation seriously, the impetus to create our agency was 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 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 (air traffic control) centers, visited several aircraft manufacturers of different sizes, attended Heli-Expo, chaired the Board Meeting for the Bedford, Massachusetts accident, was the member on-scene at the Akron, Ohio accident, and I have spoken with groups such as A4A (Airlines for America) , ALPA (Air Line Pilots Association, International), ISASI (International Society of Air Safety Investigators), GAMA (General Aviation Manufacturers Association), HAI (Helicopter Association International), and now, the 99s. I also have talked with dozens of investigators and other aviation experts. Every group and every type of aviation expert has something to teach me. Nevertheless, I am always trying to learn more - to learn from you and to learn about you – so I can have the knowledge and perspectives from different sources to do everything I can to help make aviation safer. That is a long way of saying that 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.
Let me start by describing 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 –but we also investigate major transportation accidents in rail, marine, and highways, as well as pipeline and hazardous materials 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. My Go Bag sits near my desk as a constant reminder of this.
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 of a major transportation disaster.
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 US Department of Transportation, state governments, associations, and private companies. 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 what is known as the Government in the Sunshine Act. As you can see if you ever watch our accident investigation and other board meetings, which are always webcast free to the public and often with news cameras present as well, 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, they 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 the following: 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 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 their 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, we may hold an investigative hearing. The party (or outside) participation in our process ends at the technical review of factual information and group chairman reports. We always conduct the analysis part of our investigations independently.
During our final report development, the NTSB may issue a Board Accident Report after a public meeting or may issue a brief report format. 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 the public and you can find all of the factual documents in a public docket accessible through our website (www.ntsb.org).
We separate our investigations into 4 modal offices at the NTSB: aviation, marine, highway, and combined rail, pipeline, and hazardous materials. In addition, we have 2 multimodal offices which work with all the modal offices – they are our Office Research & Engineering and our Office of Safety Recommendations & Communications which also includes the family assistance program.
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, I had the privilege of chairing the board meeting of an accident that occurred in Bedford, Massachusetts. 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. The flight data recorder and cockpit voice recorder indicated that the two flight crewmembers, who had flown together for about 12 years, had not performed a complete basic flight control check that would have alerted them to the locked flight controls. A review of the flight crew’s previous 175 flights revealed that the pilots had performed complete preflight control checks on only two of them. The flight crew’s habitual noncompliance with checklists was a contributing factor to the accident.
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 my fellow Board Member Robert Sumwalt, who is a retired US Airways captain, also went to sit in the Gulfstream as part of his meeting preparations! As you all know better than most, there is nothing like sitting in the seat and manipulating the controls. 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 noncompliance – issues that we have seen throughout many accident investigations at NTSB.
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. The accident also highlighted the importance of having a robust safety management system and routinely reviewing flight operational quality assurance data to help identify problem areas before they turn into devastating accidents. This accident was terrible, as fatal accidents always are, but we learned a great deal from it that can help prevent future such accidents from happening again. Our investigators carefully and meticulously investigate every accident to find the probable cause so we can make recommendations. But these safety recommendations are not useful if they are not known and if they are never implemented. So it is my hope, and my request, that the 99s and your colleagues in the world of aviation, and with influence well beyond the world of aviation, will help us. So I cannot leave without asking for your help in advancing our recommendations in aviation safety.
Most Wanted List
Every year, the NTSB releases our “Most Wanted List” of transportation priorities for the year. 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. Each Board Member focuses on 2 to 3 issue areas but we are all ready to work on any of the areas if needed. This year, 6 of the 10 issue areas we selected relate to aviation safety:
Disconnect from Deadly Distractions
End Substance Impairment in Transportation
Enhance Public Helicopter Safety
Prevent Loss of Control in Flight in General Aviation
Require Medical Fitness for Duty
Strengthen Procedural Compliance
All of them are important and you can find more details on our website or by contacting me.
You may be familiar with our Most Wanted List issue of “Preventing Loss of Control in Flight in General Aviation,” which my fellow Board Member Earl Weener, as a GA pilot himself, spearheads. As you in this room probably know more than most, while commercial airline accidents have become relatively rare in the U.S., we are still losing far too many pilots and passengers in GA operations. Between 2008 and 2014, about 47% of fixed wing GA accidents in the U.S. involved pilots losing control of their aircraft in flight, resulting in over 1,200 deaths. We have detailed recommendations related to education, technologies, self-assessment, and situation awareness in the cockpit that address Loss of Control. I would be happy to send those to you if you would find them useful.
I would like to focus on one issue here today that is less well-known and in fact, is often forgotten despite its incredible importance – expanding use of recorders.
