[Senate Hearing 111-605]
[From the U.S. Government Publishing Office]
S. Hrg. 111-605
AVIATION SAFETY: ONE YEAR
AFTER THE CRASH OF FLIGHT 3407
=======================================================================
HEARING
before the
SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY
of the
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 25, 2010
__________
Printed for the use of the Committee on Commerce, Science, and
Transportation
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56-412 WASHINGTON : 2010
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0SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
JOHN D. ROCKEFELLER IV, West Virginia, Chairman
DANIEL K. INOUYE, Hawaii KAY BAILEY HUTCHISON, Texas,
JOHN F. KERRY, Massachusetts Ranking
BYRON L. DORGAN, North Dakota OLYMPIA J. SNOWE, Maine
BARBARA BOXER, California JOHN ENSIGN, Nevada
BILL NELSON, Florida JIM DeMINT, South Carolina
MARIA CANTWELL, Washington JOHN THUNE, South Dakota
FRANK R. LAUTENBERG, New Jersey ROGER F. WICKER, Mississippi
MARK PRYOR, Arkansas GEORGE S. LeMIEUX, Florida
CLAIRE McCASKILL, Missouri JOHNNY ISAKSON, Georgia
AMY KLOBUCHAR, Minnesota DAVID VITTER, Louisiana
TOM UDALL, New Mexico SAM BROWNBACK, Kansas
MARK WARNER, Virginia MIKE JOHANNS, Nebraska
MARK BEGICH, Alaska
Ellen L. Doneski, Staff Director
James Reid, Deputy Staff Director
Bruce H. Andrews, General Counsel
Ann Begeman, Acting Republican Staff Director
Nick Rossi, Republican Chief Counsel
Brian M. Hendricks, Republican General Counsel
------
SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY
BYRON L. DORGAN, North Dakota, JIM DeMINT, South Carolina,
Chairman Ranking Member
DANIEL K. INOUYE, Hawaii OLYMPIA J. SNOWE, Maine
JOHN F. KERRY, Massachusetts JOHN ENSIGN, Nevada
BARBARA BOXER, California JOHN THUNE, South Dakota
BILL NELSON, Florida ROGER F. WICKER, Mississippi
MARIA CANTWELL, Washington GEORGE S. LeMIEUX, Florida
FRANK R. LAUTENBERG, New Jersey JOHNNY ISAKSON, Georgia
MARK PRYOR, Arkansas DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri SAM BROWNBACK, Kansas
AMY KLOBUCHAR, Minnesota MIKE JOHANNS, Nebraska
MARK WARNER, Virginia
MARK BEGICH, Alaska
C O N T E N T S
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Page
Hearing held on February 25, 2010................................ 1
Statement of Senator Dorgan...................................... 1
Statement of Senator DeMint...................................... 20
Statement of Senator Thune....................................... 30
Witnesses
Hon. Deborah A.P. Hersman, Chairman, National Transportation
Safety Board................................................... 2
Prepared statement........................................... 4
Margaret Gilligan, Associate Administrator for Aviation Safety,
Federal Aviation Administration................................ 10
Prepared statement........................................... 11
Appendix
Hon. Frank R. Lautenberg, U.S. Senator from New Jersey, prepared
statement...................................................... 41
Letter, dated April 6, 2010, to Hon. Byron L. Dorgan and Hon. Jim
DeMint from Deborah A.P. Hersman, Chairman, National
Transportation Safety Board.................................... 41
Response to written questions submitted by Hon. Frank R.
Lautenberg to Hon. Deborah A.P. Hersman........................ 42
Response to written questions submitted to Margaret Gilligan by:
Hon. John D. Rockefeller IV.................................. 43
Hon. Byron Dorgan............................................ 44
Hon. Frank R. Lautenberg..................................... 45
AVIATION SAFETY: ONE YEAR
AFTER THE CRASH OF FLIGHT 3407
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THURSDAY, FEBRUARY 25, 2010
U.S. Senate,
Subcommittee on Aviation Operations, Safety, and
Security,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Subcommittee met, pursuant to notice, at 9:32 a.m. in
room SR-253, Russell Senate Office Building, Hon. Byron L.
Dorgan, Chairman of the Subcommittee, presiding.
OPENING STATEMENT OF HON. BYRON L. DORGAN,
U.S. SENATOR FROM NORTH DAKOTA
Senator Dorgan. I'm going to call the hearing to order. My
colleagues will be joining me shortly, but in the interest of
starting on time, I want to begin the hearing.
This is a hearing on aviation safety of the Aviation
Subcommittee of the Commerce Committee, one year after the
crash of Flight 3407 of Colgan Air at Buffalo, New York.
I welcome our witnesses this morning. The witnesses will be
Deborah Hersman, the Chairman of the National Transportation
Safety Board; and Ms. Peggy Gilligan, the Associate
Administrator for Aviation Safety at the FAA. We appreciate
both of you coming.
I note that, this week, the National Transportation Safety
Board released a 300---I believe, 300-plus-page report on the
Colgan crash. We've just observed the 1-year anniversary, as
I've indicated. That terrible tragic accident has crystallized,
I think, a number of issues that are in front of us to try to
deal with the issue of aviation safety. The issue of pilot
training, rest, experience, a wide range of issues dealing
with, in this case, regional carriers, but a number of these
issues relate to all of the carriers.
It has become clear to me that Congress and the industry
needs to take major steps to ensure that there is indeed one
level of safety throughout the entire commercial aviation
industry. We are told that that is the standard, and yet the
evidence suggests that that is not the practice. I note that
the newspaper reports of the National Transportation Safety
Board investigation cites, quote, ``pilot error,'' unquote. And
yet, I know, from the reading that I have done and the
evaluation I have done of information that's come across my
desk, that there is much, much more to the rest of the story.
Pilot error. That would suggest that something happened in
a moment in that cockpit that caused that accident. Well, we do
know that something happened in that cockpit. A number of
things happened in that cockpit that were inappropriate
responses to the conditions in which that airplane was flying.
But, we also know that there were many other conditions leading
up to that moment that cause us great concern and cause us to
believe--some of us to believe that they were contributing
factors to that accident.
And the question, for me, is, As we look at all these
issues, what is being done to address them? Not only what is
being done, but when is it being done? When can we expect the
achievement of the goals that we establish to make certain this
cannot and will not happen again? And the discussion that's
been held between the FAA, the NTSB, the Congress, the families
of the victims of Colgan Air, all of that, I think, has led to
some real impatience about trying to make certain that this
morning, at 10:36, there's not some airplane flying in weather,
someplace around this country, in which the similar conditions
would have led to similar mistakes that will cause us to lose
the lives of other people who are on commercial airlines.
I have said, at every hearing, that we have a remarkably
safe system in aviation. I mean, if you just take--and you
measure that by how many airline crashes, how many crashes have
we had in commercial aviation in recent years. It is a
remarkably safe way to travel, and we don't want these hearings
to suggest otherwise. But, these hearings are necessary, and
the investigation of the Colgan accident, or crash, in Buffalo,
New York, describes to me that this level of safety travels on
a very thin edge.
What I have learned from this crash, and what we need to
apply to other standards across the industry here, is that a
number of things are occurring that can be causal to some
future accident if we don't take action. I'm talking about
fatigue, I'm talking about traveling all night across the
country. I'm talking about training. I'm talking about the
question of how the regional carriers carry the colors and the
brand of the majors, and yet there's--the majors, in many
cases, have no responsibility for much of anything of that
regional carrier. All of these things are issues. The full and
complete background of a pilot, that airlines don't have access
to now, in most cases, when they hire a pilot. All of these
things, in my judgment, are important, and we are required to
address them all. Because, most surely, they will come together
once again at some point and take the lives of others if we
don't address these issues.
So, let me thank the witnesses for being here. I'm going to
have a lot of questions today. I appreciate very much your
willingness to appear this week at a time when the NTSB has
issued its report.
Ms. Hersman, you have been with us before. And as I
indicated, I wanted to start on time. We will have some
colleagues join us, but I'm going to call on you for an opening
statement, and then I will call on Ms. Gilligan, and then we
will proceed from there.
STATEMENT OF HON. DEBORAH A.P. HERSMAN, CHAIRMAN, NATIONAL
TRANSPORTATION SAFETY BOARD
Ms. Hersman. Good morning, Chairman Dorgan.
On February 12, 2009, Colgan Air Bombardier Q-400,
operating as Continental Connection Flight 3407, crashed while
on approach to Buffalo, New York. All 49 people on board, and
one person on the ground, were killed.
I'd like to start by showing an animation of the last
minutes of the accident flight. As you will see, the top half
of the screen shows the 3-dimensional model of the airplane and
its motion. Superimposed over the model is the cockpit voice
recorder text. The time is shown in the middle of the screen,
on the right side. The bottom half of the screen depicts a set
of instruments and indicators.
Moving from left to right, the airspeed indicator is boxed
in red during low speed with the low-speed cue in red next to
the airspeed tape; altitude; stall protection system; stick
pusher and stick shaker; an icon depicting the control wheel
rotating right or left; and control column moving up and down.
We will now play the animation of the accident sequence. The
animation does not depict the weather or visibility conditions
at the time of the accident.
[Pause.]
Ms. Hersman. You can see the low-speed cue is visible at
this time, and the landing gear is up. The airspeed is about
170 knots. Flaps are at zero degrees. And the autopilot is
engaged, with the altitude hold mode selected, at about 2,300
feet.
[Pause.]
Ms. Hersman. See the flap handles move from 0 to 5 degrees.
The airplane is in level flight, and the control column is in
neutral position. You can see the shadowing when it's not in
neutral.
[Pause.]
Ms. Hersman. The engine power levers are moved to near
flight-idle, and during the next 10 seconds the engine
condition levers move, the airspeed starts to slow down, and
the gear comes down.
Now the upset begins. You see the stick shaker's on. The
airplane stalls. The pusher's activating. The gear comes up.
In May, the Safety Board held a 3-day public hearing to
collect testimony on issues related to the accident, including
aircraft performance, flight crew training and procedures, and
fatigue management. On February 2, 2010, we met to consider the
final report. Holding a hearing and completing this
investigation in less than a year was quite a challenge and
reflects the dedication of our staff.
One of our 46 findings indicated that, although the
aircraft had some ice accumulation, it did not affect the
crew's ability to control the airplane. We determined that the
probable cause of the accident was the captain's inappropriate
response to the activation of the stick shaker. Contributing
factors included the flight crew's failure to monitor airspeed
and adhere to sterile cockpit procedures, the captain's failure
to effectively manage the flight, and Colgan's inadequate
procedures for airspeed selection in icing conditions. We
issued 25 recommendations addressing training, fatigue,
previous flight test failures, records retention, expanding
FOQA programs, and the use of portable electronic devices.
Before closing, I would like to highlight two related
events that the Safety Board has planned for later this year.
In May, we will be holding a public forum on pilot and air
traffic controller professionalism; and in the fall, we will
hold a symposium on code sharing and its role in aviation
safety.
Thank you, and I'm pleased to answer your questions.
[The prepared statement of Ms. Hersman follows:]
Prepared Statement of Hon. Deborah A.P. Hersman, Chairman,
National Transportation Safety Board
Good morning. On February 12, 2009, about 22:17 eastern standard
time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as
Continental Connection Flight 3407, was on an instrument approach to
Buffalo-Niagara International Airport in Buffalo, New York, when it
crashed into a residence in Clarence Center, New York, about 5 miles
northeast of the airport. The 2 pilots, 2 flight attendants, and 45
passengers on board the airplane were killed, one person on the ground
was killed, and the airplane was destroyed by impact forces and a post-
crash fire.
Within minutes of the accident, the NTSB was notified, and a go-
team was launched to the accident site early the next morning. The NTSB
named 6 parties to the investigation, including:
Federal Aviation Administration (FAA)
Air Line Pilots Association
National Air Traffic Controllers Association
United Steelworkers Union (representing the flight
attendants)
Transportation Safety Board of Canada
Air Accidents Investigation Branch of the United Kingdom
In addition to the parties, other organizations participated in the
investigation--more than 60 in total--including Transport Canada,
Bombardier, Pratt & Whitney Canada, Dowty Propellers, as well as
representatives from state agencies, area-wide county and city offices,
emergency responders, police departments, service organizations, and
many others.
As part of its investigation, the NTSB held a 3-day public hearing
in Washington, D.C., May 12 through 14, 2009. Witnesses included
representatives of FAA, Colgan Air, the Air Line Pilots Association,
and Bombardier. The issues presented and explored during the hearing
were the effect of icing on airplane performance, cold weather
operations, sterile cockpit rules, flight crew experience, fatigue
management, and stall recovery training.
This tragic accident significantly changed countless lives. Many
family members and friends of the victims of Flight 3407 have come
together to tirelessly advocate for improved aviation safety. The NTSB
made a commitment to the families some months ago that we would
aggressively pursue the issues uncovered in the accident and endeavor
to complete the investigation before the one-year anniversary. Holding
a public hearing and then finalizing this investigation in less than a
year was a challenge for the agency; the last time we accomplished both
a hearing and completion of a major investigation in less than a year
was more than 15 years ago. This effort required a significant amount
of staff overtime and reprioritizing other investigative activities.
Nevertheless, our dedicated staff presented a draft final accident
report late last month, and in a public Board meeting on February 2,
the Board voted unanimously to adopt the report, thus concluding this
significant accident investigation.
The final report includes 46 separate findings and a determination
that the probable cause of the accident was the captain's inappropriate
response to the activation of the stick shaker, which led to an
aerodynamic stall from which the airplane did not recover. Contributing
to the accident were the: (1) flight crew's failure to monitor airspeed
in relation to the rising position of the low-speed cue, (2) the flight
crew's failure to adhere to sterile cockpit procedures, (3) the
captain's failure to effectively manage the flight, and (4) Colgan
Air's inadequate procedures for airspeed selection and management
during approaches in icing conditions. The final report also makes 25
new recommendations to the FAA and reiterates 3 previously issued
recommendations. The recommendations cover a wide range of safety
issues that were factors in this accident, including pilot training and
fatigue.
Pilot Training
Although the NTSB's investigation was broad-reaching, the
performance of the pilots in this accident was the primary focus of the
investigation. Not only was the captain's inappropriate response to the
stick shaker identified as the primary cause of the accident, but
several performance lapses on the part of the crew were cited as
contributing factors to the accident. Therefore, the NTSB staff spent
considerable time reviewing the pilots' performance on the night of the
accident, documenting their activities in the days leading up to the
crash, and scrutinizing their previous performance including detailed
reviews of their past proficiency checks and the training they received
while employed by Colgan Air.
Remedial Training
The captain of Flight 3407 had multiple certificate and rating
failures which were a matter of record with the FAA. His training
records at Gulfstream International Airlines showed that his flying
skills needed improvement, although he met the minimum standards
required for completion of the training. His continued demonstrated
weaknesses in basic aircraft control and attitude instrument flying
during annual checks at Colgan Air should have made the captain a
candidate for remedial training. However, at the time of the accident,
Colgan Air did not have a formal program for pilots who demonstrated
ongoing weaknesses. Furthermore, Colgan Air's electronic pilot training
records did not contain sufficient detail for the company or the FAA
Principal Operations Inspector (POI) to properly analyze the captain's
trend of unsatisfactory performance.
