Safety Board Chairman Advocates"Raising the Bar"
On a snowy February morning, U.S. National Transportation Safety Board (NTSB) Chairman Deborah A.P. Hersman, left, sat down with magazine in her L'Enfant Plaza office in downtown Washington, D.C., for a wide-ranging and broad discussion about helicopter safety.
By Brian F. Finnegan
We were joined in the chairman's office by NTSB Executive Officer Thom Zoeller, Deputy Director of Aviation Safety for Regional Operations Jeff Guzzetti, the Chairman's Confidential Assistant Cresence Stafford, and NTSB Public Affairs Officer Keith Holloway. We began by discussing Chairman Hersman's stated mission to "raise the bar" for what I called the rotorcraft industry's struggle to find its way with financing and safety and the competing priorities that they present.
Rotor & Wing: I'd like to start by talking about your "raising the bar" philosophy with respect to transportation in our highly regulated industry, particularly helicopters. What does that raised bar look like for rotorcraft?
Hersman: One of the challenges we see at the Safety Board is that people are often just meeting the minimums. But sometimes the minimums just aren't enough. Unfortunately, it takes a fatal accident and recommendations from the Safety Board to identify that. That's really what our recommendations do - address areas where the existing rules, regulations, laws and requirements aren't enough to identify the gaps and the holes in the safety net.
"Raising the bar" is stretching a little bit, doing something that might get pushback. It gets people thinking about where they want to be. I'll share with you a quote that I have often used from Roslyn Carter. "A good leader takes people where they want to go, but a great leader takes people where they need to be." For example, Bell Helicopter and American Eurocopter are both working with Appareo to install a flight recorder on all their new production helicopters. Their decision to install that equipment on newly manufactured helicopters raises the bar. That's exactly what we want to see - voluntary action leading the way. If they can do it, others can do it, too.
R&W: When Congress gets involved, things happen differently than when it's just the FAA and others. Do you feel a need to bypass the lengthy FAA regulatory process and go straight to Congress for a law?
Hersman: The Safety Board has been around for over 40 years and being effective is always something that's an evolution. You have try different approaches. I think our preference would always be to go through a normal regulatory process because FAA houses the expertise to make the objective decisions, to do the research, to bring together the stakeholders in the industry ... and really, perhaps, achieve the right conclusion.
Our recommendations are fairly broad and we'd like for FAA to make the right decision. What we've found throughout our history, though, is that we can only wait up to a point. The FAA does have huge challenges. They have over 500 open recommendations from the NTSB right now. It is a burden for them. The question you have to ask is 'How do they prioritize those 500-plus recommendations?"
One way that we help them prioritize is through our Most Wanted list. We had issued recommendations on HEMS [helicopter emergency medical services] and for years they went unheeded. After waiting for a year, two years, we made the decision to add HEMS to our most wanted list.
In the past 25 years, the number of HEMS operators in the state of Missouri has more than tripled. While a concern, the NTSB Chairman says it is trying to ensure anyone operating in a geographic area regardless of whether it is "one operator or 15 operators, they are doing so at the highest level of safety."
R&W: In Safety Recommendation A-09-106, you ask the Centers for Medicare & Medicaid Services (CMS) to develop wide ranging 'minimum safety accreditation standards for HEMS operators that augment the operating standards of 14 CFR 135.' Do you see accreditation standards on the next Most Wanted list?
Hersman: This is one of those situations the Safety Board had tried to address through the FAA. After years of inaction, we needed a new approach. When we held our public hearing last year on helicopter EMS issues, the curtain was raised on many industry practices regarding competition and scarce resources. We saw that the scales are not balanced.
You can have one operator with newer, better safety equipment and you can have another without extra safety equipment installed, such as TAWS [terrain avoidance warning system] or night vision goggles. Even though they are clearly in different financial postures competing for the same business, if they are being reimbursed through Medicare, they are getting paid a flat rate. However, the taxpayer receiving service doesn't get to pick between the good investment with high standards and a committed company safety culture or the bottom-feeder.
We had to level this playing field somehow. If FAA was not going to put forward regulatory requirements for safety enhancements, we wondered where else we could look to achieve some parity, to raise the bar. We followed the money and, frankly, it was pretty simple. We feel that CMS has an obligation when they are reimbursing a company and should do their due diligence.
R&W: Has the Safety Board given consideration to addressing any recommendations to the insurance industry?
Hersman: To my knowledge, we haven't. We did have an insurance consultant on one of the panels for the HEMS hearing and we've had insurance folks on other panels. We understand that there are a number of ways to skin the cat and we are looking at those opportunities now.