Recorders is one of the 3 Most Wanted List Issues this year that I am spearheading (the other two are occupant protection and ending substance impairment). So I would like to talk about cockpit recorders because I truly believe that recorders are the “unsung heroes” of safety. Over the decades, recorders have provided information about what happened before, during, and after an accident that would be unobtainable otherwise and this information has been vital to preventing future accidents. 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 many times single pilot and yet involve a complex system. When that pilot dies, and even when the pilot survives, important data is lost without some type of recorder.
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 that took place here, in Gaithersburg, Maryland. The airplane impacted three houses and the ground about ¾ miles from the approach end of the runway. The pilot, two passengers, and the three people in one of the houses died as a result. The flight was in operation on an IFR flight plan under Part 91. Data from the CVDR (cockpit voice and flight data recorder) provided information that demonstrated that the pilot did not use the wing and horizontal stabilizer de-ice system during the approach (even after acknowledging the right seat passenger’s observation that it was snowing when the airplane was 2.8 nautical miles from GAI) which led to ice accumulation and aerodynamic stall at a higher airspeed than would occur without ice accumulation, and the occurrence of the stall before the aural stall warning sounded or the stuck pusher activated. Because the de-ice system was not activated, the band indications (low speed awareness) on the airspeed display did not appropriately indicate the stall warning speed. The pilot did not perform the Descent checklist items that appeared on the Normal Icing Conditions checklist which included turning on the anti-ice systems.
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 note 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, as pilots, understand that data can be misinterpreted and misunderstood if we do not first ensure that it is clean and properly validated – and that takes time. We do not have the luxury of 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, policy and regulatory decisions, and that is why we are so careful at the NTSB. We always work as fast as we can and we are as eager to know that answer as anyone, but we are not looking for the fast answer, we are looking for the right answer.
All of you are aviators and, especially as women aviators, you are pioneers and probably often must speak up even when you are not in the majority. You are clearly not afraid to speak up. You are the ideal champions 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 as I have seen in touring places such as Boeing and Textron Aviation, the aviation industry invests billions of dollars in R&D, so shouldn’t we know what happened when there is a crash? They will build it if you demand it. I understand the cost concerns, especially for owners of smaller aircraft, but a crash-resistant cockpit recorder with at least audio and video (although also having data would be ideal) would be immensely useful. People may think that video is an invasion of privacy but it provides invaluable data. Even without other data, we have software than can read the needle positions on the instrument panel and calculate information, such as altitude.
With your help, championing the importance of recorders, 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 here probably do well. We think of the worst case scenario and then we think of how we can prevent it from happening. That is why you are good pilots. In addition, that is why we, at the NTSB, have made the recommendations we have made. We are not a regulatory body and I know that eventually, requirements will catch up with our safety recommendations.
But please know that we are not trying to make being a pilot of flying onerous. On the contrary, many of my colleagues in the aviation safety office and throughout the NTSB love flying and are pilots themselves. They and all of us at the NTSB are trying to make being a pilot and to make flying as safe as possible. Safety, I think, will encourage more people to fly.
With your help in championing safety recommendations, such as cockpit audio and video recorders, recommendations that sometimes may only become relevant in these worst case scenarios, millions of people across the country and indeed, around the world, will be safer.
I am proud of the work we do at the NTSB to prevent accidents 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 with the goal of preventing future injuries and deaths.
I mentioned when I started that I just accompanied our NTSB Regional Aviation Investigators on-scene to a general aviation investigation of a fatal crash at a nearby airport. The pilot involved was from this area so this accident was close to home, literally and emotionally, I think, perhaps for some of you.
Although the investigation is still ongoing, so I cannot provide the final results, I did want you to know that – I saw first-hand how our investigators showed great kindness and sensitivity towards the people at the airport as well as the first responders, many of whom know the pilot who died. In a smaller airplane crash such as this one, unlike the major transportation disasters that I usually accompany which have more personnel, the investigator in charge must serve in a variety of roles. Our investigators always conduct a thorough and independent investigation, but I was glad, but not surprised, to see that despite the workload and serious focus on obtaining the factual information, they never failed to demonstrate compassion towards the people involved.
I often am reminded of a former NTSB Chairman from the 90’s who described 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, as an individual pilot and as a member of the 99s. By the very fact that you are a member of the 99s, you are helping to advance aviation safety. Why? Because you are maintaining that important dialogue among your colleagues and because you are sharing the latest information, and because you are helping to educate the next generation of women about aviation and aviation safety. It is clear that the 99s have had positive impact on people’s lives around the globe, in the dozens of countries where 99s have chapters and beyond. Here’s wishing you and all of the 99s many more years of service to the advancement of aviation. It has been an honor to be with you today. Thank you.