Nov. 3, 2016
The second annual NBAA National Safety Forum, held on the closing day of NBAA-BACE, included a powerful reaffirmation of NBAA’s commitment to industry safety and a detailed examination of the many potential links in the chain leading to a fatal accident.
Stronger Focus on Accident Reduction
Bolen then joined with NBAA Board Chairman Paul Anderson and NBAA Safety Committee Chairman David Ryan to sign the new NBAA Safety Policy outlining the association’s extensive work to reduce the number of accidents involving business aviation aircraft.
“You now have the opportunity to understand NBAA’s vision, its values, its policy statement and our commitment to making sure that we are doing in 2016 what our founders envisioned in 1947,” Bolen said of the new policy. “To make sure business aviation is safe, and is perceived to be safe, and that we are utilizing all the best practices, tools and information available to us to make that a reality.”
FAA Associate Administrator for Aviation Safety Peggy Gilligan reiterated this mission through lessons taken from the May 2014 loss of a large business jet on takeoff from Bedford, MA, attributed to the crew’s failure to perform a pre-takeoff control check. “We cannot fix the human element with some kind of a box,” she said. “We must stay focused on what happens when we relax our guard and become complacent.”
To this end, Gilligan also lauded work done by the General Aviation Joint Steering Committee (GAJSC), of which NBAA is a member, to identify and mitigate systemic risks. “Through this partnership, we don’t need to wait for rulemaking to do the right thing,” she noted, adding that such efforts have reduced the rate of fatal GA accidents in 2015 to .99 per 100,000 hours of operation.
Christopher Hart, chairman of the National Transportation Safety Board (NTSB), also spoke about the benefits of collaboration between regulators and industry. “Historically,” he said, “we have not necessarily had such good relationships, [because] it’s important that we give an independent, unbiased and impartial report of what happened”.
“I am very pleased to see that people are starting to realize the wealth of information we bring to the table from things we see in accidents, and that can inform the improvement process significantly,” Hart continued.
Hypothetical Accident Simulation
The remainder of the daylong, interactive forum examined multiple factors in a hypothetical – yet highly realistic – business aviation accident, depicted through a simulated NTSB probable cause hearing after the fatal runway excursion involving a medium-size business jet that overran a short, wet runway.
The scenario included a range of realistic factors including unfavorable weather conditions, pilot fatigue, pressure to complete the mission, and lack of crew and passenger familiarity with a new aircraft type.
“In the confusion of the accident, emergency egress was hampered,” noted one of the video’s accident investigators. “Four of the fatality injured passengers were found huddled in the aft cabin near the lavatory seat, where [the company’s prior aircraft’s] door would have been located.”
Building off the conclusions reached by the depicted NTSB members, panel discussions then examined these factors through the perspectives of risk management, technical excellence, professionalism and fitness for duty.
Panelists also invited audience members to share their thoughts through the NBAA Events app about the many steps in which that accident chain may have been broken, to ultimately arrive at an alternate and more favorable outcome aligned with the closing statement in the video presentation.
“If each of you involved in business aviation pauses just a moment to think about the safety decision implications of each decision you are a part of,” said the video’s fictional NTSB chairman, “future business aviation accidents will be prevented because the accident chains will be broken.”
As with NBAA’s Single-Pilot Safety Standdown held earlier this week, a live webcast of the entire National Safety Forum was streamed online, with the archived presentation to be made available soon.