In 2005, the NTSB recommended that the FAA require all Part 121 air
carrier operators to establish oversight and training programs for
pilots who have demonstrated performance deficiencies or have
experienced failures in the training environment (A-05-14). In
response, the FAA issued SAFO 06015, ``Remedial Training for Part 121
Pilots,'' the purpose of which was to promote voluntary implementation
of remedial training for pilots with persistent performance
deficiencies. While the FAA had recently conducted surveys to determine
if carriers have remedial training programs consistent with the SAFO,
the POI for Colgan Air stated during the NTSB's public hearing that he
was not aware of the existence of this SAFO.
Remedial training and additional oversight for pilots with training
deficiencies and failures would help ensure that the pilots have
mastered the necessary skills for safe flight. In 2003, during our
investigation of a landing accident involving a Fed Ex MD-10 in
Memphis, the NTSB's review of FedEx's pilot training procedures and
oversight revealed that, consistent with other operators in the
aviation industry, it focused on a pilot's performance on the day of
the checkride with little or no review of that pilot's performance on
checkrides months or years earlier. The NTSB was concerned that this
single-event focus does not allow a carrier to monitor changes or
patterns in a pilot's performance history that could provide
significant information about the competency of a pilot. For example,
in the FedEx case, the first officer's repeated substandard
performances on checkrides were addressed as singular events that did
not require further evaluation or monitoring after the checkride was
satisfactorily completed. Yet, post-accident review of the first
officer's training history and post-accident interviews suggested a
pattern of below-standard performance. In our report on Flight 3407, we
reiterated our 2005 recommendation to the FAA (A-05-14) and issued
several additional recommendations focused on pilot training.
The NTSB also reiterated our concern about reviewing all available
pilot records for new hires. Following the 2003 Air Sunshine ditching
accident near the Bahamas, which involved a pilot who had failed 9 FAA
flight checks, the NTSB issued recommendations to address the
importance of obtaining all pilot records prior to hiring. In addition
to reiterating our 2005 recommendations (A-05-01), we issued 3
additional recommendations addressing the maintenance and sharing of
pilot training records (A-10-17, A-10-19, and A-10-20).
Stall Training
As pilots transition to larger transport-category airplanes, they
do not have an opportunity to experience stalls in flight or in a
simulator, because air carrier training does not require pilots to
practice recoveries from fully developed stalls. The FAA's practical
test standards for pilot certification currently require pilots to
recover from an ``approach to stall'' with minimal altitude loss. This
recovery procedure can be effective as long as an airplane is not fully
stalled. However, altitude loss standards are not appropriate for
responding to a fully developed stall. Once a stall has occurred, an
airplane cannot be recovered until the wing's angle of attack (AOA) is
reduced, which will usually necessitate a loss of altitude.
The current air carrier approach-to-stall training did not fully
prepare the crew for an unexpected stall in the Q400 and did not
address the actions that are needed to recover from a fully developed
stall. The stick shaker, which is a component of the stall warning
system in the Q400, produces an audible vibration of the control yoke
when it activates to alert the pilot to take immediate action. However,
the existing industry practice of training to approach-to-stall does
not prepare pilots for unexpected situations where the stick shaker
activates and simultaneously disconnects the autopilot. The stick
pusher response is another feature designed to prevent and/or recover
from a stall by pushing the control yoke forward and achieving a nose
down attitude. Stick pusher training was not consistently provided to
pilots of Q400s, nor was it required by the FAA.
The NTSB has investigated other accidents in which the pilots
applied inappropriate nose-up pitch control inputs during an attempted
stall recovery, including West Caribbean Airways Flight 708 in 2005,
Pinnacle Airlines Flight 3701 in 2004, and an Airborne Express DC-8 in
1996. We remain concerned that classroom training of this important
system is incomplete because the training does not familiarize pilots
with the forces associated with stick pusher activation or provide them
with experience in learning the magnitude of the airplane's pitch
response.
The NTSB believes that more realistic stall and upset training is
possible due to advances in simulator technology. Flight crew training
on full stalls and recoveries has not previously been included in
simulator training partly because of industry concerns about the lack
of simulator aerodynamic model fidelity in the post-stall flight
regime. However, research demonstrates that simulator fidelity can be
significantly improved and the useful data envelope for upset training
can be expanded. Pilots could have a better understanding of an
airplane's flight characteristics during the post-stall flight regime
if realistic, fully developed stall models are incorporated into
simulators that are approved for such training.
Colgan Air pilots were trained to address tailplane stalls through
a NASA-produced video intended to enhance a pilot's ability to assess
hazardous icing conditions. The tailplane stall recovery procedure
discussed in the video required pilots to pull back on the control
column, reduce flap setting, and for some aircraft, reduce power.
However, the tailplane stall recovery procedure presented in the video
was the opposite of the recovery procedure for a conventional wing
stall, which requires lowering the nose and adding power. Many Colgan
pilots believed the Q400 was susceptible to tailplane stalls, but
according to Bombardier, the manufacturer, it was not. Training in
tailplane stalls, when it is not appropriate for the aircraft for which
the pilot is being trained, may add confusion to a pilot's reaction in
addressing conventional wing stalls.
To address stall recovery and stick pusher training in simulators,
NTSB recommended that the FAA:
Require Parts 121, 135, and 91K operators and Part 141 pilot
schools to develop and conduct training that incorporates
stalls that are fully developed, are unexpected, involve
autopilot disengagement, and include airplane-specific
features, such as a ref speeds switch (A-10-22);
Require Parts 121, 135, and 91K operators with stick pusher-
equipped aircraft to provide their pilots with pusher
familiarization simulator training (A-10-23);
Define and codify minimum simulator model fidelity
requirements to support expanded stall recovery training (A-10-
24);
Identify which airplanes operated under Parts 121, 135, and
91K are susceptible to tailplane stalls and then require
operators of those airplanes to provide appropriate stall
recovery training, and direct operators of airplanes that are
not susceptible to tailplane stalls to ensure that their
training does not include tailplane stall recovery.
Training for Active Monitoring
The flight crew of Flight 3407 failed to monitor the airplane's
pitch attitude, power, and especially its airspeed, and they failed to
notice, as part of their monitoring responsibilities, the rising low-
speed cue on the indicated airspeed (IAS) display. There are multiple
strategies to use to protect against catastrophic outcomes resulting
from monitoring failures like this one, not the least of which is pilot
training.
Current pilot training programs often do not address monitoring
skills in a systematic manner. Some of Colgan Air's guidance to its
pilots referenced the importance of monitoring, and the subject was
discussed and evaluated during simulator training and initial operating
experience. However, the company did not provide specific pilot
training that emphasized the monitoring function. Further, the
company's crew resource management (CRM) training did not explicitly
address monitoring or provide pilots with techniques and training for
improving their monitoring skills.
As a result of this accident investigation, the NTSB reiterated a
recommendation that was issued in 2007. That recommendation called for
the FAA to require that all pilot training programs be modified to
contain modules that teach and emphasize monitoring skills and workload
management and include opportunities to practice and demonstrate
proficiency in these areas (A-07-13).
The crash of Flight 3407 and a subsequent event near Burlington,
Vermont, revealed that Colgan Air's standard operating procedures did
not promote effective monitoring behavior. The NTSB is concerned that
other air carriers' standard operating procedures may also be deficient
in this area. We therefore recommended that the FAA require Part 121,
135, and 91K operators to review their standard operating procedures to
verify that they are consistent with the flight crew monitoring
techniques described in the FAA's advisory circular, AC 120-71A, and to
revise the procedures if they are not (A-10-10).
Training Captains for Leadership
The captain of a flight is responsible for setting the appropriate
tone in the cockpit and managing communications and workload in a
manner that promotes adherence to standard operating procedures. The
captain of Flight 3407 did not establish a professional environment in
the cockpit when he performed checklists and callouts late, initiated
and encouraged non-pertinent conversation in flight, and failed to
effectively manage the workload in the cockpit or communicate with the
first officer during an emergency situation.
Industry changes have resulted in opportunities for pilots to
upgrade to captain without having accumulated significant experience as
a first officer in a Part 121 operation. Furthermore, Part 121
operators are not required to provide upgrading captains with specific
training on leadership skills. When the captain of Flight 3407 upgraded
in October 2007, Colgan Air provided an 8-hour training course on
duties and responsibilities, the content of which focused on the
administrative duties associated with becoming a captain. It did not
contain significant information about developing in-cockpit leadership
skills, management oversight, and command authority.
The NTSB recommended that the FAA issue an advisory circular with
guidance on leadership training for upgrading captains at Parts 121,
135, and 91K operators (A-10-13). The guidance should include:
methods and techniques for effective leadership;
professional standards of conduct;
strategies for briefing and debriefing;
reinforcement and correction skills;
other knowledge, skills, and abilities that are critical for
air carrier operations.
Training Pilots for Adherence to Sterile Cockpit and SOPs
Both pilots of Flight 3407 engaged in non-pertinent conversation
during the flight, and neither pilot addressed the other pilot's
deviation from sterile cockpit procedures. Their ease in engaging in
non-pertinent conversation suggested that the practice is not unusual
among company pilots during critical phases of flight.
The sterile cockpit rule (14 CFR 121.542) is intended to ensure
that a pilot's attention is directed to operational concerns during
critical phases of flight rather than nonessential activities or
conversation. In 2006, the NTSB recommended that the FAA direct POIs of
all Parts 121 and 135 operators to reemphasize the importance of strict
compliance with the sterile cockpit rule (A06-7). In response to this
recommendation, the FAA issued SAFO 06004 on April 28, 2006, to
emphasize the importance of sterile cockpit discipline. Four months
after the SAFO was issued, the crew of Comair Flight 5191 attempted to
take off on the wrong runway in Lexington, Kentucky. There were 49
fatalities in that accident, and the NTSB determined that the crew
missed important cues during their taxi because they were engaged in
non-essential conversation. Since the SAFO was issued, the NTSB has
continued to investigate other accidents where the sterile cockpit rule
was violated.
Even though the responsibility for sterile cockpit adherence is
ultimately a matter of a pilot's own professional integrity, pilots
work within the context of professionalism created through the mutual
efforts of the FAA, operators, and pilot groups. The continuing number
of accidents involving a breakdown in sterile cockpit discipline
warrants innovative action by the FAA and the aviation industry to
promptly address this issue. In the accident report for Flight 3407,
the NTSB recommended that the FAA develop and distribute to all pilots
multimedia guidance materials on professionalism in aircraft operations
(A-10-15). The guidance should contain:
standards of performance for professionalism;
best practices for sterile cockpit adherence;
techniques for assessing and correcting pilot deviations;
examples and scenarios;
detailed review of accidents involving breakdowns in sterile
cockpit and other procedures, including this accident.
Fatigue
The crash of Flight 3407 gave the NTSB an opportunity to reexamine
fatigue in aviation, an issue that has been on our Most Wanted List of
Transportation Safety Improvements since 1990. Numerous accident
investigations, research data, and safety studies show that flight
crews who are on duty but have not obtained adequate rest present an
unnecessary risk to the traveling public. Fatigue results from
continuous activity, inadequate rest, sleep loss or nonstandard work
schedules. The effects of fatigue include slowed reaction time,
diminished vigilance and attention to detail, errors of omission,
compromised problem solving, reduced motivation, decreased vigor for
successful completion of required tasks, and poor communication.
Although the schedules of both pilots of Flight 3407 were within
flight and duty time requirements, the flight crew was likely fatigued
according to factual information gathered by NTSB investigators. The
night before the accident, the captain likely did not obtain quality
sleep because he slept in the company crew room, and his sleep time was
interrupted, as evidenced by multiple log-ins to the company scheduling
system at 21:51, then at 03:10, and again at 07:26. At the time of the
accident, the captain had been awake at least 15 hours. A 1994 NTSB
study identified performance degradation in accident flight crews when
they have been awake for 12 hours.\1\
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\1\ National Transportation Safety Board (1994). A Review of
Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 Through
1990. Safety Study NTSB/SS-94-01. Washington, D.C.
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Similarly, the first officer likely was not properly rested when
she reported for duty. The night before the accident, she commuted from
Seattle to Newark, changing planes shortly after midnight in Memphis,
and arriving in Newark at 06:30, which was 03:00 Seattle time. In the
preceding 34 hours, she had obtained a maximum of 8.5 total hours of
sleep. Approximately 3.5 of those hours were obtained as she traveled
cross-country in an airplane jumpseat, and those hours were interrupted
by her stop in Memphis. She obtained the remaining 5 hours resting in
the company crew room. Although the crew room had couches and
recliners, it was not isolated and was subject to interruptions,
uncontrolled noise and activity, lights, and other factors that prevent
quality rest.
Scientific research and accident investigations have demonstrated
the negative effects of fatigue on human performance, including reduced
alertness and degraded mental and physical performance. Evidence
suggests that both pilots were likely experiencing some degree of
fatigue at the time of the accident. However, because the errors and
decision made by the pilots cannot be solely attributed to fatigue, the
NTSB stopped short of making fatigue a causal factor in the accident.
Commuting
The NTSB continues to look at the many factors that affect a flight
crew's ability to achieve adequate rest. Long-distance commuting by
pilots is often a necessity because of base transfers that change a
pilot's home base to a location that is far from family or is in a
high-cost area. About 70 percent of the Colgan Air pilots based in
Newark were commuters, and approximately 20 percent of the pilots, like
the pilots of Flight 3407,\2\ commuted from over 1,000 miles away. Some
commuting pilots rent ``crash pads'' (shared rooms or apartments) at
their base, and some operators provide crew rest facilities so that
crews can obtain uninterrupted sleep. Colgan Air did not have a crew
rest facility, and neither of the pilots of Flight 3407 had a crash
pad. Colgan Air's commuting policy addressed their pilots'
responsibility to arrive at their base and report for duty on time, but
the policy did not reference ways to mitigate fatigue resulting from
commuting.
---------------------------------------------------------------------------
\2\ The captain commuted from Florida, and the first officer
commuted from Seattle.
---------------------------------------------------------------------------
As a result of this accident investigation, the NTSB recommended
that the FAA require all Parts 121, 135, and 91K operators to address
fatigue risks associated with commuting, including identifying the
number of pilots who commute, establishing policy and guidance to
mitigate fatigue risks for commuting pilots, using scheduling practices
to minimize opportunities for fatigue in commuting pilots, and
developing or identifying rest facilities for commuting pilots (A-10-
16). Unfortunately, in the aviation industry, fatigue-related decisions
by operators and pilots--such as minimum crew hires, flight crew
schedules and commuting--are decisions that too often reflect the
economics of the industry, rather than the data and science of fatigue
and human performance.
Most Wanted List of Transportation Safety Improvements
The issues of pilot proficiency and human fatigue are among the
NTSB's most critical areas of concern in the safety of aviation. Last
week, the NTSB updated its 2010 Most Wanted List to better emphasize
these two safety concerns.
Improve the Oversight of Pilot Proficiency
The investigation of Flight 3407 demonstrated once again that there
are troubling loopholes in the system under which airlines check
records of prospective flight crew employees. When Colgan Air conducted
a background check of the captain prior to his employment, the airline
checked records from other airlines in accordance with the Pilot
Records Improvement Act of 1996 (PRIA). However, these records do not
include a review of FAA certificates of disapprovals. The captain of
Flight 3407 had reported on his employment application that he had
failed 1 FAA checkride, when in fact he had failed 3. Neither PRIA nor
FAA's guidance under PRIA requires operators to obtain notices of
disapproval for flight checks for certificates and ratings.