The Safety Board is very persistent and we're trying to be flexible in the way that we look at things. The recommendation that you just asked me about - regarding the accreditation process - is a demonstration that we are willing to think out of the box and not pursue just the sole regulatory path. It's a good point and I have taken the opportunity to meet with insurance company staff in the past to ask them what we could do.
R&W: After the August 8, 2009, midair over the Hudson River, both the FAA and the Safety Board were quick to issue recommendations.
Hersman: The FAA convened a working group about five days after the accident and their recommendations came out a few weeks after that. Our recommendations preceded the FAA panel's recommendations, but they were very similar. There were a lot of synergies there.
R&W: Was there collaboration?
Hersman: No.
R&W: Is it appropriate to collaborate?
Hersman: The Safety Board feels there is value in us being able to understand what's going on with the industry and the FAA, but we also value our independence and we think it's important for there to be some separation. The public is counting on us to take an independent stance and have a critical eye about what's going on in the industry and with the regulators. We have to be the watchdog of the regulators, so to speak.
We don't want to be involved in their decision-making process because at some point in the future we might be called to investigate an accident that resulted from some activity that they've taken and we want to be free to identify any shortcomings without having ownership of them. We do need to make sure that we are getting feedback, but we do maintain our independence and we guard it fiercely. Sometimes that means putting a wall down to separate ourselves.
R&W: Data indicate that the number one cause of HEMS accidents is inadvertent flight into IMC (instrument meteorological conditions) and you've addressed that with several recommendations, in particular asking for two pilots or autopilot. Do you see two pilots or autopilot as a Most Wanted item?
Hersman: We're going to be having our Most Wanted list meeting two weeks from now (Feb. 18, 2010). I really cannot comment on that until the board adopts a new list. I will say that the HEMS issue area on our Most Wanted list is one of the most visible and one that has a high degree of public and Congressional attention. There have been efforts to adopt all of our Most Wanted list recommendations in legislative vehicles, verbatim, both on the House and on the Senate side in the past couple years. That's a testament to the Most Wanted list and how it serves its purpose. It helps us to identify, of those hundreds of open recommendations, which ones we think need immediate action.
R&W: Regarding fatigue, there is a recommendation that the FAA Aerospace Medical Certification exam for pilots include some kind of sleep apnea analysis (A-09-61). Then you go forward and you actually make a recommendation directly to the Maryland State Police (A-09-134) that they develop their own sleep apnea recognition program. With the FAA recommendation already in place, why would you make a specific recommendation to Maryland State Police? Also, if it were important enough to mention it to the Maryland State Police, why wouldn't you just recommend it to the whole industry?
Hersman: By asking the FAA to address it on medical certificates, that's our effort to reach the entire population. However, we recognize those changes might take some time to occur.
When we go to an accident investigation, especially a fatal accident, we sometimes find an organization who may not want us there and is uncomfortable that we're investigating. They may not really want to share information. With the Maryland State Police, that was not at all what we found. They really wanted to take an internal look and say: 'This was devastating to us. We want to figure out anything we can do to make our operation better.' Some of our discussions with the Maryland State Police led us to believe that they were willing to be industry leaders when it came to adopting and making change.
On the sleep apnea issue, there was a recognition among the family members of the pilot and the crewmates who served with him. This gentleman snored so loudly in the crew quarters that everyone knew when he was there. Our investigators felt they could ask Maryland State Police to be an industry leader and demonstrate to other operators how they did this. It wasn't singling them out. We're saying, 'How can we raise the bar?' If we have individual organizations that are willing to lead, then that's helpful to everyone in the industry.
R&W: Is there a process by which you can follow up or give them an opportunity to share how they've gone forward?
Hersman: Since we've made the recommendation to them, it's open. They have an obligation to respond to us about their plans. We also have a concurrent obligation to check in with them to get a status update on how they're progressing. Our investigators had such a positive experience with the Maryland State Police leadership that we felt good about making that recommendation to them. Now, if they can't get the resources or execute a program like that, that's another issue. It was worth making the effort to ask. With every organization, adversity makes them take a step back and look at their processes and procedures and really reevaluate what's important and what they want to do.
R&W: We put a message on the Rotor & Wing Facebook page that we were going to have this interview with you to make sure we at least gave the industry an opportunity to come up with some topics for discussion and we got a few comments back.
Hersman: Great! This is my favorite part. Questions from the people.
R&W: OK, well here's one. Should there be a limit on the number of HEMS operations in a given geographic area or region? (See charts on page 28.)
