Voice of Aviation Experience speaks through the White Noise that Repetition may drown out
Safety Consciousness needs frequent, approaching constant reinforcement. Such repetitive communication, or “white noise.” indistinguishable and loses its impact, less noticeable and meaningful over time. Even well designed reminders, clever posters, ingenuous messages, meaningful reminders, etc. can diminish the value of the SAFETY points bring conveyed.
Another common effort, in trying to remind all involved that their focus must be on the critical details of their work, comes from EXPERTS—lectures from academics, the spokespersons of aviation trade associations, aviation safety advocates, omniscient Members of Congress, FAA staff, the DOT IG’s savants and the NTSB Board Members. Typically, the content of their transmission involves analyses of the massive data bases that are available. Numbers that may impress the audience, but not necessarily the information that is retained and reappears in the consciousness of a pilot or AMT or flight attendant when a SAFETY DECISION is being made.
Below is a presentation made by NTSB Member Michael Graham [see also fn.1 below]. Yes, he cites the Board’s statistics and underlines that body’s all-t00-often repeated ACCIDENT REPORTS, SAFETY RECOMMENDATIONS and MOST WANTED LISTS.
The below transcript of Member Graham’s talk at the BOMBARDIER SAFETY STANDDOWN carries with it three decades of flying in high performance Navy jets, 10,000 flight hours as certified Airline Transport Pilot and type rating in six different Citation models. He has designed, implemented and led Safety Management Systems.
His talk is punctuated with real world experience. His memories in cockpit relate easily to all at the Standdown attendees. HIS EXAMPLES WILL COME TO MIND WHEN THOSE AVIATION PROFESSIONALS ARE FACED WITH SIMILAR RISK DECISIONS ON THEIR FLIGHTS!!!
Michael Graham Talks Safety Culture at Standdown
Influence shapes safety culture in aviation
By Amy Wilder • Writer
November 14, 2024
NTSB board member MICHAEL GRAHAM[1] addressed attendees this week at the BOMBARDIER SAFETY STANDDOWN to discuss how influence shapes safety and what we can learn from recent close calls. His presentation, “IMPACTS OF INFLUENCE,” examined the ways people can influence aviation culture in sometimes surprising ways. To make his point, he delved into two case studies of runway incursion incidents at JFK and in Austin, Texas, over the past two years.
Graham, referencing the overarching event theme of “Elevate Your Influence,” opened by reflecting on the pervasive influence of advertising, government, and social media on buying habits and behaviors. He noted that sometimes simple actions can have a significant influence, which could be either positive or negative.
He played a 90-second 2012 Dollar Shave Club Ad, which he said cost about $4,500 to produce and load to YouTube, and led to a 12,000-person membership increase within two days. “Four years later…they sold the company for $1 billion,” Graham said. “Do you think that when he posted that, he thought it was going to have that much influence? Sometimes it’s the real simple things that make a big difference out there.”
Growing up in Albuquerque, Graham was inspired to become an aviator by watching airplanes flying over his home. His parents and teachers helped shape his values and career aspirations. A commanding officer in his first fleet squadron impacted his leadership and career development. Graham drew a line from these critical early influences to the importance of developing younger, inexperienced members of the aviation community and stressed the importance of setting a good example, even when not being watched.
“I think it’s really important that the most influential people in my life are probably not even aware of the things they’ve taught me,” he said. “And each one of you can be that out there. I’m going to try to influence you today.
“I hope you READ OUR ACCIDENT REPORTS like I did, and learn from them, and apply the lessons learned there, because that’s the most important stuff. It’s not what happened, but UNDERSTANDING HOW AND WHY, so we can prevent future accidents like that from happening again. I’m going to talk to you about a couple of near misses here—and the FAA would call them ‘close calls.’”
Looking at the history of RUNWAY INCURSIONS, Graham noted that audience members might look at statistics and see a steady state with no recent fatalities domestically. “That doesn’t mean that the potential is not there,” he cautioned.
Recent data shows an uptick in runway incursions, particularly in Alpha and Bravo airports. “We actually have 11 incursions that we’re investigating right now,” Graham said.
He outlined a runway incursion incident at JFK Airport that occurred nearly two years ago, which was impacted by pilot task saturation, changed clearances, and lack of standard operating procedures (SOPs) for verifying which runway the crew was crossing after being cleared to cross. Action by ATC alerted one of the crews to abort its takeoff in time to avoid a collision.
Graham said the information came from crew interviews about a month after the incident rather than from cockpit voice recorders (CVR) because the two-hour recording limit meant that data had been recorded over.
“One of the things that we recommended out of this was for [Part] 91K, 135, 121, operators that you incorporate into your SOP, a better procedural cross-check if you don’t have this already, by verbalizing the runway that you’re crossing, so others can be tied in, especially if they’re doing other tasks at the time, and that should be based on runway signs,” Graham said. “Now, I know some of you have the technology out there that tells you where you’re at, so use that. You’ve always got to be vigilant out there.”
