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Monday, October 29, 2007
NTSB Declares War on Error
Repeating concerns the National Transportation Safety Board originally expressed during the Air Line Pilots Association (ALPA) safety forum last summer, Chair Mark Rosenker told pilots and mechanics of corporate aviation departments, that while they are maintaining an enviable safety record, accidents in recent years have highlighted shortcomings in several important elements of their industry. Related Story
Rosenker said that corporate jet and turboprop airplanes flown by professional crews under part 91 have accident rates that are comparable to scheduled air carriers.
“Some flight departments, however, operate aircraft on a shoestring budget with inadequately experienced or trained crews or shoddy maintenance practices,” he said, speaking before than 500 pilots and maintenance personnel taking part in Bombardier’s Safety Standdown 2007 seminar in Wichita. “These types of operations are typically the ones that garner the NTSB’s attention. They also give your industry a black eye in the white-hot media spotlight.”
In his speech, Rosenker touched on flight crew and mechanic training, preflight preparation, fatigue, and maintenance issues. In recounting accidents in which flight crews failed to perform their duties to an acceptable level, he said pilots need to be professional.
“Don’t confuse getting paid to fly with being a professional pilot,” he said. “Professionalism has absolutely nothing to do with the size of a paycheck or the size of your airplane. Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts, precise compliance with standard operating procedures (SOPs) and regulations, including sterile cockpit compliance. Quite simply, professionalism means doing the right things, even when no one is watching.”
He recounted the August 2006 Comair Bombardier CRJ 100 accident, in which 49 were killed shortly after taking off from the wrong runway at Lexington, Kentucky’s Blue Grass Airport. The NTSB ruled that the primary cause of the early morning crash was pilot error including violation of the sterile cockpit rule. "We recommended that all Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for takeoff,” he said. “Even with all the information provided to pilots via cockpit displays publications and air traffic controllers, the final line of defense is you, the pilot.”
Rosenker also said that “regulation is not the only way to improve safety…Voluntary action by industry, in partnership with government, is one of the most effective ways to decrease accidents.”
Addressing the safety forum, he said: “It seems that even though the airplanes that you all fly and maintain have gotten more advanced over the years, and even though the requirements for the certification of the hardware have gotten more stringent, the biggest killer of corporate airplanes continues to be human failure, not unlike other forms of transportation. As long as I am leading this agency, I am committed to supporting the War on Error.”
The workshop portion of Safety Standdown offered attendees practical seminars in: CPR/AED training; crew member medical emergency training; ditching and water egress training; and international procedures workshops. New this year was a fifth workshop designed specifically for maintenance managers, focusing on human factors. Topics addressed included: Professional Airmanship; Advanced Aerodynamics; Applied Aviation Psychology; Fatigue Countermeasures; and Professionalism. New topics on the roster included Organizing for High Reliability and the Role of Non-Verbal Communication on the Flight Deck.
Rosenker said that corporate jet and turboprop airplanes flown by professional crews under part 91 have accident rates that are comparable to scheduled air carriers.
“Some flight departments, however, operate aircraft on a shoestring budget with inadequately experienced or trained crews or shoddy maintenance practices,” he said, speaking before than 500 pilots and maintenance personnel taking part in Bombardier’s Safety Standdown 2007 seminar in Wichita. “These types of operations are typically the ones that garner the NTSB’s attention. They also give your industry a black eye in the white-hot media spotlight.”
In his speech, Rosenker touched on flight crew and mechanic training, preflight preparation, fatigue, and maintenance issues. In recounting accidents in which flight crews failed to perform their duties to an acceptable level, he said pilots need to be professional.
“Don’t confuse getting paid to fly with being a professional pilot,” he said. “Professionalism has absolutely nothing to do with the size of a paycheck or the size of your airplane. Professionalism is a mindset that includes hallmarks such as precise checklist usage, precise callouts, precise compliance with standard operating procedures (SOPs) and regulations, including sterile cockpit compliance. Quite simply, professionalism means doing the right things, even when no one is watching.”
He recounted the August 2006 Comair Bombardier CRJ 100 accident, in which 49 were killed shortly after taking off from the wrong runway at Lexington, Kentucky’s Blue Grass Airport. The NTSB ruled that the primary cause of the early morning crash was pilot error including violation of the sterile cockpit rule. "We recommended that all Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold-short line for takeoff,” he said. “Even with all the information provided to pilots via cockpit displays publications and air traffic controllers, the final line of defense is you, the pilot.”
Rosenker also said that “regulation is not the only way to improve safety…Voluntary action by industry, in partnership with government, is one of the most effective ways to decrease accidents.”
Addressing the safety forum, he said: “It seems that even though the airplanes that you all fly and maintain have gotten more advanced over the years, and even though the requirements for the certification of the hardware have gotten more stringent, the biggest killer of corporate airplanes continues to be human failure, not unlike other forms of transportation. As long as I am leading this agency, I am committed to supporting the War on Error.”
The workshop portion of Safety Standdown offered attendees practical seminars in: CPR/AED training; crew member medical emergency training; ditching and water egress training; and international procedures workshops. New this year was a fifth workshop designed specifically for maintenance managers, focusing on human factors. Topics addressed included: Professional Airmanship; Advanced Aerodynamics; Applied Aviation Psychology; Fatigue Countermeasures; and Professionalism. New topics on the roster included Organizing for High Reliability and the Role of Non-Verbal Communication on the Flight Deck.

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