Hersman: The Safety Board is trying to ensure that whoever is operating in a geographic area or region, regardless of whether it's one operator or 15 operators, they are doing so at the highest level of safety. We are fully cognizant of some of the pressures that emerge when you have a competitive market and so that is what was at the heart of our recommendations last September to FICEMS (Federal Interagency Committee on EMS) and CMS. We think that if there are higher standards, then perhaps you can weed out some of the less safe operators.
R&W: I did not find any maintenance discussion in the last round of recommendations, but I did find quite a few maintenance issues in the tour operators recommendations that were published in 2008. Are maintenance problems a broader issue than just with tour operators or were they just not a problem in these EMS accidents?
Hersman: We make our recommendations based on each accident that we investigate and we see what the issues are. I don't think that means that maintenance is not an issue across the board because it's always an issue. You've got to stay on top of that, especially as fleets age. We did not find maintenance issues in Trooper 2. We've looked at other HEMS accidents and I think you've hit the nail on the head. By and large, we found that they were human factors issues. The majority of them were happening at night, or in weather. It's trying to keep pilots out of those higher risk situations that were a problem. The facts of the accidents are going to speak to us. Everybody has got to stay on top of maintenance. It's the human, the machine and the environment in which you are operating. Those are the three things. You've got to be on top of that.
R&W: What about public use aircraft? Is it the Safety Board's view that the FAA should have regulatory authority over all non-military aircraft operating in the national air space?
Hersman: One particular concern in the Maryland State Police accident, which was public use, was that we could not get a consistent read from the FAA about whether or not EMS operators should be covered by them. Our concern is that it doesn't matter whether they are private, for hire, commercial operators or they are public use. They are still providing a service. We want to make sure everybody is operating at the same high standards. Maryland State Police were actually seeking FAA oversight.
They wanted to get the FAR Part 135 Certificate and the FAA couldn't figure out whether or not they wanted to do that or if they could do that. That is an issue that concerns us. If an operator wants this type of oversight and to have these standards, we ought to be doing that.
R&W: Regarding electronic news gathering (ENG) organizations, the Safety Board recommended at the beginning of 2009 that FAA host annual safety conferences (A-09-06) to discuss operational and safety issues affecting all ENG as well as those pertaining to their specific region. How can operators and associations work to support this recommendation?
Hersman: We recognize the value of organizational leadership. Groups such as IHST (International Helicopter Safety Team) and HAI (Helicopter Association International) are many times the ones who can put together a collaborative effort. They're ones that achieve voluntary industry audit standards and help to raise the bar. They can reach out to their membership in a way that is non-punitive and help support them.
We value the role that they can play and we would encourage any efforts that would result in better information dissemination, communication, collaboration and support for operators in a particular area when it comes to safety. Frankly, we've seen a lot of voluntary measures taking place absent FAA requirements. The FAA has not really been delivering on the mandatory requirements.
R&W: But even if the wealthy organizations improve like that, you're still going to have the laggards. Aren't the laggards really the only ones for whom the regulations are written?
Hersman: Well, the bottom feeders are always going to be a problem in any industry. There is always going to be someone trying to figure out how to do something cheaper and easier. The public can't figure out how to differentiate between operators and that is really the tragedy of it. In the absence of regulatory action, you're going to have people who are way behind on the power curve of safety.
For example, we were told that the majority of the industry had voluntarily adopted risk matrices for making the go/no-go decisions. Then we investigated accident after accident where an operator didn't have them. Or they would say, 'Well, they're not written. We kind of do it in our head.' Well that's not assessing risk. It's so easy and it's cheap. We've appended them to our report [Special Investigation Report on Emergency Medical Services Operations. For a sample risk assessment from that report, see page 30]. Print them out or put them on your computer and use them. What's the weather? What are the lighting conditions? What is my experience? These are pretty straightforward things.
R&W: Finally, what can we do to ensure that your message of raising the bar gets out to the industry and how can industry support the mission of the Safety Board?
Hersman: People who read the magazine can help by advocating for our recommendations. If they think there are things that they want to see happen, whether it's through the rule-making committees they participate in at the FAA or whether it's through Congress, keep us informed about what's going on. It goes back to what I said at the very beginning of our conversation. A lot of voluntary things are being done out there to raise the bar.
It is a challenging environment that helicopters operate in. They have missions that I think would probably make a lot of other people very uncomfortable. Every day when they come in and they shut it down and it's been a safe day, that's something they should be proud of. When you ask how they can help us - it's by not having accidents. Don't just take organizational responsibility; take personal responsibility. Do the right thing when nobody's watching.