NTSB Chair Deborah Hersman Addresses Air Safety
Investigators
In a speech to the International
Society of Air Safety Investigators in Chantilly, Virginia,
National Transportation Safety Board Chairman Deborah A.P. Hersman
said Thursday that the use of data to manage and improve safety in
the aviation industry has had a positive effect on the world's
improving aviation safety record. But she cautioned against
over-reliance on these systems to the neglect of forensic
investigation.
"We have reached an era when aviation accidents are extremely
rare," Hersman noted. She cited the use of data - particularly, but
not exclusively, Safety Management Systems (SMS) - in accident
prevention and investigation.
The Board has been advocating the use of SMS for a decade,
having issued 17 recommendations in favor of implementing SMS in
the aviation industry. When implemented correctly, Hersman
said, "SMS holds real promise in a variety of scenarios." She
noted several instances where SMS helped
eliminate potential unsafe conditions, notably a corporate flight
operation that used flight data to determine that high bank angles
occurred on repositioning flights, and a review of commercial
aircraft approach data that indicated a high rate of TCAS (Traffic
Alert and Collision Avoidance
System) warnings at a particular airport. In these instances,
she said, "data management adeptly identified a clearly measurable
set of information and allowed for a relatively simple and
effective solution."
However, Hersman
(right) noted, SMS works well for companies that are already
"getting it right," but may provide little more than false
confidence for companies with less than robust safety cultures.
Also, there are accidents caused by a combination of
factors that SMS cannot possibly detect. As an example,
Hersman mentioned the British Airways Boeing 777 crash at Heathrow
Airport two years ago involving a dual engine failure on
approach. It was not data analysis that solved the mystery,
but detailed forensic analysis; the circumstances were so unusual
that a data analysis system would not pick them up.
Hersman said she hoped that with all the focus SMS will place on
data collection and analysis, "let's not lose focus on
outcomes. The success of SMS won't be measured by how much
data we collect, but by how many lives we save."
"I will enthusiastically support any approach that will make our
nation safer," she said. "But I think we need a measured
approach - one that acknowledges the potential benefits and
limitations of SMS, and further, doesn't discount tried and true
methods for identifying vulnerabilities, such as accident
investigations."