Reflections of Christopher Hart, a Former NTSB Chairman

Chairman Hart
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The JDA Journal is quite proud to present the thoughts of the recently retired, distinguished and long-serving NTSB Member, Christopher Hart

 

NTSB Headquarters

Reflections of Christopher Hart, a Former NTSB Chairman

After 20 years of service

Former Chair, Vice Chair and Member

Shares his thoughts on the Board’s contribution to Safety 

WHAT A GREAT RIDE this has been! Being at the NTSB since 2009, and especially being Chairman for 3 years, including a year as Acting Chairman, has been the pinnacle of my career.  For that I owe thanks to many.

US Capitol

Thanks to Congress.  I would like to start with Congress. In 1967 Congress created the NTSB and did so in a way that helped ensure that the NTSB would be relatively apolitical to enable it to conduct unbiased and impartial investigations to determine what caused transportation mishaps. For example, the NTSB is led by five Members, including a Chairman and Vice Chairman, all nominated by the President and confirmed by the Senate, but in order to make the agency as apolitical as possible, its enabling statute allows only three of the five Members to be of the President’s party. The statute also created staggered five-year terms for the five Members, with one term expiring at the end of each year, so a new President can only replace Members with expired terms. Most important, making the Members appointees for fixed terms, instead of having them serve at the pleasure of the President as most political appointees do, helps ensure that an entity whose accident is being investigated cannot ask the President to replace any Members simply because the entity dislikes the direction the investigation has taken. The bottom line is that Congress created a structure that helps ensure that the NTSB’s conclusions and recommendations are based upon the facts and the evidence rather than political influence.

Thanks to Presidents. I would also like to thank the Presidents who put me here – Most recently, President Obama, for nominating me as a Member in 2009, for designating me as Vice Chairman in 2009, and for nominating me as Chairman in 2015. Thank you, President Obama, for giving me the opportunity to join, and to lead, such a great agency.

Nearly two decades earlier, President Bush (senior) nominated me to be a Member in 1990, and I would like to thank him for starting me down this exhilarating path.

NTSB

Thanks to Everyone Else. Last but not least are the amazing people that I have had the opportunity to work with, both inside the agency and elsewhere. The agency is populated with passionate and motivated professionals who are dogged detectives who don’t like to stop until they can determine what caused the mishap, but much to their credit, they are willing to admit if they unable to determine the cause. Outside the agency, it has been thoroughly enjoyable working with so many people in a variety of organizations who are trying to improve transportation safety, and who are good at working together to generate that improvement. Thanks to all of you for working so well together in this shared endeavor and for doing all the hard work while I, especially as Chairman, received more of the credit than I deserved.

High points. There were several high points during my time at the NTSB. As Chairman, I asked the staff for improved collaboration, both internal and external, and for continuous improvement.

My emphasis on collaboration resulted from my experience at the FAA from 1995 until 2009 with CAST, the Commercial Aviation Safety Team. After declining significantly for decades, the commercial aviation fatal accident rate began to get “stuck on a plateau” in the early 1990s. The airline industry became very concerned about the flattening rate because the FAA was projecting that the volume of flying would double in 15-20 years, which meant that the public would soon see twice as many burning, smoking airplanes, and the industry found that outcome to be unacceptable. That catalyzed them to begin a collaborative program for improving safety that included everyone who “had a dog in the fight” – the airlines, the manufacturers, the pilots, the controllers, the airports, and even the regulator. This level of industry-wide collaboration had never occurred before, and has never occurred since, in any industry. The outcome was amazing – among other benefits, the flat stuck rate, which many experts thought was about as good as it could ever get, was reduced by more than 80% in only 10 years. What an amazing example of the power of collaboration.

My emphasis on continuous improvement resulted from the reality that the transportation industries are always seeking ways to improve, and if the NTSB didn’t continue improving with them, it would become irrelevant and no longer be adding value to the safety improvement effort. It would become a maker of film in a world in which people are taking pictures with electrons.

An important addition to this quest for collaboration and continuous improvement was my view on mistakes. Collaboration and improvement will necessarily involve “thinking out of the box,” and thinking out of the box often results in mistakes, when not everything works out as planned. I made it clear that if I see mistakes from people who are trying to do the wrong thing, heads will roll, but if I see mistakes from people who are trying to do the right thing, and are trying to collaborate and innovate, my response will be to see what can be learned from the mistakes rather than to look for someone to punish. Imagine how excited I was to discover, in a visit to the 3M Innovation Center in Minneapolis, a similar policy statement by William L. McKnight, Chairman of the Board at 3M from 1949 until 1966.

How amazing it was to watch the NTSB staff take the collaboration and improvement balls and run with them.

Collaboration

Collaboration. Internally I saw several examples of offices within the NTSB working better together. Externally, our broader reach in accident investigations, discussed further below, has been facilitated by increased collaboration with several entities, including several that we had not worked with previously.  For example, we have collaborated more extensively with our neighbor to the north, the Transport Safety Board of Canada, such as in the tragic oil train derailment in Lac Megantic, and after a tragic mid-air collision of two private planes, one piloted by an FAA employee and the other by an NTSB employee, in which the objectivity of both the FAA and the NTSB would have been challenged if we had investigated the collision.