Our testimony has already discussed the captain's demonstrated
weaknesses in basic aircraft control and attitude instrument flying
during annual checks at Colgan Air, which should have made the captain
a candidate for remedial training. The NTSB has long recommended
remedial training. On October 30, 2009, the FAA indicated that about
one-third of carriers had implemented remedial training programs,
including 6 of 27 regional carriers; less than 3 months later, on
December 10, 2009, the FAA Administrator stated during his testimony
before this committee that two-thirds of the air carriers without
advanced qualification programs had systems in place to identify and
manage low-time pilots and pilots with persistent performance problems.
In their ``Call to Action'' report published in January 2010, the FAA
stated that only 15 carriers had some part of a remedial training
program and 8 carriers did not have any component of a remedial
training program in place. While the NTSB asked for the complete survey
results, this information has not been provided, and the NTSB has not
determined the extent that air carrier remedial training programs
address pilot performance deficiencies and failures during training.
Therefore, we added 2 recommendations to the 2010 Most Wanted List
under a new issue area, ``Improve the Oversight of Pilot Proficiency:''
Require all Parts 121 and 135 air carriers to obtain any
notices of disapproval for flight checks for certificates and
ratings for all pilot applicants and evaluate this information
before making a hiring decision. (A-05-01);
Require all 14 Code of Federal Regulations Part 121 air
carrier operators to establish programs for flight crewmembers
who have demonstrated performance deficiencies or experienced
failures in the training environment that would require a
review of their whole performance history at the company and
administer additional oversight and training to ensure that
performance deficiencies are addressed and corrected. (A-05-
14).
Fatigue Management Systems
In June, 2008, the NTSB issued recommendations to the FAA to
develop guidance for fatigue management systems (A-08-44) and to
develop and use a methodology to continually assess the effectiveness
of fatigue management systems used by operators (A-08-45). A fatigue
management system incorporates various components and strategies to
mitigate the hazards of fatigue in aviation operations, including
scheduling policies and practices, attendance policies, education,
medical screening and treatment, personal responsibility during non-
work periods, task and workload issues, rest environments, commuting
policies and napping policies. The FAA has neither guidance nor
regulations addressing fatigue management systems.
In response to the FAA's lack of action in this area, the NTSB
updated the Most Wanted List issue area ``reduce Accidents and
Incidents Caused by Human Fatigue in the Aviation Industry'' to include
these recommendations on fatigue management systems.
Conclusion
Our investigation of Flight 3407 revealed 2 other aviation safety
issues which we will explore in greater depth in events planned for the
coming months. On May 17-19, 2010, we will hold a Public Forum on
Ensuring and Supporting High Standards in Flight Crew and Air Traffic
Controller Performance. At this forum we plan to bring industry leaders
together to discuss the selection of pilots and controllers, training
methods, and the development of techniques that support safe practices,
such as peer mentoring and support, voluntary reporting programs, and
the use of technology in oversight.
Later this fall, we will hold a Public Symposium on Airline Code-
Sharing Arrangements and Their Role in Aviation Safety. The symposium
will provide background information on domestic and international code-
sharing arrangements and their oversight, and provide insight into the
best practices regarding the role of major airlines in ensuring the
safety of regional code-sharing partners.
In conclusion, the tragic crash of Flight 3407 brought the world's
attention to the seriousness and complexity of maintaining safety in a
transportation industry that continually evolves. If we are serious
about aviation safety, we must establish a system that minimizes pilot
fatigue and ensures that flight crews report to work rested and fit for
duty. We must also have a system in which we are steadfastly confident
that all of our commercial pilots are proficient and well-trained.
Senator Dorgan. Ms. Hersman, thank you very much.
Ms. Gilligan?
STATEMENT OF MARGARET GILLIGAN,
ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY,
FEDERAL AVIATION ADMINISTRATION
Ms. Gilligan. Thank you very much. I'm pleased to be here
today to update you on the FAA's Call to Action on airline
safety and pilot training--to strengthen our safety program.
We released the final report on Call to Action at the end
of January. We have given copies to your staff. The report
details the results of our efforts, including the new and
renewed commitments we received from industry and labor, the
results of our Focused Inspection Initiative, and an update on
our rulemaking activities.
But, efforts have not stopped, nor even slowed down, just
because we completed the final report. For example, since the
final report was issued, we've published an Advance Notice of
Proposed Rulemaking seeking recommendations from the public to
improve pilot performance and qualifications. Just last week,
we completed a survey to follow up on the results of our
Focused Inspection Initiatives. The survey revealed even more
improvement in the number of carriers who have implemented
remedial training programs. When we first did the inspection
initiative, 15 carriers had only partially implemented remedial
training programs, and 8 carriers had no program at all. As of
last week, 93 of the 95 active certificates have completed--
completely implemented remedial training programs, and the
remaining 2 have implemented parts of those programs. Safety is
at the core of FAA's mission, and we will always strive to make
the safe system even safer.
Our efforts in the Call to Action reflect the same approach
we've taken to establish the unprecedent level of safety we
enjoy today: identify voluntary actions, monitor
implementation, propose new standards, and oversee the
compliance of the industry. Unfortunately, FAA safety programs
are too often measured by how precisely, or how rapidly, we
comply with NTSB recommendations for rulemaking. This measure
creates a misimpression about the safety of the aviation safety
system and the efficacy of the FAA.
For example, since the Board added fatigue recommendations
in aviation to its most wanted list in 1995, we have reduced
the passenger fatality rate by 85 percent, even while
operations increased and approximately 11 billion passengers
traveled by air. Few industries in the world can claim that
kind of success. Using the same multipronged approach we've
used in the Call to Action, we took action to address pilot
fatigue while longer-term solutions were being developed. The
FAA supported--and, in fact, in most cases, financed--the
research that has been done to advance the scientific study of
fatigue as it affects aviation. While we were doing that
research, in order to mitigate the remaining risk, we clarified
the requirements of our existing regulations, and we focused
our oversight to ensure that those rules were followed.
During that same 15 years, FAA issued nearly 400 final
rules, more than 20 final rules every year. These rules
introduced new technology, improved training, and enhanced
procedures. More importantly, these actions virtually
eliminated accidents such as controlled flight into terrain,
wind shear, and even icing, just as an example, from scheduled
commercial aviation. Acknowledging that we can never remove all
the risk in the system, we've improved the design standards for
aircraft to ensure passengers have every possibility to
evacuate a damaged aircraft. And we have seen the success of
those efforts in recent years.
While we are proud of the aviation safety record we've
established, safety professionals at FAA have not been resting
on our laurels while the Board has issued recommendations.
We've been acting, we have been implementing, and ultimately
we've been improving the safety of the system.
Much of our work in those years has addressed Board
recommendations. We appreciate the direction that the Board
helped set, and we appreciate the fact they have found our work
acceptable in 82 percent of those recommendations.
But, it's important to note, we don't wait for
recommendations. In fact, when the Board issued the 25 new
Colgan-related recommendations this week, we already had work
underway to address many of them.
Since aircraft accidents are so rare, the tragic Colgan
accident has served, as you've noted, to refocus our ongoing
efforts to improve aviation safety. The FAA's work over the
last 50 years of commercial aviation has yielded measurable and
meaningful safety improvements, and I assure you, under the
leadership of Administrator Randy Babbitt, that will continue.
That concludes my opening remarks, Mr. Chairman. We'll be
glad to take any questions.
[The prepared statement of Ms. Gilligan follows:]
Prepared Statement of Margaret Gilligan, Associate Administrator for
Aviation Safety, Federal Aviation Administration
Chairman Dorgan, Senator DeMint, members of the Subcommittee:
Thank you for inviting me here today to provide you with an update
on the Federal Aviation Administration's (FAA's) Call to Action on
airline safety and pilot training. There is no question that the FAA's
job is to ensure that we have the safest aviation system in the world.
The aviation safety record in the United States reflects the dedication
of safety-minded aviation professionals in all parts of our industry,
including the FAA's inspector workforce. In an agency dedicated to
aviation safety, any failure in the system, especially one that causes
loss of life, is keenly felt. When accidents do happen, they reveal
risks, including the tragic Colgan Air accident. Consequently, it is
incumbent on all parties in the system to identify the risks in order
to eliminate or mitigate them. As Administrator Babbitt noted when he
appeared before you in December, history has shown that we are able to
implement safety improvements far more quickly and effectively when the
FAA, industry, and labor work together on agreed upon solutions. The
fastest way to implement a solution is for it to be done voluntarily,
and that is what the Call to Action was intended to facilitate. On
January 27, the FAA issued a report that describes the progress made
toward fulfilling commitments made in the Call to Action and offers
recommendations for additional steps to enhance aviation safety. I
would like to use this opportunity to review the issues the
Administrator identified in December and let you know where we stand on
them.
Pilot Flight Time, Rest and Fatigue: When Administrator Babbitt was
last here he told you that the aviation rulemaking committee (ARC) he
convened for the purpose of making recommendations on flight time, rest
and fatigue, consisting of representatives from the FAA, industry and
labor organizations, provided him with recommendations for a science-
based approach to fatigue management in early September. While we were
extremely pleased with the product provided, the ARC did not reach a
consensus agreement on all areas and was not charged with doing any
type of economic analysis. Consequently, in spite of the
Administrator's direction for a very aggressive timeline in which to
develop a Notice of Proposed Rulemaking (NPRM), his hope that a
rulemaking proposal could be issued by the end of last year was not
realized. The complexities involved with these issues are part of the
reason why the FAA has struggled to finalize proposed regulations on
fatigue and duty time that were issued in the mid-1990s. However, with
the Administrator's continued emphasis on this topic, we hope to issue
an NPRM this spring. Although this is slightly later that we originally
hoped, it is still an extremely expedited schedule, and I can assure
you the FAA team working on this is committed to meeting the target.
One of the issues contributing to fatigue, that I know is of
interest to many of you, is that of pilots who commute by air to their
job. I would like to describe some of the e-mails and letters the
Administrator has been receiving on the issue of commuting, from pilots
who choose to commute by air to their job. As you can imagine, those
pilots who commute responsibly are understandably concerned that they
could be forced to relocate because of the irresponsible actions of a
few. Should some sort of hard and fast commuting rule be imposed, it
could result in families being separated, people being forced to sell
homes at a loss, or even people being forced to violate child custody
agreements. It is important to keep in mind these personal accounts,
because, to people not familiar with the airline industry, the issue of
living in one city and working hundreds of miles away in another does
not make sense. But in the airline industry, this is not only a common
practice, it is one airline employees have come to rely on. So we want
to emphasize these issues are complex and, depending on how they are
addressed, could have significant impacts on people's lives.
Focused Inspection Initiative: From June 24, 2009 to September 30,
2009, FAA inspectors conducted a two-part, focused review of air
carrier flight crewmember training, qualification, and management
practices. The FAA inspected 85 air carriers to determine if they had
systems to provide remedial training for pilots. The FAA did not
inspect the 14 carriers that have FAA-approved Advanced Qualification
Programs (AQP) because AQP includes such a system. Seventy-six air
carriers, including AQP carriers, have remedial training programs. An
additional 15 air carriers had some part of a remedial training
program. There were eight air carriers that lacked any component of a
remedial training program that received additional scrutiny and have
since instituted some component of a remedial training system. Since we
started, all carriers have implemented some component of a remedial
training program. The FAA inspectors also observed 2,419 training and
checking events during the evaluation. In the few instances we observed
regulatory non-compliance, we took corrective action.
Training Program Review Guidance: Based on the information from
last summer's inspections, the FAA is drafting a Safety Alert for
Operators (SAFO) with guidance material on how to conduct a
comprehensive training program review in the context of a safety
management system (SMS). A complementary Notice to FAA inspectors will
provide guidance on how to conduct surveillance. SMS aims to integrate
modern safety risk management and safety assurance concepts into
repeatable, proactive systems. SMS programs emphasize safety management
as a fundamental business process in the same manner as other aspects
of business management. Now that we have completed our data evaluation
and drafting, both guidance documents are in internal coordination.
Obtain Air Carriers' Commitment to Most Effective Practices: To
solidify oral commitments made at the Call to Action, Administrator
Babbitt sent a letter to all part 121 operators and their unions and
requested written commitments to adhere to the highest professional
standards. Many airlines are now taking steps to promote the larger
airline's most effective safety practices at their smaller partner
airlines. The Air Transport Association's Safety Council is now
including safety directors from the National Air Carrier Association
and the Regional Airline Association in their quarterly meetings.
Several large air carriers are conducting periodic meetings with those
with whom they have contract agreements to review safety information
and we are encouraged by these efforts.
In addition, I am pleased to say that since July 2009, after the
Call to Action, the FAA approved 12 new Flight Operations Quality
Assurance (FOQA) programs. Three air carriers that had no Aviation
Safety Action Programs (ASAP) have now established them. Four more air
carriers have established new ASAP programs for additional employee
groups. All of this supports the contention that the Call to Action did
make a difference.
Professionalism and Mentoring: Last week, the FAA met with labor
organizations to discuss further developing and improving
professionalism and transfer of pilot experience. In the interim, these
organizations have answered the Call to Action and support the
establishment or professional standards and ethics committees, a code
of ethics, and safety risk management meetings between the FAA and
major and regional air carriers. We also believe that labor
organizations can explore some of the ideas raised in the Call to
Action road shows, such as establishing joint strategic councils within
a ``family of carriers,'' use of professional standards committee
safety conferences, and mentoring possibilities between air carriers
and university aviation programs, with the goal of coming up with
concrete ideas on mentoring. These ideas merit further discussion and
the FAA looks forward to continuing to work with these organizations on
these concepts.
Crew Training Requirements: As the Administrator explained during
his last appearance before this committee, the FAA issued a rulemaking
proposal in January 2009 to enhance training programs by requiring the
use of simulation devices for pilots. More than 3,000 pages of comments
were received. The FAA is now developing a supplemental proposal that
will be issued in the coming months to allow the public to comment on
the revisions that were made based on the comments that were submitted.
One of the things that the Call to Action has shone a light on is
the issue of varying pilot experience. The FAA is attempting to address
this issue with an Advanced Notice of Proposed Rulemaking (ANPRM) in
which we can consider possible alternative requirements, such as an
endorsement on a commercial license to indicate specific
qualifications. We know some people believe that simply increasing the
minimum number of hours required for a pilot to fly in commercial
aviation is appropriate. As Administrator Babbitt has stated
repeatedly, he does not believe that simply raising quantity--the total
number of hours of flying time or experience--without regard to the
quality and nature of that time and experience--is an appropriate
method by which to improve a pilot's proficiency in commercial
operations.
The ANPRM requests recommendations from the public to improve pilot
performance and professionalism; specifically on whether existing
flight crew eligibility, training and qualification requirements should
be increased for commercial pilots engaged in part 121 operations. The
FAA is requesting comments and recommendations on four concepts for the
purpose of reviewing current pilot certification regulations. The four
concepts are: (1) requirement for all pilots employed in part 121 air
carrier operations to hold an Airline Transport Pilot (ATP) certificate
with the appropriate aircraft category, class and type rating, or meet
the aeronautical experience requirements of an ATP certificate; (2)
academic training as a substitute for flight hours experience; (3)
endorsement for air carrier operations; and, (4) new additional
authorization on an existing pilot certificate. The FAA has also asked
for recommendations from industry and the public on any other concepts
they may wish to offer. The ANPRM was published in the Federal Register
on February 8.