The NTSB has also asked that airlines investigate their data to look for surface navigational errors caused by crew performing other tasks at the time, and if so, to work to mitigate it. In addition, “For 24 years now, since 2000, there are two things we’ve been asking for: SURFACE DETECTION EQUIPMENT in the towers and DETECTION EQUIPMENT IN THE COCKPIT that will visually and orally alert flight crews of traffic on the runway or taxiway, approaching to land, or taking off,” Graham said. “I am aware there is one avionics manufacturer that has this technology. It’s all using ADS-B data, and there’s another one who has most of the avionics in the larger airliners that is very close to completing this technology for the cockpit…and we’ve gotta retrofit it” for aircraft in fleets that fly for decades.
Graham went on to detail an incident between a Southwest Airlines 737 and a FedEx 767 in Austin. The Southwest airplane was given takeoff clearance while on the taxiway and advised of another aircraft on approach; it subsequently taxied onto the runway and then paused for an engine run-up, reducing separation with the approaching FedEx airplane. There were low-visibility conditions, and the air traffic controller could not see aircraft from the tower, on the surface, or on approach. The FedEx airplane, on a low-visibility approach, called for a missed approach just in time.
The incident highlights the IMPORTANCE OF PILOTS INFORMING ATC OF ADDITIONAL TIME NEEDED ON THE RUNWAY FOR RUNUPS OR SIMILAR PROCEDURES—particularly in conditions in which the tower has no visual contact with aircraft. Graham reiterated the call for the installation of surface detection equipment and said that, in this case, the CVR recording had also been lost due to the two-hour recording limit. He also emphasized there is a continued need for vigilance among aviation professionals and clear communication between pilots and ATC.
“Anybody who’s heard me speak in the last couple of years, or anybody from the NTSB for that case, is probably aware that we were really hounding the FAA on requiring 25-hour CVRs out there,” Graham said. “In 2023, all the incursions that we investigated out of all that, and the one collision we had down at Houston Hobby between the Hawker and the Citation Mustang—you know how many CVR readouts we got from all those? Zero. We got zero.
“The two-hour CVR is old and dated. There’s no reason why we can’t have 25-hour CVRs. They’re doing them over in Europe on the new aircraft. Congress got involved with the reauthorization of the FAA here this year, and they said, ‘Hey, FAA, guess what, you’re required now to have these within one year on new aircraft and within six years retrofitted out there.’ So hopefully that will help.”
Graham previously served as director of flight operations safety, security, and standardization at Textron Aviation. He served in the U.S. Navy, with flight time in A-7s and F/A-18s; holds a B.S. in mechanical engineering from the University of New Mexico; and is a certified Airline Transport Pilot with more than 10,000 flight hours.
The Safety Standdown event and webcast, which is marking its 28th year, continues through today. There is no charge for attendance.
[1] Michael Graham took the oath of office as the 45th Member of the National Transportation Safety Board on January 3, 2020.
Before coming to the NTSB, Member Graham was with Textron Aviation, Inc. (Cessna/Hawker/Beechcraft) from 1997 to 2019. Since 2012 he served as their Director of Flight Operations Safety, Security & Standardization and was responsible for the safe and secure operations of all domestic and international flights conducted in support of the company. The scope of his responsibility included managing the flight operation’s Safety Management System and its certification, administering the Emergency Response Plan, supervising Air Safety Investigations, and overseeing two company airports and a control tower.
Mr. Graham joined Cessna as a Demonstration Pilot and held positions in Production Flight Test and Delivery. He was instrumental in the merging of Beechcraft flight operations with Cessna’s after its acquisition. Mike also started the company’s highly successful Aviation Safety Action Program which became the model program for Part 91 operators.
Member Graham also provided safety leadership to multiple industry and government advisory committees during his tenure at Textron Aviation. He served as Chairman of the Air Charter Safety Foundation and Board of Governors, led the Single Pilot Safety Working Group of the National Business Aviation Association’s Safety Committee and was a member of the General Aviation Information Analysis Team. Mr. Graham was presented with Flight Safety Foundation’s 2019 Business Aviation Meritorious Service Award for his work.
Mr. Graham began his career in the U.S. Navy as a Naval Aviator flying A-7’s and F/A-18’s and completed two operational deployments including Combat Air Patrol missions over Iraq and Kuwait in support of Southern Watch. He served as a F/A-18 Flight Instructor, Evaluator and model manager for all Navy and Marine F/A-18’s. He was handpicked to develop the first ever F/A-18 Aircrew Coordination Training syllabus and facilitated the training of the first group of instructors. He received a Navy Achievement Medal for his development of an Occupational Safety and Health program and twice received the Top Eleven Award for best landing grades aboard the USS Abraham Lincoln.
From 1995-1997 he worked at Boeing/McDonnell Douglas as a F/A-18 aircrew instructor. Along with instructing, he developed courseware and served as an operational analyst and lead integration engineer receiving the Quality Achievement Award for his work.
Member Graham earned his B.S. in Mechanical Engineering from the University of New Mexico. He is also a certified Airline Transport Pilot with 10,000 flight hours and is type rated in six different Citation models.
