Leading Edge: The new face of safety at NTSB

 - August 12, 2008, 6:35 AM

You said recently that the NTSB could become more proactive if it investigated incidents, as well as accidents. Please explain.

We have seen in other modes that indicators can occur–for instance the Firestone tire issue–where data was known, and, had it been collected, reviewed and applied appropriately, perhaps time could have been saved and information been able to help support safety sooner, rather than waiting for the significant deaths and accidents to occur.

I believe there is a body of knowledge throughout the safety world in all modes of transportation that we could be drawing on more by allowing time and resources to be allocated to incidents, as well as after the fact of the accidents themselves. I’d like to be as proactive in safety as possible. And if we can prevent an accident, isn’t that better than going in after the fact?

The Board is still investigating the November 2001 crash of American Airlines Flight 587 on Long Island (an Airbus A300-600). Early on, there were questions about possible structural failure involving composite material. Has anything turned up as far as a failure on the part of composites?

It’s been previously identified there are a variety of issues that are being reviewed. Yes, laminates is part of it. So is pilot training. So are human factors, weather and probably another half-dozen considerations, which will be part of the thorough and comprehensive review of probable cause. As soon as we felt that there were things that were important to get out there, we’ve immediately issued that information on this investigation. We are near the home stretch.

Last January’s crash of Air Midwest Flight 5481 in Charlotte is another ongoing investigation in which much attention has been given to third-party maintenance. What can you share with us about the NTSB’s findings?

I think it’s important to focus on the technical issues that are involved in our accident investigations and not be deviated to issues that are separate. When we talk about maintenance, you’re focused on the maintenance, and that includes the training, the procedures, the policies, the parts, the process, the individual and all factors inherent within the maintenance process. But to isolate it versus in-house or third-party maintenance is a false identifier if you are focusing on that issue versus performance.

We want to have thorough maintenance that is appropriate, with people who are appropriately trained, who do a thorough job following all of the appropriate processes and procedures, training manuals, maintenance manuals, doing the procedure itself correctly–everything from using the proper wrench to turning it however many times one has to turn the screws, so to speak. I think it’s an artificial construct to look at it differently. We want the job to be done right. Performance is what matters.

Is the FAA able to meet its maintenance oversight responsibilities?

I think that’s a question for FAA Administrator Marion Blakey, not for me. I’m not the safety regulator of the FAA. We issue recommendations, not regulations. That being said, we are the watchdogs of safety in that we have our bully pulpit, and in my daily services we are telling everyone that good business includes safety as part of its operating procedures. Safety is not something that is optional; safety is not something that you think about later.

Safety is part of your number-one daily business decisions, and that includes safety oversight for the FAA, internal safety programs for the airlines, safety designs for the manufacturers or safety training across the board. In the business of transportation, job number one has to be safety. We have to find ways to accomplish our tasks with the resources we are allocated.

Would the NTSB ever recommend to the FAA that the agency make changes in the way it oversees third-party maintenance?

Within the purview of the NTSB and our accident investigations, that’s the initial step for our recommendations. We don’t issue recommendations without a reason. Therefore, were we to find these issues, then they would result in a recommendation to the FAA. Please understand, the NTSB has a big stick with our bully pulpit, but our statutory mandate is very specific. Our recommendations come through the accident investigation report, the determination of probable cause and the subsequent recommendations that are issued for it not to happen again. While we are proactive safety advocates, we have to have the horse and the cart in the right order.

Haven’t you and Administrator Blakey discussed speeding up the FAA’s responses to NTSB recommendations?

Actually, the ping-pong responses and counterresponses are an issue that I brought to focus when I was a modal administrator over at the Department of Transportation. I was one of the first administrators to say, “Stop this insanity. Can’t we just talk?” The letters that were going back and forth were not really communicating. We had a lot of one-way communication, and we need to be partners in safety to get the recommendations implemented.

When I came to the NTSB, one of the first things I suggested–and I have met with almost all of the modal administrators–is that we should form SWAT teams, which I call “safety with a team.” I asked Administrator Blakey and the other modal administrators to identify within their staff key personnel who will then meet with our staff to look at the open recommendations, put them out on the table and then clean them up.

That was my challenge to the DOT and I’m pleased to say that there are some like minds. The other modal administrators–of which I am a former one–share the same frustration. We are very much in agreement from both the modal administrator perspective and the NTSB perspective that an open recommendation is a job undone, and we need to ensure that we solve these open recommendations.

Tell me yes, tell me no or give me another alternative. But let’s not ignore them. We’re also willing to ask: Were we wrong? Should we modify? Can you give us an alternative? We’re willing to have a two-way dialog as long as safety is the result. It’s not our way or the highway. There is a dialog that is necessary to ensure that we achieve our safety mission. And that has not been seen in the past. It’s critical that we work together to close these recommendations.

Doesn’t the NTSB’s “Most Wanted” list contain recommendations that have been on it for years?

When I was at RSPA, pipelines were on the “Most Wanted” list for 12 years, and we got those off in less than a year because we put our mind to it. As someone who has gotten something off the “Most Wanted” list from the other side, I can assure you that it can be done. The key is to find the safety solution. It’s not one size fits all.

I have challenged the FAA and our own team to find alternatives–low-cost, low-tech, staged approaches. Let’s get the job done. Let’s not delay safety to find the perfect technology or solution if we can find a variety of approaches that can be individually applied, piggybacked or staged. This is a situation that is unacceptable to have it continue the way it is. I think we’ve studied it enough. We need to start choosing.

Why was adoption of a new “Most Wanted” list postponed?

The “Most Wanted” list was reviewed to determine its efficiency as a tool to support our mission. It had not been, as a concept, reviewed for 13 years. What had started out as kind of a quasi-acknowledgment of a top-10 list without ever saying specifically that it be limited to only 10 had become actually somewhat cumbersome, because it was burdened with both individual recommendations and safety goals. We had almost 60 or so pieces of recommendations on this list within the categories.

So it’s very confusing. Is this a list of recommendations, a list of safety goals or a list of safety topics? Each topic on the list might have 10 or 15 recommendations associated. So how would it ever get done? It was very frustrating, I think, to all of the Board and the staff, as well as the recipients of the recommendations. How do you get off the list? How do you get the job done if one piece can hold up everybody else?

We voted to have a staff review of the “Most Wanted” list and its efficiency and its performance. And an excellent report came back from the staff indicating that the list–refined and more retooled as the spearhead–will be an incredibly effective tool if put together as a combination of advocacy efforts by the Board along with the recommendations.

So the Board has divided up both the states and topics for the individual Board members to get out there and conduct those daily services from the bully pulpit, to go out to the states, as well as industry and trade associations, to help this “Most Wanted” list to be the effective tool that we want it to be.

I think you are going to see an aggressive pursuit of safety under the new Board. Three of the NTSB’s five members are new appointees. In the past, we issued the recommendation. Now we are going after the implementation of the recommendation.

You have said the NTSB could use more people, and the training academy is about to open. How have you fared in the latest round of congressional budgeting?

We are delighted that Congress gives such serious consideration to the needs of the NTSB, and we are appreciative of its support for both our mission and our resources. I believe that we will continually be able to meet our obligations for our current staffing numbers and perhaps improve them in the areas where we need that resource allocation.

The academy is a huge opportunity for the NTSB that we want to ensure is as self-reliant as possible. My goal is to have the academy, except for capital cost, be self-reliant within five to 10 years. I think it’s critical that we prove ourselves in the marketplace that what we are offering has value and we are able to bootstrap ourselves as soon as possible.