Pilot Records: While Congress is working to amend the Pilot Records
Improvement Act of 1996 and the FAA amends its guidance to airlines,
Administrator Babbitt asked that air carriers immediately implement a
policy of asking pilot applicants to voluntarily disclose FAA records,
including notices of disapproval for evaluation events. The airlines
agreed to use this best practice for pilot record checks to allow for a
more expansive review of records created over the course of a pilot's
career. The expanded review would include all the records the FAA
maintains on pilots in addition to the records airlines already receive
from past employers. Of the 80 air carriers that responded to the FAA
on this issue, 53 air carriers, or 66 percent, reported that they
already require full disclosure of a pilot applicant's FAA records.
Another 15 percent reported that they plan to implement the same
policy.
As the Administrator stated when he appeared before you in
December, the core of many of the issues facing the air carrier
industry today is professionalism. It is the duty of the flight crew to
arrive for work rested and ready to perform their jobs, regardless of
whether they live down the street from the airport or a thousand miles
away. Professionalism is not something we can regulate, but it is
something to which we must encourage and urge pilots and flight crews
to aspire. The conversations we have been having, in part because of
the Call to Action, help emphasize the importance of professionalism in
aviation safety.
In conclusion, our efforts will not stop or even slow down just
because the final report on the Call to Action was issued. We have been
gratified with the response to this effort. We believe that the
collective efforts of FAA, the airlines, labor unions and, of course,
Congress, will continue to result in implementing best practices,
transferring pilot experience, and achieving an overall improvement in
safety. Safety is at the core of the FAA's mission, and we will always
strive to make a safe system safer.
Mr. Chairman, Senator DeMint, members of the Subcommittee, this
concludes my prepared remarks. I would be happy to answer any questions
that you might have.
Senator Dorgan. Thank you very much.
It is true that accidents--commercial aviation accidents
have become rare. There's no question about that. And yet, as I
look at this particular accident and all of the evaluation of
issues that relate to it, it seems to me that we are very
fortunate that accidents have been rare.
I was on the phone this morning, on some airline service
issues for a community, and like most communities, that
community's service has changed substantially over the years.
Used to be served by a carrier that would fly 727s originally,
and then 319s, and so on, larger carriers--or, larger planes
with pilots from the trunk carrier. Now most of the service in
that particular city is by regional carriers. Eighty percent--I
think 75 percent of the service is RJ--50-seat regional jets.
And so, the companies that fly them are, in many cases, very
different than the companies that were flying into that city
previously, despite the fact that most passengers wouldn't know
that, because the planes look the same, same company name on
the planes, and so on.
So, service has changed very substantially. With 50 percent
of the flights--as I understand it, 50 percent of the flights
in this country are now regional carrier flights. And the
question is, Do we have one level of safety? And so, I want to
ask a series of questions.
First of all, I think, Ms. Gilligan, you mentioned, in the
Focused Inspection Initiative, which started June 24, 2009, you
wanted to go to these carriers and inspect the carriers to
determine, Do they have remedial training for pilots? And you
indicated that eight carriers lacked any component of any
remedial training program. These are carriers, I assume, that
are picking up passengers at various airports around the
country?
Ms. Gilligan. Yes.
Senator Dorgan. All regional carriers, would they have
been?
Ms. Gilligan. I don't know that, off the top of my head
right now.
Senator Dorgan. What would you----
Ms. Gilligan. We do have the names of the carriers, and we
can certainly check that.
Senator Dorgan. What would you think?
Ms. Gilligan. They were not the eight or nine mainline
carriers that most people are familiar with, but they--I don't
know that they were providing service that is--regional
service----
Senator Dorgan. Right.
Ms. Gilligan.--or were independent operators.
Senator Dorgan. But I was stunned that----
Ms. Gilligan. But, we can provide that.
[The information referred to follows:]
Prior to the Call to Action, these eight carriers (three of which
were predominately cargo carriers) lacked procedures for identifying
pilots who needed remedial training as a result of substandard
performance during a check ride. In one case, however, the carrier had
in place an Advanced Qualification Program (AQP), a voluntary
alternative to the traditional regulatory requirements for pilot
training and checking under which the FAA may approve significant
departures from traditional requirements, subject to justification of
an equivalent or better level of safety. At the time of the focused
inspection, however, the carrier had just acquired a new aircraft type
that was not yet covered by its AQP. Therefore, we listed the carrier
as not meeting the focused inspection criteria.
Senator Dorgan. I was stunned that you have eight
commercial air carriers that are--that were, last summer,
picking up passengers and flying passengers around the country,
that would have had no remedial training program for pilots, of
any type. Does that stun you?
Ms. Gilligan. It surprises me. But, if I may put that in a
little context?
Senator Dorgan. Sure.
Ms. Gilligan. By regulation, anytime a pilot fails a check
ride or an event in that training, they are required by
regulation to receive additional training and to be signed off
by an instructor pilot before they can take that check again.
So, by regulation, any pilot who does fail a particular event
must get additional training, have that signed off, and then is
tested by a different independent check pilot. All of the
carriers meet that regulation.
Several years ago, we put out guidance that recommended the
creation of a remedial training program, which not only assured
that regulatory requirement, but recommended that the carriers
track, over the career of the pilot, those failures. Because
you may have one, and it may be 5 years before you may have
another one. It may be 5 months. It was important, we believed,
that they be able to track that, for two reasons: to evaluate
the effectiveness of their own training programs, and to
continue to identify if there are particular pilots who
demonstrate the failure of check items more often than others.
It is that tracking program that those eight carriers had not
then implemented. As of today, I believe six of those have
implemented fully, and I believe the two that still only have
partial programs were part of that original eight, and we can
give you all of that data, if you'd like.
[The information referred to follows:]
Through a Safety Alert for Operators (SAFO), the FAA strongly
encourages part 121 air carriers to establish remedial training
programs for pilots with persistent performance deficiencies. Remedial
training programs are specific to each carrier's operations and to its
FAA-approved training program. Although these programs are voluntary,
we are happy to report that of the 95 carriers active today, 93 meet
the intent of the FAA's SAFO regarding remedial training. The remaining
two carriers offer remedial training programs, but they do not meet the
full intent of the SAFO because they do not currently have procedures
in place to follow up and ensure the effectiveness of the remedial
training.
Senator Dorgan. But, it just seems to me--I understand that
most carriers complied, and moved, as a result of the request
of the FAA, and some did not.
Ms. Gilligan. Yes.
Senator Dorgan. And it seems to me to be pretty persuasive
evidence that you've got to make things happen. I mean, the FAA
has to make sure that carriers are doing what the FAA wants
them to do. And I----
Anyway, let me go on to the range of issues that are
raised. Ms. Hersman, you said 25 recommendations, is that
correct, in your report?
Ms. Hersman. Yes.
Senator Dorgan. Can we begin to go through some of those in
the major categories? What have you recommended, or what is in
your report with respect to fatigue or crew rest?
Ms. Hersman. In our report, the Safety Board issued a
recommendation specifically to address commuting. One of the
things that we thought was important in this accident, was that
this crew were both commuting pilots, and they both commuted
from some distance away. But we did identify that this wasn't
unusual. In Colgan's base in Newark, 70 percent of the pilots
at that base were commuter pilots, and over 20 percent of those
commuting pilots commuted from over 1,000 miles away. What we
found in this investigation was that neither of the crew
members had a residence or a crash pad in the Newark area, and
so we did identify some concerns about the choices that they
made, either commuting across country on an overnight flight,
with a stop in Memphis, or sleeping in the crew room. The
captain had slept in the crew room two of the three previous
nights before the accident. And we know that not just the
quantity of sleep is important, but the quality of sleep is
important. Trying to get sleep on a redeye, coming across
country, is not going to produce quality sleep. So, we did make
a recommendation----
Senator Dorgan. Can I stop you at that point?
Ms. Hersman. Sure.
Senator Dorgan. The captain of this flight, you say, spent
two of the previous three nights in the crew room, all night
long. Is that correct? I mean, during the night and morning
hours? Are there beds in the crew room?
Ms. Hersman. No. They do have some sofas and some reclining
chairs in the crew room, but it is not set up for recuperative
rest. And the company actually prohibited overnighting in the
crew room.
Senator Dorgan. All right. So, the--this issue of--which
is, I think, somewhat different than how the FAA classifies
fatigue--I mean, that's--I think that relates more to a workday
period. But, this issue of commuting, and then whether they
have a crash pad or someplace to sleep, or whether, in this
case, a pilot of an airplane spends two nights in a crew room
with no bed, prior to a flight, in the winter, with icing, and
so on--that just begs the question of, Is that a very unusual
occurrence? Or have you done anything to determine whether this
is just, sort of, an aberration? This is one captain who wasn't
thinking very clearly about not sleeping in a bed someplace.
Have you done any surveys to find out, at LaGuardia, is this
the only captain that did that, or has done that, or is doing
that? What's your sense of that?
Ms. Hersman. In this accident investigation, we could find
specific information about this crew and we know that this was
a commuting concern, because many of the pilots recently had
been moved to Newark. When we asked Colgan to look at how many
of their pilots were commuting--we actually have a chart that
shows where they're commuting from around the country. What was
of most concern to us was that 70 percent of the pilots were
commuting pilots, and 20 percent were commuting from over 1,000
miles away.
[Additional information from Ms. Hersman follows:]
These data were provided by Colgan during the Flight 3407
investigation. They apply to pilots assigned to the Newark base, and
are described in section 1.17.4.1 on page 47 of the NTSB accident
report (AAR1001). The chart is contained on page 26 of the Human
Performance Group Chairman's Factual Report (http://www.ntsb.gov/
Dockets/Aviation/DCA09MA027/418082.pdf).
The NTSB has heard anecdotally that as many as 50 percent of pilots
commute to work. Pilots sometime choose to commute to work from distant
cities as a matter of personal choice and sometimes out of necessity.
Air carriers occasionally close bases, forcing many of their pilots to
relocate or begin commuting.
One of the other issues that we identified was that the
first officer's pay was fairly low. Many pilots--some who
contacted us with anecdotal information, during the public
hearing and after--described circumstances where their bases
were changed, and they could not afford to live in the new
area. We noted that Colgan's management did have a cost-of-
living adjustment for living in the Newark area, but the pilots
did not.
Senator Dorgan. But, let me put up--these are the Colgan
air pilots commuting to the Newark base. You will see--and this
is probably the chart you're referring to, it's the one we are
working with--and it shows the locations across the country
from which pilots are traveling to Newark.
But, my question is more specific. Do any of us in this
room have any knowledge of whether this is a--just a complete
aberration with one captain, who spends two nights in a crew
room with no bed prior to this flight that ended in tragedy? Do
we have any knowledge, have we done any surveys, have we asked
anybody about that? And I would ask both of you--Ms. Hersman,
any surveys done? And, Ms. Gilligan, is it your sense that this
is a practice that's prevalent, or highly unusual?
Because it seems to me, on this issue of fatigue and crew
rest and commuting--all of which kind of go into one bundle,
for me--it seems to me that, clearly, if any one of us in this
room were about to board an airplane, and someone told us,
``That captain that's getting in the cockpit hasn't slept in a
bed for two nights,'' would any of us have second thoughts
about that? You'd better believe we would.
So, tell me, what do we know about this? Do we know, is--we
know about this crew. Do we know anything else? Or are we just
blind on everything else, at the moment?
Ms. Hersman. The Safety Board doesn't have any further
information, beyond our survey of the commuting pilots in
Newark. We don't know how many of them had crash pads. We do
know the information about the two pilots involved in this----
Senator Dorgan. How----
Ms. Hersman.--accident.
Senator Dorgan.--about the carrier itself even asking for
self-reporting? Have they, in the aftermath of this accident,
said, ``You know what? We had a captain here that hadn't been
in a bed for two nights. We'd better ask the others?'' How
prevalent is it to find people spending all night in a crew
room, without a bed, before a flight? Do they know whether
Colgan has asked other pilots, at least on a self-reporting
basis, to know what is happening there?
Ms. Gilligan. I don't know, sir, but we can certainly ask
the carrier and find out if they have done any kind of review
to that extent. We do know commuting is a fairly common
practice within the industry, both for the major and for the
regional carriers, and it has been for a very long time. As the
Chairman indicates, the movement of bases, the pilots bid on
different equipment out of different locations, for career
reasons. It is a--there are lots of reasons why where a pilot
works changes over the course of his or her career. And their
decision to remain living where their family is located is a
decision that is not uncommon.
We do know it sounds--to most of us who drive a few miles,
perhaps, or take the metro into work like an odd decision to
make. But, many pilots have commuted for their whole careers,
and do so very responsibly. And we agree, we need to address
this as we look at the issues of fatigue.
Senator Dorgan. But let me ask you whether you think that
this is a reasonable concern.
If--Ms. Gilligan, if you have a flight at 12 o'clock from
National this afternoon, and you're about to drive out and get
on that Dash-8, and you know the captain hasn't slept in a bed
for two nights--does that give you pause about whether you want
to take that flight?
Ms. Gilligan. Certainly, sir. We expect pilots to react
professionally and to be responsible and arrive at work rested
and ready to take their responsibilities. I absolutely agree.
Senator Dorgan. The thing that kind of troubles me about
this is, when--and we'll get to all of these things--stick
shaker training and sterile cockpit and commuting and--the
thing that troubles me is, we now have done an unbelievable
inspection of what happened in that cockpit of one airplane
taking one flight, and it appears to me to have about six or
eight very serious problems. And the question is, Is this just
serendipitous, that it all is created in that one cockpit and
doesn't exist elsewhere, or are we seeing the evidence of
problems that we really need to get on and address and fix?
And in this area of commuting, and the question of, ``At
the end of your commute, where are you getting some rest in
order to be prepared for that next flight, as a professional
pilot?''--that's a very important question. And the thing is,
we apparently--the three of us in--well, four of us--know
nothing about the practice, beyond the description of these two
people. My understanding is that the copilot herself--the
copilot did not have--in your investigation, the copilot was
not seen to have had a rest period in a bed, either. Is that
correct?
Ms. Hersman. No, the first officer flew from Seattle. She
boarded a flight in Seattle the evening before the accident,
flew in the jumpseat of a cargo operator, to Memphis, got off
in Memphis, and then flew from Memphis to Newark. There's a 3-
hour time difference that she experienced as she traveled
across country, as well. They estimated that she received a
couple of hours of sleep when she was flying across country.
She tried to nap, also, in the crew rest area that morning,
before she went on duty.
So, both individuals did not have recuperative-quality
sleep the night before the accident. That's why we made our
recommendation to the FAA to address fatigue risks associated
with commuting: identifying pilots who commute, establishing
policy and guidance to mitigate fatigue risks for commuting
pilots, using scheduling practices to minimize opportunities
for fatigue, and developing or identifying rest facilities for
commuting pilots.
We don't think that Colgan is unique. We know that this
goes on in the industry. I think our problem is that we can't
identify what the issues are until an accident occurs, and we
investigate what happened in that situation.
After the accident, Colgan did take some action. One of the
things that the company did was to put out a policy that
required the lights to stay on in the crew room at all times,
24 hours-a-day. That wasn't mitigating the challenge for people
who were commuting; it was just ensuring that any sleep
obtained in the crew room was going to be with the lights on.