Continuous Improvement. While I was at the NTSB we began investigating several types of accidents that we had never investigated before.  When a Virgin Galactic space launch test flight experienced a fatal crash in 2014, we had never investigated a manned space launch before. Coincidentally, our staff had just attended an unmanned space launch accident the week before as observers, in their efforts to be ready if needed. Virgin Galactic was a new experience for us; it was new experience for the FAA because Congress gave it a very different regulatory responsibility for space launches than it has for commercial aviation; and it was certainly a new experience for the launching entities. Our staff handled that first-time investigation admirably.

Tesla

Another example is the first crash of a Tesla while operating in an automated mode in 2016. Most of our highway crash investigations involve large trucks and buses, with drivers who have commercial driver’s licenses. Rarely have we investigated a crash involving Joe or Suzy Public with their private cars. I had not originally planned to send an investigation team to the Tesla crash, but the staff was eager to go, and when I saw their push for continuous improvement, I heartily endorsed it. Again, it was a new experience for us and it was a new experience for Tesla and the other entities involved, but our staff handled that investigation admirably as well.

 

 

When the cargo ship El Faro sank near the Bahamas in 2015, we were faced with the challenge finding the ship and then retrieving a voyage data recorder from more than 15,000 feet of water. The data recorder was very important to help us determine what caused the worst maritime catastrophe involving a US cargo ship in decades – all 33 crewmembers were lost. Finding the ship and retrieving the recorder, which ultimately required three missions, involved close collaboration with the Coast Guard, the Navy, and several other government and non-government entities, and it involved many innovative new finding and retrieval techniques. Our staff rose to the challenge and we were able to determine what went wrong in order to help prevent such a tragedy from happening again.

 

Investigated Entity Testimonial. NTSB staff sometimes feels like dentists – nobody wants the NTSB to show up at their door because that usually means that something terrible has happened. Being investigated after an accident involves investigators and others going exhaustively for several months through every detail of the operation that led to the accident, and it is not necessarily a pleasant experience. As noted above, in 2016 we began investigating the first fatal crash of a Tesla in automated mode. Later that year there was a SpaceX crash, which we were not intending to investigate because it did not involve any fatalities. When Elon Musk learned that we were not going to investigate the SpaceX crash, he asked us to do so, even though we were deeply involved at that time in investigating his Tesla crash. What an amazing testimonial that was of the value that an investigated entity feels that we bring when he asked us to investigate one of his mishaps while we were already involved in investigating another of his mishaps. Lest there be any doubt, that certainly confirmed for me what a world-class investigating agency the NTSB is.

Drs. Duncan and Schuda

Low points. The deaths of two NTSB employees in private plane crashes were undoubtedly low points of my time at the NTSB.  One was a midair collision between two private planes in 2012, resulting in the death of Dr. James Duncan, the NTSB’s Chief Medical Officer. Ironically the other plane, which landed successfully after the collision, was piloted by an FAA accident investigator. The other was a nighttime crash in 2017 that resulted in the death of Dr. Paul Schuda, who was the Director of the NTSB’s Training Center in Ashburn, VA, after the engine failed in a single-engine private plane. These were particularly difficult for the agency not only because both men were so highly regarded at the NTSB, but also because so many of us are pilots, and we, too, have had midair close calls, and we, too, fly single engine planes at night.

Two low points in the NTSB’s efforts to improve transportation safety include the difficulties we have encountered for decades regarding various aspects of highway safety, such as impairment (alcohol, synthetic drugs), distraction (personal electronic devices), fatigue, and motorcycle helmets; and our decades-long push for what is now called Positive Train Control, that can help prevent trains from colliding, derailing on curves, and killing railroad work crews. These issues are all on the NTSB’s Most Wanted List of Transportation Safety Improvements, and the agency will continue pursuing all of them.

Next steps. Now the question is what I intend to do when I grow up.  I do not plan to be at home watching Ellen. Instead, I would like to take what I’ve learned at the NTSB and apply it to improving safety in two other very broad ways.

automated automobiles

The first is exploring how to apply aviation automation lessons learned to automating our cars. So far, the car makers have been making the same automation mistakes that aviation made decades ago, and they could benefit greatly by learning from that past in order to avoid making the same mistakes.

workplace Safety banner

The other is figuring out how to take the very successful collaborative CAST program, referred to above, which has been used to improve process safety (preventing airplane crashes), and transferring it to improving workplace safety (preventing slips, trips, and falls). There is a major gap between process safety experts and workplace safety experts that, if bridged, could significantly improve workplace safety, just as CAST did for process safety.

Closing. I would like to thank everyone who has helped to make my time at the NTSB so gratifying and enjoyable, both the agency staff and the other Members – I have been very fortunate regarding the Chairs and other Members while I was there. I would also like to thank so many in industry and elsewhere who are tirelessly pursuing further improvements in transportation safety. Last, but not least, I wish everyone the best of continued success in that important endeavor.

Christopher A. Hart

February  2018

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