Senator Dorgan. Yes. The difficulty is, this also relates
to the question of compensation, because someone who is living
in Seattle, flying to the duty station in LaGuardia, and is
paid--I don't know what--I think it was $20- or $23,000 a
year--is not very likely going to have the resources to go get
a hotel room somewhere. So, there's a relationship there, as
well.
Well, I--what do you--just on--leaving this point, what do
you think we need to do to understand whether this is a common
practice or a very unusual practice, that we've got people
boarding commuter airlines with no sleep, or very little sleep?
You're making recommendations. What do we do at the FAA to
implement those recommendations?
Ms. Gilligan. Well, I think, as you know, we already have
our flight and rest rule under executive review within the
Administration. As the Administrator committed, we're moving as
quickly as possible to put forward that new proposal, which
will enhance the requirements for flight and rest, and how work
is assigned.
In that, we were also asking for additional insight into
this particular issue, because, again, commuting has been a
part of the industry for quite a long time, and can be done
responsibly. We want to understand how we can set a framework
for that and how the airlines can hold their crew members
responsible for that. And I think we'll see real progress in
that way.
The recommendation is for additional guidance materials. I
think that will be a part of how we will implement our new
rulemaking. We will provide guidance on how the airlines can
best address these kinds of risks.
Senator Dorgan. But, the issue is, there's already a rule.
I mean, the rule would have told both of those pilots, ``You
can't show up at LaGuardia and spend your time in the crew
room. You've got to get rest somewhere.'' Right? I mean----
Ms. Gilligan. Yes, sir.
Senator Dorgan.--doesn't that rule exist?
Ms. Gilligan. Yes, sir.
Senator Dorgan. So, then the question is--then the question
is, not just a new rule, although a new rule is probably
reasonable, but, How do we enforce rules?
Ms. Gilligan. That's right.
Senator Dorgan. And what do we know about whether these
current rules are enforced, generally, or not enforced much at
all?
Ms. Gilligan. And that's why the Administrator is calling
for a renewed emphasis on pilot professionalism, because, at
the end of the day, oftentimes it is up to the pilot himself or
herself to evaluate that they have met their personal
responsibility. In the meantime, you're right, we can enhance
the framework within the regulations, we can give both the
airline and the individual crew member better opportunities to
be properly prepared for the flights. But, the pilot must come
to work prepared to work----
Senator Dorgan. All right.
Ms. Gilligan.--and rested and mentally fit and physically
capable. And we are putting a huge push on pilot
professionalism as part of the Administrator's agenda.
Senator Dorgan. All right. I'm going to ask about a series
of things that--the credentials of a pilot, that are necessary
to fly an airplane, the responsibility of trunk carriers for
the regionals that bear their name, and specifically about
training issues. But, before I do that, I want to call on the
Ranking Member of the Subcommittee, Senator DeMint.
STATEMENT OF HON. JIM DeMINT,
U.S. SENATOR FROM SOUTH CAROLINA
Senator DeMint. Thank you, Mr. Chairman. And I really
appreciate your line of questioning.
The Chairman has mentioned, several times, the idea of a
survey. I did a lot of that in my previous life, and I think he
has made an excellent point. We know what happened in this
particular situation, a year ago. The rules weren't followed,
so making new rules is not necessarily going to help the
situation.
But, it does seem that an anonymous-type survey of pilots
could, not only help determine what is really happening now,
but also get some ideas from them on what they see as a way to
assist in this lifestyle, that has apparently been created over
many years of sometimes very long commutes. We don't have a
real handle on whether this is a problem of 5 percent of pilots
or 80 percent of pilots. Hopefully, some of their ideas on what
could assist them during their commutes, whether it's per diems
or just other facilities available would be useful. It seems
like we're flying in the dark here, really. And after a year of
knowing we had serious, and multiple problems in this one
cockpit, it doesn't seem as we know much more today about how
widespread that is than we did a year ago.
And so, I'm concerned about the approach here of
encouraging accountability and professionalism and things like
that without trying to find out more about how widespread it is
or even how they--the carriers--could assist pilots in making
sure that they have every resource available to be
professional, and to show up rested. I'm just curious why there
hasn't been more pursuit to find out, industrywide, the degree
of this problem.
Ms. Gilligan. Well, I think, sir, there are two things. One
is that we do know that the vast majority of pilots come to
work prepared to work. The data shows that.
Senator DeMint. Now, how do you know that?
Ms. Gilligan. Because the safety data indicates that. We
are not seeing accidents and incidents in----
Senator DeMint. OK, so----
Ms. Gilligan.--any vast number, and----
Senator DeMint. But, you don't know that they're rested,
you just know that we don't have a lot of accidents, right?
Ms. Gilligan. We know they are performing and meeting their
responsibilities----
Senator DeMint. OK.
Ms. Gilligan.--and that is a measure of whether or not
they're properly rested. You're right, we can't know exactly,
but I think it's a reasonable measure that most pilots are
professional. We can't implicate the whole community based on
this accident.
So, you're right. We need to find exactly what the sweet
spot for this issue is.
There is the ability for pilots to self-report, right now.
All the airlines have programs for pilot reporting, anonymous
reporting. They can then look at the results from that
reporting and begin to address those safety trends. I haven't
asked the airlines whether they're seeing a trend in reports
related to either commuting or fatigue, but we certainly can do
that. I think that's a wise thing to do.
The industry comes together twice a year to review their
general results on those safety reports, and we will ask them
at the next meeting to come in and report on what they are
seeing on the issues of commuting, and whether there's a trend
there. That would certainly be helpful.
Senator DeMint. OK, go ahead.
Senator Dorgan. Let me just--on that point--because the
entire system has changed so dramatically, with half the
flights now being regional carriers, isn't it just something
that we should assume, that when you've got somebody making
$20- or $22,000 a year flying across the country to get to
their duty station, that they're not going to have the money to
go out and get a hotel room? So, shouldn't we just assume that
there is probably a larger problem here, that is a growing
problem as you have more and more flights that are commuter
airline flights with lower-paid pilots?
Ms. Gilligan. Well----
Senator Dorgan. Shouldn't we assume that's a problem?
Ms. Gilligan. I think we certainly agree that it is a risk
area that we have to understand better. I completely agree with
that. I don't know how far most pilots commute. I don't know--
and perhaps we need to know that data. I agree with you, sir,
that that's something that we should be pursuing, certainly as
we're looking at our fatigue rule, to see whether and how we
can give better guidance on how both the pilots and the
operators can try to address this issue. I agree.
Senator DeMint. Mr. Chairman, I know you've got a line of
questioning. But, I would encourage you, just that--the power
of finding out the extent of the problem. I know the carriers,
they say the pilots can report. But, I think we should consider
the idea of asking all the carriers to get all of their pilots
to fill out some anonymous survey that helps us to create a
pattern of what's going on now, to seek pilots' advice on how
we could help.
The carriers have a different role to play than we do here.
Our job is strictly safety, and they have to run an airline,
they have to make a profit, they have to do a lot of things.
And I know safety's at the center of that for them, as well.
But, this is more than a carrier-to-carrier issue, and I would
just ask you to consider ways that we might collect information
and develop a clear assessment of the situation today to see
if--from the pilots and the carriers perspective, that there
may be a role that we play that can either limit this commuting
system or make it work in a way that's safer. Because, just
because the safety record is good does not mean the pilots are
rested. All of us have driven cars on long trips and wondered
how we ever got there, we were so tired. We made it, so we had
a safe outcome. But I think we need to take it a step further
here. And I really do think the Chairman's right, that we don't
know how widespread this is, I'm not sure we can fix the
problem, or--and neither can the carriers.
Senator Dorgan. Senator DeMint, thank you.
I think we're going to ask to have some kind of survey
done. We'll work together on that. Because I think we need to
understand, What is the dimension of the issue out there, and
the problem? It just seems logical to me that if we--if we've
got more low-paid people out there commuting across the
country--in this case, both people in the cockpit going through
the evening without having proper bed rest--I just--it's
unlikely, to me, that--it seems unlikely to me that this is the
only circumstance.
Maybe this has become a practice; that's the way you do
things. If it is, it has to stop. And----
Let me ask some questions about training, if I might. Ms.
Hersman, my understanding is that, in that cockpit that
evening, the stick shaker and the stick pusher both were
engaged at some point, right? And the--tell me your conclusion
about the pilots' acquaintance with, and response to, the stick
pusher.
Ms. Hersman. The stick pusher and the stick shaker are two
different things. Once the upset started, the stick shaker was
pretty much firing continuously, telling the pilot that they
needed to get some additional airspeed and get the nose of the
airplane down. The stick pusher actually takes action and
attempts to push the yoke forward to try to get the airplane's
nose down. It's the airplane almost trying to help itself. The
captain never pushed forward. Once the onset of the shaker
occurred, he continued to pull back, which is exactly the
opposite of what he had been trained to do in response to a
stick shaker. The stick shaker was giving him an approach-to-
stall indication. Pilots are trained on approach-to-stall, so
they should know how to respond when they get a shaker. This
pilot did not respond according to his training or give any
response that our investigators would have expected of him. The
first officer didn't recognize what was going on and intervene
or take any corrective action, such as calling ``stall,'' and
helping to push the yoke forward.
Senator Dorgan. But, I'm talking--did this pilot have
adequate training on--you know, look, in the first 10 hours of
instruction, when you want to get a pilot's license, you learn
what a stall is and how to recover from it. That's--I mean,
that's one of the most----
Ms. Hersman. Right.
Senator Dorgan.--basic things you learn when you learn to
fly an airplane. So, it's not--it's surprising to me--not
surprising to me, I guess, that in that airplane, when
something happened with the airspeed and that plane began to
stall, they got the stick shaker that was sounding warnings to
them, and so on. But, I--what I don't understand is, Did the
pilot have adequate training in both the mechanics of the
shaker and the pusher? And what's your conclusion of his
actions?
Ms. Hersman. We----
Senator Dorgan. And the training.
Ms. Hersman. We've made recommendations about upset
training in the past. We've reiterated some of those
recommendations.
There are two issues here that I want to make clear. The
pilot did get the required training. One of the things that we
found was that this pilot had multiple practical test failures,
some in scenarios similar to the accident scenario, in which he
did not respond appropriately. So, we made recommendations
about multiple test failures and remedial training. His
performance in the cockpit was somewhat consistent with his
previous performance on past tests.
However, we've also made recommendations about improving
training. We think that there's a lot of room for improvement
for training in upset situations. Pilots get trained on
approach-to-stall; they don't get trained in a full stall.
We've made recommendations that pilots need training in that
area. Simulator fidelity is improving. And we have recommended,
also, in the past, based on other accident investigations, that
pilots be exposed and trained to stick pusher. They are not
generally exposed to that. We asked Colgan's training pilots,
``When pilots were exposed to pusher, if they exposed them to
it, what did they do?'' And they said 75 percent of the pilots
in training who might have been exposed to pusher tried to
override it, as this pilot did, which was the wrong response.
We've made recommendations, in the past, to train pilots to
pusher. They're not trained that way now.
Senator Dorgan. Well, your recommendations say, ``Stick-
pusher training was not consistently provided to pilots of the
Q-400s, nor was it required by the FAA.''
Ms. Hersman. That's true. We've made recommendations that
they need to have that training; we found that they weren't
trained in this situation. They were trained to shaker, not to
pusher.
Senator Dorgan. Let me ask about the icing issue, if I
might, because you have some comments and some recommendations
on icing in your report. Can you describe them?
Ms. Hersman. Yes. In our investigation, we found that this
aircraft did go through icing conditions, it had accumulated
some ice, but it was well within its performance capabilities.
The ice, the pilots were aware of, and they had addressed it,
to some extent. They did make some mistakes. They didn't
correlate a switch and the landing speed that they needed to
do, which we found was a contributing factor. But, the aircraft
was certainly capable of performance in that ice and to fly out
of the stall that it was in. We did make some recommendations,
however, about information about icing, to make sure that
pilots are trained.
We also found that the dispatch materials that were
provided to the crew did not contain required information to
tell the crew what weather conditions they were facing. This
has been a concern in the past. We've made recommendations, in
this accident, to make sure the crew has full information. We
know that they were aware of the ice, so this wasn't a causal
issue in the accident, but it was an area that we identified as
a concern.
Senator Dorgan. When you talk about the dispatcher, is that
a dispatcher from this company?
Ms. Hersman. Yes. The dispatcher is a company dispatcher,
but they contracted for that weather information. They weren't
properly overseeing their contract to ensure that they had the
right materials in the information that they provided to their
pilots.
Senator Dorgan. And have you evaluated whether that is a
unique condition, again, to this particular carrier in this
circumstance, or is this something that may be a problem across
commuter carriers?
Ms. Hersman. It's something that could be a wider problem,
and that's why we made the recommendation to the FAA to look at
this issue and address it.
I will say that the Safety Board has had concerns in the
past. We've looked at other accidents where the materials that
the pilots were provided were not always helpful. They get
large packets. The information isn't always sorted for
priority. You don't want to have the icing alert on the 40th
page of the materials that you're being handed. We have looked
at this issue of information and how it's presented to the
pilots, in other accidents, including the Comair accident.
Senator Dorgan. So, this issue was contracted out by Colgan
to a contractor, and Colgan did not oversee the contractor
properly, you're saying?
Ms. Hersman. Yes.
Senator Dorgan. Has that been remedied?
Ms. Hersman. I would hope so, since it was brought to
Colgan's attention. But, what we found in the accident was that
it was not handled properly for this flight.
Senator Dorgan. Ms. Gilligan, when I ask, ``Has that been
remedied,'' the question is always, not ``What are the rules?''
but ``How are they enforced?'' So, do we know whether Colgan
has responded to that?
Ms. Gilligan. I don't know, sir. I'll certainly look into
whether they specifically have done so.
[The information referred to follows:]
To address concerns about provision of weather information to
flight crews, Colgan Air has updated its computer system and
streamlined its requirements for weather data packages. These packages,
which are part of the flight release given to the captain, include
departure, en route, and arrival weather.
As part of its overall surveillance of Colgan Air, the FAA is
monitoring the carrier's provision of weather data to flight crews.
Ms. Gilligan. But, it is common for airlines to acquire the
weather information that they need from official weather
providers. The airlines themselves don't collect their own
weather. And so, there's fairly common use of information
related to weather. We will look closely at the Board's
recommendation, to make sure that--either in the Colgan case,
in particular, or, as you suggest, that more broadly through
the system--that we don't have a risk here that has not been
addressed.
Senator Dorgan. Let me ask you some questions about the
issue of the major carriers and their relationship to, and
responsibility for, the regional carriers.
Ms. Hersman, as I understand it, the movement in the
industry toward regional carriers with smaller planes, in most
cases, and having the regional carrier carry the brand of the
major carrier, is a circumstance where they have a contractual
relationship. But, the major carrier, in most cases, does not
have responsibility for, or liability for, the regional
carrier. Is that correct? Do you know the circumstances of
that?
Ms. Hersman. I'm sorry, Mr. Chairman, can you----
Senator Dorgan. Well----
Ms. Hersman.--please restate your question?
Senator Dorgan. Yes, perhaps it was--as we've gone to
regional carriers--and the major trunk carriers have employed
the regional carriers to service part of their territory--is
that relationship between the major and the regional carrier
one in which the major carrier has liability for the actions of
the regional carrier? Or is it a--kind of an arm's-length
transaction, where the regional carrier is autonomous, although
it has the colors and the brand on the fuselage of the
airplane, it is not, in fact, part of, or is not the
responsibility of, or the--of the major carrier, for training
and many other things?
Ms. Hersman. I think that's a very complicated question,
because there is a business arrangement, clearly, that's an
arm's-length arrangement. But, then there are other
relationships. That is one of the reasons why the Safety Board
is holding a symposium later this year to really try to
understand the structure of those relationships, the
performance requirements that exist, and the support that might
be provided for those carriers.
They are separate entities. Colgan was a party
representative in the accident investigation, not Continental.
So, they are----
Senator Dorgan. Why is that----
Ms. Hersman.--clearly separate entities----
Senator Dorgan. Why is that the case? It was a
Continental--it was called a ``Continental'' flight, right? The
flight number----
Ms. Hersman. Yes.
Senator Dorgan.--was a Continental flight number.
Ms. Hersman. Because they are separate entities, and Colgan
is responsible, and they have control of the day-to-day
operations. We recognize that this is a very complex
relationship, and we want to understand it better, not just for
the oversight purposes, but for the aftermath of the accident.
Following an accident, generally the smaller carriers, such as
Colgan, don't have the resources to provide the support to the
families, and so the care teams usually come from the codeshare
partner, the larger partner. We've seen this in other
accidents. That's one of the reasons why we want to have our
symposium to identify these practices, the procedures, the best
practices, these relationships. For example, if there's a
requirement for the regional carrier to have an audit, would--
is that some--is that information that the mainline carrier
ought to have information about?
We found, in this accident investigation, that there were
two audits. There was an IATA-IOSA audit, where there were some
findings, and then there was a separate Department of Defense
audit of Colgan. Continental did not have that information.
Senator Dorgan. That also is stunning to me, because those
airplanes are flying with Continental's name on it. And it
seems to me that Continental--in this case, Continental; we
could be talking about any of the major carriers--will want to
understand everything about a carrier--a regional carrier that
is carrying the brand name of the major carrier.
My understanding is, both the FAA and NTSB are looking at
code sharing arrangements between the regionals and the majors.
So, what do you hope to determine from that effort? And what
is--what's the status at this point?
Ms. Hersman. We would be looking at the structures, the
present practices, and oversight of both domestic and
international codeshares. Certainly the FAA would be a part of
the work that we would do. This symposium is designed to give
us a better understanding of these relationships and to
identify best practices. If there's room for improvement,
that's what we want to focus on.
Ms. Gilligan. I believe you're aware that, as a part of the
Call to Action, the Administrator asked the airlines to commit
to work more closely with their regional partners, and that
effort has already begun. All of the majors who have codeshare
partners--and not all of them do--have begun having regular
meetings, generally quarterly meetings, to share the kinds of
audits that the Chairman refers to, to identify shared safety
risks, to share best practices.
It gets a little complicated, because there are several
regional carriers who provide support to more than one of the
mainlines. And what we don't want is to have different
mainlines creating different requirements for the same
operator. So, the next step now will be to make sure that we--
with FAA's participation--are refining what those expectations
are, so that the regional carrier has one set of shared
information.
But, this is very important. The Administrator saw that as
one of the first positive steps that he could initiate, and
that's already underway.
Senator Dorgan. Are there cases in which the regional
carrier is wholly owned by the major carrier and, therefore,
subject to identical requirements--training, and all the other
requirements--of the major carrier?
Ms. Gilligan. All the carriers are held to the same
standards, because as the Chairman points out, Colgan holds its
own certificate, issued by the FAA. We provide oversight--first
we determine that they meet the standard, we issue the
certificate, we provide oversight to Colgan with a team from
the FAA that is only assigned to Colgan. So, in that regard,
they're held to the same set of safety standards. There are
some regional carriers that are a part of the same corporate
structure as a mainline carrier. But, from an FAA safety
perspective, each certificateholder has its own responsibility
to demonstrate compliance with these standards and our
inspectors oversee each certificateholder.
Senator Dorgan. I understand that. I think I'm----
Ms. Gilligan. Oh.
Senator Dorgan. I'm asking about a slightly different
approach.
Ms. Gilligan. I'm sorry.
Senator Dorgan. The carriers--the major carriers themselves
have their own routine and their own procedures for training
and a range of other employee practices. And my question was,
Are there regional carriers that are wholly owned by the majors
and, therefore, subject to identical practices and procedures
of the major that it--that owns it?
Ms. Gilligan. I don't know, offhand. I can certainly find
out.
[The information referred to follows:]
Several ``regional'' air carriers are owned by holding companies
that also own ``major'' air carriers. Examples include American Eagle/
American Airlines (AMR Corporation) and Horizon Air/Alaska Airlines
(Alaska Air Group). Although these airlines are owned by a common
holding company, they are separate entities as certified by the FAA.
The FAA oversees each airline separately, with a separate certificate
management team for each one. These airlines may share common
practices, but they are not required to do so. In some cases, the
procedures developed for one airline may not be appropriate for the
other.
Ms. Gilligan. There is----
Senator Dorgan. American Eagle, for example.
Ms. Gilligan. Yes.
Senator Dorgan. Is that--would that not be a case?
Ms. Gilligan. Well, American Eagle has its own training
programs and its own set of simulators, and has demonstrated
that it meets all of our regulations on its own. But, I'll be
glad to look at, just, whether there is a sharing of some of
those training and other facilities. I'm just personally not
aware.
[The information referred to follows:]
Both American Airlines and American Eagle have independent training
programs, individually developed by the air carriers and individually
approved by separate FAA certificate management teams. Although the
simulators for American Airlines and American Eagle are co-located at
the same training facility, the air carriers do not use the same
training program, because the training programs are designed to meet an
individual carrier's specific operational needs and requirements.
Senator Dorgan. The larger question is--I have a list of
some of the regional carriers here--Shuttle America, Pinnacle,
Freedom, Chautauqua, Atlantic, Southeast, Colgan, ExpressJet
Chautauqua, Trans States, GoJet, Great Lakes, Mesa, SkyWest,
and the list goes on. Trans States. And the larger question
from all of this is, Is there now one level of safety in this
country, with the names of the carriers I have just read, as
compared to the trunk carriers--or the--I should--I don't know
that the--the word ``trunk carrier'' is a term of art these
days--but, the major carriers--and I think that describes a
group of carriers that are the larger carriers--is there one
level of safety? I think there's supposed to be, right, dating
back to the 1990s?
Ms. Hersman, do you think there is one level of safety?
And, Ms. Gilligan, do you?
Ms. Hersman. I think that all Part 121 carriers are
required to meet the same minimum standards.
Senator Dorgan. All right, I'll respond to that and ask
another question.
Ms. Gilligan, you?
Ms. Gilligan. It is accurate, as the Chairman has just
responded. There is one set of standards for anyone who
provides commercial transportation under Part 121 of our
regulations. Those standards must be demonstrated by anyone who
holds a certificate. FAA inspectors make the determination,
that carriers meet those standards, and oversee continued
compliance.
I think, Mr. Chairman, you are asking whether there are
different ways to demonstrate compliance with those standards?
And yes, there are. And some of those may well be more mature
than in other cases. There are some carriers that are quite
small. They meet the standards by demonstrating compliance
through logbooks and paper records. There are some that are
quite large and complex, and they have automated systems and
very mature safety risk analysis processes. That's accurate.
Within the system, there are some differences.
Senator Dorgan. Do you think the confluence of mistakes
that occurred in the cockpit, and even prior to entering the
cockpit of the Colgan flight that evening, would that
confluence of mistakes be able to be found in a major carrier's
cockpit, do you think? I mean----
Ms. Gilligan. I think----
Senator Dorgan.--we all know, now----
Ms. Gilligan.--to the extent----
Senator Dorgan.--that six or eight----
Ms. Gilligan. I'm sorry.
Senator Dorgan. Go ahead.
Ms. Gilligan. I think, to the extent that pilot performance
is implicated, the human in the loop in this case is a part of
our risk. People make mistakes. People demonstrate bad
judgment. And in this case, as the Board found, the primary
cause of this accident was personal and human failure. And so,
yes, I think those can occur on--because humans can make those
kinds of mistakes.
I think that we have provided the level of safety that we
have, by having a huge number of redundancies within the system
that allow us to trap those errors, most of the time, when they
occur.
I believe people are making mistakes as they operate
airplanes, but the airplane itself, or the second pilot, or the
training that comes to bear at the right moment, help trap
those errors and continue to maintain the level of safety that
we expect in the system.
Senator Dorgan. But, I--I'm thinking that it is almost
expected, given the way the system has developed, that we would
begin to see these mistakes. I mean, it just will not
surprise--it shouldn't surprise any of the three of us--that
two of the people who got in a cockpit that day to fly to
Buffalo, one hadn't slept in a bed for two nights, and the
other hadn't been in a bed the night before. Pretty weary,
pretty difficult time for them, I assume. And so, they make
mistakes in the cockpit. That's not surprising. You make
mistakes when you are either ill trained or when you are tired.
You make mistakes.
And I'm wondering if we--if you don't agree that we're
setting up a system here that is guaranteed to provide more and
more mistakes. Because, as I--it is not rocket science to
believe that a young woman who wants a career in aviation and
has--and is living out in--I think--perhaps living with her
parents out in Seattle, flying across the country at night to
get to the duty station, and not having a full night's rest,
is--I mean, it's not rocket science to believe that that
particular pilot is more prone to mistake. And if you don't get
a night's rest in a motel because you're being paid $20,000 a
year, again, it is not surprising that we see someone sitting
in a crew lounge all night. It's wrong, but not surprising.
And it's not surprising to me, I guess, that we don't know
anything about that subject. We just think, OK, we've got this
little telescope focused on one little spot. We know what we
know about that spot, and that's it. But, that is not it. This
goes way beyond that. And that's what I'm trying to--I'm trying
to understand how we get our arms around this.
I just think--I think this whole system has morphed into a
different kind of commercial airline service, and we're kidding
ourselves if we don't think some of the things that we've seen
with respect to this Colgan crash aren't happening today and
tonight.
Last night I was at an airport--late last night--and I saw
a young pilot walk off an airplane. And I thought--and I was
thinking about this hearing, because--- it was a young pilot--
I'm sure, somebody, you know, cares a lot about their career,
God bless them; I'm sure they feel, ``I'm glad I've got a
job.'' But, this person looked bone tired, dragging that bag
behind her. And I was just thinking about how little they are
paid, in many cases, sitting in the second seat in a regional
jet. And then we expect all the same things to exist, with
respect to the rules, as exist with somebody that's flying in a
757 Dulles-to-Los Angeles nonstop, being paid, you know,
$90,000 or whatever. And the fact is, those same circumstances
will not exist for that young pilot. And it's not unusual
that--it's shocking to me, but, again, probably not unusual
that we have found these confluence of mistakes that led to
this crash.
``Pilot error'' is a term that relates to so many other
issues leading up to those two people getting in that cockpit,
and then flying in ice, and then making very bad judgments
about how to control that airplane.
Well, I--again, I have some additional questions. I
appreciate your indulgence.
We're joined by Senator Thune.
Senator Thune?
STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
Senator Thune. Thank you, Mr. Chairman, for your focus on
this subject.
On the 1-year anniversary of this very tragic crash, we
continue to try and get answers, and continue to try and come
up with policies that we think make sense and that will prevent
anything like this from ever happening in the future. So, I
appreciate the focus and attention that you've placed on this,
and welcome our panel today to the Committee.
I want to follow up on an issue that I've been focused on
throughout the course of the hearings that we've had on this
subject, and it deals with the whole issue of pilot fatigue.
And I know that, in the report, it wasn't necessarily the
factor that was pointed to in this particular incident, but it
does seem to me that it's a broader issue with regard to the
whole debate about safety.
I'd be interested in hearing, from both of you, on how you
reconcile the industry and the FAA claim that pilot fatigue and
commuting need to be solely the responsibility of individual
pilots. It seems, to me at least, that the safety of the
passengers, both for regional carriers and large carriers,
should be the overriding factor, versus self-reporting. I think
it's somewhat alarming that roughly 70 percent of the Colgan
pilots based in Newark commute, and 20 percent of those pilots
commute from over 1,000 miles away. And so, it kind of comes
back to what Senator Dorgan was alluding to.
But, give me your perspective on that, because it seems
that the argument, that this ought to be solely the
responsibility of individual pilots, runs clearly in the face
of the testimony that I think we've had in hearings, and in
listening to different comments and observations about this
throughout the course of this debate.
Ms. Gilligan. Senator, we believe, as I think everyone
does, that this issue of commuting is quite complex, and
clearly one that we need to work within the industry to
understand and address. The dilemma is that there's no easy
solution. Someone can drive to National Airport from
Fredericksburg, and I don't think any of us would think that
was an unreasonable commute. But, it can run into several
hours. On the other hand, someone can fly from St. Louis to
National Airport and be there in an hour after having slept the
night at home, in their own bed, not in a motel. So, it's
complicated. If we could do it easily, we would have.
I do think you'll see, in the new rulemaking that we're
putting forward, that we are asking these kinds of hard
questions. What is the role of government in this kind of a
question? And beyond that, what can the airline and the
individual pilot be expected to do, and be held accountable to
do, to perform professionally? But, it is a very difficult
issue for the government, I believe, to take on, and we're
looking at how we could do that.
Ms. Hersman. Senator, I think the issue of fatigue is very
complicated. It's not just about commuting. It's about flight
and duty time; it's about a medical condition, such as sleep
apnea; it's about having good policies at a company, so that if
a pilot is fatigued, for whatever reason, they can call in and
be taken off duty, without punishment.
We've investigated accidents in the past where pilots have
gotten very little sleep the night before, because they had
insomnia or something else was going on, not because of their
schedule. They were nervous about calling in ``fatigued,''
because they were afraid they would lose their job. So, they
flew, they made bad decisions and they had an overrun on an icy
runway, they had gotten 1 hour of sleep in the past 30 for
example.
Commuting is only one part of this issue. That's why the
Safety Board issued our recommendation to the FAA following the
Colgan accident to address this commuting issue and to look at
scheduling practices. I think the challenge is to identify
whether a commute is appropriate or inappropriate. I've seen a
case where a pilot based in Hawaii, who lived in Florida. At
some point, there are things that go beyond what makes sense
for anyone to do.
I looked at that first officer in the Colgan accident,
flying on a red-eye flight from Seattle to Newark with a stop
in Memphis the night before the accident. I feel very
uncomfortable having to perform my job after I've taken a red-
eye flight, and I don't hold peoples' lives in my hand.
I think that probably all of us reasonably can say that
commuting is a challenge and it needs to be addressed. It's
going to take the cooperation of the FAA, the industry, and the
pilot's unions to try to address it.
Senator Thune. To the extent that you can, please comment
on your rulemaking. How does it address that?
Ms. Gilligan. I believe the Administrator previously shared
with this committee that, at this point, the rulemaking
advisory committee we put together, made up of pilots and the
airlines, did not make a recommendation in the area of
commuting. They believe that it is a pilot responsibility, and
that is the recommendation that they made to the Administrator.
We will seek additional input into that rulemaking, asking
for ideas, because, as the Chairman points out, we don't have a
ready solution to this. So, we are asking for comment, we are
asking for the insights from the industry, both the pilots and
the airlines, to see how we might go about addressing this in a
reasonable and professional way.
Senator Dorgan. Would the Senator yield on that, please?
Senator Thune. Yes.
Senator Dorgan. I believe there are some cargo companies
that have a ready solution for it, right? I mean, there are
cargo companies that have commuting pilots that pay for their
pilot's motel room when they show up for their duty station the
night before the flight. Is that not correct?
Ms. Gilligan. There is, I believe, one that does that.
There is also a cargo carrier that provides rest facilities, at
some of their locations, that are temperature controlled and
lighting controlled, and those kinds of things. So, there are
some options that have been implemented by some in the
industry. We want to understand those, and we want to see how
those might be able to be applied more broadly throughout the
industry.
Senator Thune. Well, it just seems like the example of a
pilot who lives in Hawaii and operates out of Florida--it--just
as a practical matter. Hopefully that's an outlier, but at some
point, it seems like practical considerations would come into
play here.
I understand there's a balance you have to strike, and
you've got to try and find what makes the most sense. Clearly,
common sense too, would seem to be a consideration here, but, I
think people push themselves, and they do things that they
probably shouldn't do and put themselves in situations where
they are fatigued. That's an issue that, I think, needs to be
addressed. I hope that the process that you're undertaking
right now can get at that, and perhaps use some of the ways in
which the cargo carriers are dealing with this issue as an
example of how to best address it.
But it seems to me, at least right now, that we've got a
problem, and it needs to be addressed.
Ms. Gilligan. We agree, sir. And I think, to the Chairman's
point, there is a role for everyone in this--the airline, the
pilot, and the government. And we're trying to understand those
roles and responsibilities--how to best describe those--so that
everyone holds each other accountable. The airline should be
determining that their crew is competent and ready to fly. The
individual pilot should be able to report if he or she is not.
The copilot or others on the crew should be ready to report if
they are concerned that there is a member of the crew who is
not ready to take that flight. So, there are roles and
responsibilities here for all of the parties.
Senator Thune. OK.
Thank you, Mr. Chairman.
Senator Dorgan. Let me--I'm going to ask about pilots'
qualifications and hours. But, first I want to ask about the
issue of pilot experience in icing.
You are aware that the second officer says that she had,
really, no experience with icing. Senator Thune and I--I've not
talked to Senator Thune about this, but I assume that he--as
have I, been in a lot of small planes, where we shine
flashlights on the wings to find out how much rime ice has
developed. In our part of the country, it is not unusual to fly
and have some icing as you go up or come down in a charter
flight.
But, this is a copilot who speaks about icing. She says,
``I have 1,600 hours,'' she says, ``I have 1,600 hours, all of
that in Phoenix. How much time do you think, actual, I had, or
any, in ice? I had more actual time on my first day of IOE than
I did in my 1,600 hours when I came here.'' And then she says,
``I've never seen icing conditions. I've never deiced. I've
never seen any--I've never experienced any of that. I don't
want to have to experience that and make those kind of calls.
You know, I freaked out. I'd have, like, seen this much ice and
thought, oh my gosh, we're going to crash.''
So, I want, Ms. Hersman, for you--the NTSB, I assume, has
analyzed this. What kind of icing experience did this copilot
have? And this is a plane--this is a dash-8 with, I assume, hot
props and boots on the wings--flying in the winter, in icing
conditions, in the Northeast. That's where this pilot was
assigned. And at least on the voice cockpit recorder, this
copilot is saying, ``I've never seen any of this, and have no
experience with it.''
Your investigation of that?
Ms. Hersman. Chairman Dorgan, when the first officer is
talking about that on the cockpit voice recorder, she's
reflecting back to when she first started at Colgan. She came
from Phoenix, and she had not had a lot of time in winter
weather conditions. She's talking to the captain, telling him,
``I got more time in my Initial Operating Experience in my
first days on the job at Colgan in ice than I'd had in my
entire career.'' And then she goes on to talk about captain
upgrades, that in the first year when she was with the company,
that a lot of people were upgrading to captain early, and that
she was glad that she didn't have to upgrade to captain early,
because she had not had a lot of experience in icing conditions
and she would not have wanted to make those decisions that you
reference. She's reflecting back, saying, ``If I had had to
operate in conditions like this in my first year, and upgrade
to captain, I would have been very uncomfortable.''
Since she was employed with Colgan, she did operate in
winter weather conditions, and she had accumulated over 2,200
hours. She did have exposure to winter weather conditions and
the kind of environment she was flying in the night of the
accident while she accumulated those additional hours at
Colgan.
But, I think your point is, is that----
Senator Dorgan. That may be the right----
Ms. Hersman.--when she first came----
Senator Dorgan. Yes, that----
Ms. Hersman.--that when she first came, she didn't have a
lot of experience. That's----
Ms. Gilligan. Right.
Senator Dorgan. That may be the right interpretation of her
second comment, I don't know.
Ms. Hersman. Yes.
Senator Dorgan. But, her first comment suggests that she
saw more ice in her first day than in her--flying in that
area--than her entire previous 1600 hours.
Ms. Hersman. Yes.
Senator Dorgan. So, you put someone with 1600 hours in a
cockpit and say, ``Go fly,'' and fly into ice--what she seems
to have been saying to the captain is, ``I was put out here
with almost no experience in icing.'' Is that what you hear?
Ms. Hersman. Yes. That's something that the Safety Board
has been concerned about. In the past, we have made
recommendations about training, certainly in the aircraft type
and in the conditions that a pilot is going to be exposed to.
In our investigation of the Montrose, Colorado, accident that
involved Dick Ebersol's family, we found, that the pilot and
the captain had a high number of hours but when we looked back
at his experience and found that in the previous 4 years even
though he'd flown about 18 times in the northern half of the
U.S.--he hadn't been in icing conditions.
There are definitely challenges about making sure that
people are prepared for the conditions that they're flying in,
and that's why it's important for the carrier, depending on
what environment they're operating in--it may be a challenging
airport, it may be challenging weather conditions--they need to
make sure that their crew is appropriately trained for those
conditions.
Ms. Gilligan. And sir, if I might just clarify. She did
receive training from Colgan in icing and what the
characteristics of the aircraft are, and how to respond to it.
In addition, the Initial Operating Experience is a regulatory
requirement. She must be paired with an experienced pilot or a
check airman for her Initial Operating Experience, for this
very purpose, to make sure the transfer of knowledge has
occurred. So, in those early flights she was accompanied by or
assigned to an experienced pilot who would have been evaluating
whether, in fact, she had had the proper transfer of knowledge
to be able----
Senator Dorgan. Could that happen with passengers in the
back of the plane?
Ms. Gilligan. It is with passengers, sir.
Senator Dorgan. See, I'm not----
Ms. Gilligan. It is her Initial Operating Experience.
Senator Dorgan. See, I'm not sure--I don't agree that the
first flight--the first experience you might have with icing
should be in a cockpit where you're carrying passengers.
Ms. Gilligan. Well, her training would have occurred in
simulator.
Senator Dorgan. I understand that, but I'm talking about
experience in the air. There's no--I've been in the simulator--
there's no ice in the simulator. I understand the value of a
simulator, and so on----
Ms. Gilligan. Right.
Senator Dorgan.--but actual experience flying through
icing, if--what you're saying is, they are trained, then put in
a cockpit in the second seat, and--but always the person in the
first seat has good experience. You know, this is their first
experience with icing--under the supervision of someone who has
been there, but what if something happens to the captain? The
purpose of the copilot is to take over, and this is their first
flight with--first experience in icing, and they've got
passengers in the back. I mean, I think that's--I don't know.
I----
Let me also ask a question, before I talk about pilot
qualifications. I'm looking at the transcript here, and--22,
13, 58--the last sound in this cockpit--minutes later, there is
still discussion about the career. And it relates to this
question of a sterile cockpit. What are the requirements with
respect to a sterile cockpit?
Ms. Gilligan?
Ms. Gilligan. The regulatory requirement is that they
should maintain sterile cockpit below 10,000 feet. And that
means that the exchange of information should be related only
to the operation of the aircraft so as to complete the approach
into the arriving airport.
Senator Dorgan. Let me ask about ATP license. Is it an ATP
``license''?
Ms. Gilligan. An Airline Transport Pilot certificate, yes,
sir.
Senator Dorgan. Certificate. ATP certificate.
Tell me about the ATP certificate, and what the requirement
is for its use. How does one achieve one?
Ms. Gilligan. The Airline Transport Pilot certificate is
the highest rating that FAA issues. It is accomplished after
someone goes through the steps of private pilot certificate,
instrument rating, and commercial pilot certificate. They often
get instructor certificates, as well. And at each level, from
private to commercial to airline transport pilot, we have
increasing requirements for both the number of hours of
experience as well as training and other kinds of experiential
learning, and those kinds of things.
Senator Dorgan. And what gross hour--are there any gross
number of hours----
Ms. Gilligan. Yes.
Senator Dorgan.--that are required to get an ATP?
Ms. Gilligan. Yes. It's a minimum 1500 hours.
Senator Dorgan. So, a minimum of 1500 hours. All right.
What is the requirement for a--the hiring of a captain or
someone in the right seat, a copilot, on the major carriers or
the commuter carriers?
Ms. Gilligan. The rules permit----
Senator Dorgan. Regional carriers.
Ms. Gilligan. The rules permit anyone with a commercial
pilot certificate to be able to be compensated for flying. So,
anyone with a commercial pilot certificate is eligible to be
hired into commercial service. For a commercial pilot
certificate, a minimum of 250 hours is required.
Senator Dorgan. And what is the common purpose of, and the
requirement for, an ATP license, then? In other words, if you--
you can fly a charter flight or get hired by a regional airline
or a major carrier with, let's say, 300 hours.
Ms. Gilligan. Right.
Senator Dorgan. What is the function of, and the purpose
of, an ATP?
Ms. Gilligan. To serve as pilot in command in that
operation, you must have an Airline Transport Pilot
certificate. The purpose of that was to assure that there would
be pilot-in-command responsibilities assigned to someone who
has demonstrated the ability to take on that additional
responsibility.
Senator Dorgan. Is that true for all of commercial
airline--is that true for all of the flights that exist on a
commercial airline? The pilot in command must have the 1500
hours and the ATP license?
Ms. Gilligan. For all scheduled----
Senator Dorgan. Or certificate, rather?
Ms. Gilligan. For all scheduled passenger carriage, yes,
that's correct.
Senator Dorgan. So, everyone in a left seat for all
scheduled--Senator Thune, did you have any other questions? I
wanted to make sure you--all right.
So, it is true, for all scheduled commercial flights, that
the person sitting in the left seat will have an ATP?
Ms. Gilligan. Yes, sir.
Senator Dorgan. And have a minimum of 1500 hours.
Ms. Gilligan. Yes, sir.
Senator Dorgan. All right. And what is the requirement,
generally speaking, for the person in the right seat?
Ms. Gilligan. Again, that pilot may have a commercial pilot
certificate. Airlines can set different requirements. But, by
regulation, in order to be paid, you must have at least a
commercial pilot certificate.
Senator Dorgan. And that's the 250 hours.
Ms. Gilligan. 250 hours minimum.
Senator Dorgan. And you say different airlines set
different requirements. Can you tell me about some of those
carriers and requirements? Are there some carriers that say
that everyone who steps in a cockpit of ours should have an
ATP?
Ms. Gilligan. I'm not familiar with any that have that
requirement, but carriers set their requirements based on what
their hiring pool permits. And so, many of the carriers require
more experience than what the regulation permits. And pilot----
Senator Dorgan. Ms. Hersman----
Ms. Gilligan. I'm sorry?
Senator Dorgan. Go ahead.
Ms. Gilligan. No, I'm just saying, pilots build that
experience through flight instruction or other commercial kind
of operation, whether it's spraying crops or doing some charter
work, as you suggest. They build additional time, beyond the
250 hours, for the purposes of being hired into those
commercial positions.
Senator Dorgan. Ms. Hersman, do you want to comment on the
issue of ATP license and the practice of requiring only a
commercial license for the right seat? Has that played a role,
in your judgment, in anything that you have investigated?
Ms. Hersman. The Safety Board investigated events in which
things went wrong, and so, we don't always have a control group
about what went right. We've investigated accidents where we've
seen very high-time pilots, and we've also investigated
accidents where we've seen low-time pilots.
We don't have any recommendations about the appropriate
number of hours for different categories. We see that they do
have different standards. As Ms. Gilligan referenced, some
might use 250, some may have higher standards, require 600
hours, 800, 1,000.
We do know that there is a correlation, from our accident
investigations and some studies we've done, between individuals
who fail practical flight tests, and their potential likelihood
to be involved in an accident later, but we don't have any data
supporting the number of hours for a certificate, or its
correlation with being involved in an accident.
Senator Dorgan. Would that data be useful? You don't have
it just because you don't have it, or you don't have it because
you've never felt the need to go look for it, or--I mean, I
guess I'm asking the question, Is there something here we
should know? And I don't know the answer to it.
But, it does seem to me that someone with 250 hours is--has
dramatically less experience than someone with 4,000 hours. And
someone with 250 hours has substantially less experience than
someone with 1,500 hours. And the question, I suppose, is--and
I don't know the answer--is, If there is a regional carrier out
there that is hiring someone, for the right seat, who has a 280
hours, received a commercial license, has the capability to be
hired, because--meets the minimum requirement--is--what does
that airline do, then, to further prepare that pilot? Or is
that pilot put in the right seat and able to fly around with
passengers in the back, and gain experience by sitting next to
a skilled captain?
So, Ms. Gilligan----
Ms. Gilligan. Right.
Senator Dorgan.--can you tell us your impression of what's
happening----
Ms. Gilligan. Our----
Senator Dorgan.--in the real world?
Ms. Gilligan. Yes, sir. Our impression is quite clear, that
we are concerned as to whether or not those are sufficient
criteria. That's why the Administrator had us already issue an
Advance Notice of Proposed Rulemaking, asking those----
Senator Dorgan. Right.
Ms. Gilligan.--particular questions. Should there be a
difference in hours? Should there be a different kind of
certification for a commercial pilot who is operating in Part
121 passenger-carrying service. It may well be a gap. We'll see
what the response is to our rulemaking, and we will take
appropriate action, because it is an area of concern to all of
us.
Senator Dorgan. And that rulemaking is welcomed by the
Congress. But, you know, as we all understand, the rulemaking
process takes too long, it's difficult, it's--you know, we've--
Administrator Babbitt was here--has been here twice--and I know
they had set, originally, a--on--I think it was on the fatigue
issue--the December timeline, and that is now, I believe,
March.
Can you tell us what the new timeline is on the work you're
doing in that area?
Ms. Gilligan. That rule is in executive review with the
Department of Transportation. After that, we will also consult
with the Office of Management and Budget. But, we have a
package that is, we believe, complete, and as soon as that is
through executive review, we'll publish that for comment.
Senator Dorgan. And--but, that includes--it has--you'll
publish for comment----
Ms. Gilligan. Yes, sir.
Senator Dorgan.--after OMB passes on it?
Ms. Gilligan. Yes, sir. It'll go out for public comment in
the standard process.
Senator Dorgan. Yes. Well, that's a--I mean, OMB is--as you
know, is a major problem, because things go into OMB that no
human being ever sees again.
Ms. Gilligan. The Administrator is quite dedicated to this
project. I'm certain that----
Senator Dorgan. Right.
Ms. Gilligan.--we'll see this project.
Senator Dorgan. All right. I mean, I think there's an
urgency here that needs to be reflected in the actions of the
FAA. I appreciate that--new administrator. I think he is taking
some action that has not previously been taken. But I--I do
think there's an urgency on the fatigue issue, there's an
urgency on the issue of qualifications. We need to get at this.
And my own view of this tragedy is, I think it's very
unlikely that we are seeing a series of about eight--eight
significant problems that existed on this flight, that is
unique only to this flight. I think that's very unlikely. I
think we would be very unwise if we didn't understand the
consequences of these actions, the consequences of pilots that
are flying without enough rest. It's very serious. That's what
relates to pilot error. The consequences of the lack of
adequate training or the consequences of the lack of adequate
credentials and, you know, the consequences of not having
liability existing between those who have rented their name out
to a regional carrier. You know, all of these things together--
and there are more, but it--there are just so many of them that
have come to the front here on this issue that it just
literally demands that we say, ``You know what? Things have
changed dramatically in the commercial aviation sector, and we
have to make changes to respond to it.''
If you go back three decades, there were not many regional
carriers at all. Just--I mean, we--you know, and my State's a
good example. We basically had the major carriers coming in and
picking people up in a hub-and-spoke system, taking them to a
hub, and moving out of the hub. That's just the way it all
worked. That has morphed into something that is completely
different.
We now have the same major carriers' brands and colors and
logos on different airplanes run by different companies--
smaller companies and younger companies, newer companies. And I
think this--the question of whether there is one level of
safety is a question that is fairly easily answered these days.
The answer is no. We're not quite measuring up with the same
level of safety with this new area of regional carriers.
I'm not saying they are unsafe as a group, but I am saying
I think that people that get into airplanes, where, in the
cockpit, there is dramatically less experience than they are--
they would have, getting onto an airplane on a 757 flying
Dulles to Los Angeles--it just makes sense for us to
understand, if you're getting into an airplane where someone in
the cockpit's being paid $18- or $20,000 a year, they are going
to be somebody with substantially less experience, as well, as
opposed to the kind of pilots you would expect in other
circumstances.
So, I think all of these things together tell us that we'd
better get moving here and understand that things have changed
in this industry, and we need to understand the implications of
those changes, and respond to those implications.
And I'm not--again, you know, I don't want to scare people.
I think we have a circumstance of safety that is admirable.
This is an industry that has a pretty remarkable safety record.
But, that record is of no consolation to those who lose loved
ones in a tragic accident that should not have happened, and
could have and should have been prevented.
So, let me say, Ms. Hersman, I've really appreciated and--
more than ever--the work of the NTSB. I've watched NTSB folks
come on television and explain things in the news cycle and--
haven't paid as much attention as I should have to the way the
NTSB works, and the work that is done there. I appreciate your
work. These 300 pages, I hope, is now a clarion call to
substantial change, and is the roadmap to making those changes.
And, Ms. Gilligan, again, I'm going to be appreciative of
Administrator Babbitt, but, in the weeks and months ahead,
unbelievably nettlesome about wanting to make sure we get
things done on time. You've--and let me help you with OMB, if I
can. They're very fond of me.
[Laughter.]
Senator Dorgan. And I do know that it's difficult to get
things through OMB, but it's even been more difficult in the
past to get something out of the FAA, so with a new
administrator and a new approach, I want the FAA to work, I
want our government to work, and I want Ms. Hersman's most-
wanted list not to be ignored. I want them to be implemented,
and implemented post haste.
Let me thank both of you for spending part of your morning
with us. And this discussion will continue throughout this year
as we try to see if we can implement some changes that will
provide an added margin of safety in our commercial airline
sector.
This hearing's adjourned.
[Whereupon, at 11:06 a.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement of Hon. Frank R. Lautenberg,
U.S. Senator from New Jersey
One year ago, after taking off from Newark Liberty International
Airport, Colgan Flight 3407 crashed outside Buffalo, taking the lives
of 50 people.
The crash was a horrible and deadly reminder that we have more work
to do to make sure that when passengers board a commercial aircraft,
they have pilots that are well rested, well trained, and ready for any
task that is put before them.
Whether passengers are flying a regional carrier from state to
state or a major carrier from continent to continent, planes must be
equally safe and the crews should be performing at an equally high
standard.
That means we need to have--and enforce--consistent safety and
training standards across the board. Tragically, that was not the case
with Colgan Flight 3407.
The National Transportation Safety Board has concluded its
investigation of the Colgan Flight 3407 crash. In its findings, the
NTSB revealed that the aircraft's pilots were ill-trained and
unprepared to meet the demands of their mission, as well as possibly
too fatigued to fly.
Pilot fatigue is not a new issue. The NTSB first called on the FAA
to update the flight and duty time rules for pilots in 1990 and has
renewed that call in the wake of this deadly crash. The current FAA
flight and duty rules have not been updated for over fifty years. I
urge FAA Administrator Babbitt to put in place a rule that is
scientifically-based and takes into consideration the demands facing
today's pilots.
Furthermore, all airlines--regional and mainline carriers alike--
have a responsibility to ensure that all of their pilots are trained
and ready to take the controls before they step on-board any aircraft.
And all airlines must guarantee that every pilot is not only trained to
complete their mission, but also getting enough pay and rest. There are
far too many examples of pilots stretched beyond their capabilities
because of inadequate rest and compensation.
The millions of passengers that fly everyday deserve an efficient,
comprehensive transportation network where safety comes first.
Our aviation system is safe, but the tragedy of Colgan Air Flight
3407 serves as a stark reminder that we cannot be complacent when it
comes to our aviation safety.
You can be sure that I, and this committee, will continue to work
to keep our aviation system the safest in the world.
Thank you.
______
National Transportation Safety Board--Office of the
Chairman
Washington, DC, April 6, 2010
Hon. Byron L. Dorgan, Chairman,
Hon. Jim DeMint, Ranking Member,
Subcommittee on Aviation Operations, Safety, and Security,
Committee on Commerce, Science, and Transportation,
U.S. Senate
Washington, DC.
Dear Chairman Dorgan and Ranking Member DeMint:
Thank you for providing the transcript of the hearing of the
Subcommittee of February 25, 2010, on the crash of Colgan Air Flight
3407 for review and correction. Although most of the corrections are
minor, I would like to take this opportunity to draw your attention to
a substantial correction of the record.
During the question and answer portion of the hearing, I stated
that Colgan Air did not share the findings and recommendations of the
International Air Transport Association (IATA) and the Department of
Defense (DOD) safety audits with its code-share partner, Continental
Airlines. Following the hearing, it was brought to my attention that I
misspoke on this particular point.
In fact, Colgan Air did share the IATA and DOD audits with
Continental Airlines. However, the audit information was not shared
with the Federal Aviation Administration. In his statement provided to
our investigators, the principal operations inspector for Colgan Air
stated that the FAA did not get copies of these audits. We noted this
directly in our report where we stated that ``the Colgan POI stated
that he was aware of these audits but did not get a copy of the
reports, which prevented him from having a comprehensive understanding
of the reports' findings.'' \1\
---------------------------------------------------------------------------
\1\ ``Loss of Control on Approach, Colgan Air, Inc, Operating as
Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ,
Clarence Center, New York, February 12, 2009,'' Accident Report of the
National Transportation Safety Board, NTSB/AAR-10/01, at page 137.
---------------------------------------------------------------------------
I regret my error regarding who received copies of the audits and
appreciate the opportunity to correct the record.
Sincerely,
Deborah A.P. Hersman,
Chairman.
______
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to
Hon. Deborah A.P. Hersman
Question 1. The First Officer of Colgan Flight 3407 earned a base
salary of around $20,000. The salary of Captain Sullenberger, the
veteran pilot of U.S. Airways Flight 1549, also known as the ``Miracle
on the Hudson,'' was cut 40 percent in recent years, forcing him to
take a second job. Given all of the responsibilities that commercial
pilots shoulder, do you consider low pilot pay a safety issue?
Answer. The NTSB has not systematically studied whether pilot pay
is a safety issue. Historically, accidents and incidents have not been
limited to pilots new to the industry earning entry level wages. The
NTSB is concerned that cost of living at some bases can affect a
pilot's ability to live nearby or identify suitable accommodations. The
NTSB discussed this issue in its Colgan Flight 3407 report and issued a
recommendation. Specifically, recommendation A-10-16 asks the FAA to
address fatigue risks associated with commuting, including identifying
pilots who commute, establishing policy and guidance to mitigate
fatigue risks for commuting pilots, using scheduling practices to
minimize opportunities for fatigue in commuting pilots, and developing
or identifying rest facilities for commuting pilots. However, it is
important to note that although their wages were different, the pilots
for both the Colgan and the U.S. Airways accidents were commuters.
Therefore, low pilot pay is not the only driver of the safety issue
addressed (commuting) in the NTSB's recommendation. The extent to which
pay affects other aspects of pilot performance has not been determined
in our investigations.
Question 2. Regional airlines operate half of all domestic
departures and move more than 160 million of our Nation's passengers
each year. If we are to have one level of safety for both regional and
major network carriers, shouldn't the pilots of regional carriers be
trained and compensated at the same level as pilots for major network
carriers, particularly if they are flying identical routes?
Answer. In 1997, the FAA required what were then known as commuter
airlines to conform to the certification standards of 14 CFR Part 121,
which applies to major airlines, and to thereby achieve one level of
safety throughout the airline industry. The Colgan investigation
revealed low levels of pilot experience, inadequate training records,
non-existent remedial programs, and immature safety programs as well as
strained FAA oversight resources at that airline. Even though airlines
are now regulated to the same minimum standards, it appears that not
all airlines are equal. The NTSB will examine code share safety
standards later this year in a symposium. As to compensation at
regional carriers, bargaining methods between pilots and companies are
long established and outside the scope of our investigation.
Question 3. One airline has a program where pilots that commute
long distances to their duty station are provided with free air travel,
as well as hotel accommodations at their assigned station. This is in
stark contrast to the First Officer of Colgan Flight 3407, who had to
commute from Seattle to Newark flying stand-by on a ``red-eye'' flight.
In the wake of the Colgan crash and other fatigue-related incidents,
what should airlines be doing to provide a stable, predictable commute
and proper accommodations for their pilots?
Answer. The NTSB believes that airlines need to take action to
identify and understand the extent to which commuting affects the
safety of their operation. In its report on the Colgan Flight 3407
accident, the NTSB issued Safety Recommendation A-10-16 which asked the
FAA to ``address fatigue risks associated with commuting, including
identifying pilots who commute, establishing policy and guidance to
mitigate fatigue risks for commuting pilots, using scheduling practices
to minimize opportunities for fatigue in commuting pilots, and
developing or identifying rest facilities for commuting pilots.''
Question 4. The Captain of Flight 3407 failed five proficiency
tests before he was hired--a fact he never disclosed to Colgan. At what
point should the FAA revoke a pilot's license for failing proficiency
or training tests?
Answer. Certificate revocation is a punitive enforcement action
which is not appropriate for training failures. However, the NTSB
believes that complete disclosure of a pilot's certificate history and
any prior training problems is an essential part of the commercial
pilot employment process. In addition, air carriers and commercial
operators must maintain detailed, accurate training records and must
proactively address pilot proficiency issues as they occur, and the FAA
must aggressively police such issues.
______
Response to Written Questions Submitted by Hon. John D. Rockefeller IV
to Margaret Gilligan
Question 1. The problems experienced with the FTI programs--
specifically outages in key components of the FAA's communication
systems--raises concerns about the agency's ability to implement large
modernization projects in a timely and cost-effective manner. What
steps are you taking to ensure the FAA has the capacity to effectively
manage the modernization programs in cost-effective manner?
Answer. We agree that Air Traffic Control modernization programs
require proper management and oversight to ensure success. Over the
years, the agency has taken major steps to ensure that modernization is
managed in an effective manner and we have successfully fielded
multiple new systems into operation throughout the country, including
new air traffic displays, runway safety systems, and weather processing
systems. In addition, we have met our cost and schedule goals for
modernization programs for the past 5 years.
In January 2009, the Government Accountability Office (GAO)
recognized the major improvement in FAA's management of Air Traffic
Control Modernization and removed the FAA from the GAO's High Risk
List.
In removing the FAA from the High Risk List, the GAO determined
that the FAA had addressed weaknesses in managing modernization and
that FAA executives, managers, and staff had demonstrated a strong
commitment to--and a capacity for--resolving risks. The GAO recognized
the FAA for: (1) improved management capabilities on major projects;
(2) development of an enterprise architecture--a blueprint of the
agency's current and target operations and infrastructure; (3)
implementation of cost estimating methodology and a cost accounting
system; (4) implementation of a comprehensive investment management
process; and (5) assessment of human capital challenges and plans to
address critical staff shortages.
Question 2. Do you have the personnel with the expertise to manage
these complex modernization projects?
Answer. Yes. In fact, the FAA requires program managers for major
acquisition programs to be certified program managers, which means they
have the education, training, experience and demonstrated competencies
to manage complex systems acquisition. FAA's certification standards
exceed the Federal Acquisition Certification for Program and Project
managers.
Additionally, the FAA began publishing the Acquisition Workforce
Plan in 2009. This plan is updated annually and focuses on the
technical and acquisition workforce that is engaged in the design and
development of mission critical National Airspace System (NAS) systems,
including program managers, engineers/system engineers, business and
financial analysts, contracting officers and specialists; Contracting
Officer's Technical Representatives (COTRs); and other specialized
support disciplines. The Acquisition Workforce Plan serves as FAA's
guide for workforce hiring and development, to ensure FAA maintains the
staffing and skills needed to successfully manage complex modernization
projects.
The FAA has also recently taken the following actions to strengthen
the management skills of FAA acquisition personnel and meet the
challenges of complex modernization programs:
Established the Acquisition Career Management (ACM) Group to
institutionalize these efforts. For example, the ACM monitors
the Agency's overall certification compliance.
Strengthened the overall governance of the Acquisition
Workforce and the management practices by establishing both an
Acquisition Workforce Council (AWC) and an Acquisition
Executive Board (AEB). The AWC provides oversight for the
development and implementation of acquisition workforce
development strategies and the AEB oversees the complete
institutionalization of acquisition management practices. The
two entities work closely to ensure the FAA meets its
objectives for establishing and maintaining a well-trained
acquisition workforce.
Building the skills and talents of its Acquisition Workforce
through career management programs for contracting officers,
COTRs, Program Managers, Systems Engineering, Systems Test and
Evaluation, Cost Estimating, and Procurement Attorneys. The
programs define competency requirements for each role and
related curricula and training to support skills and competency
development. FAA policy requires certification for acquisition
program managers, Contracting Officers, and COTRs.
Strengthening practices used to develop and implement
acquisition programs with the introduction of Acquisition
Management Practices toolkits that were developed by FAA
subject matter experts and are based upon industry best
practices. They contain practical guidance for implementing the
FAA's Acquisition Management System (AMS).
Question 3. The recent Northwest Airlines flight that overflew
Minneapolis was quite alarming. The hand-off of the plane between air
traffic controllers raises questions about procedures that (are) in
place to track aircraft as they transit the national airspace. What
steps is the FAA taking to make certain that hand-offs between
controllers do not delay responses to potential problems with aircraft?
Answer. The FAA's investigation of the incident involving Northwest
Airlines flight 188 (NWA 188) resulted in several recommendations to
improve awareness, communications and internal notification procedures
to the FAA's domestic event network (DEN). A workgroup, including
representatives from the FAA and National Air Traffic Controller
Association (NATCA) was formed to implement those recommendations.
The workgroup developed changes to FAA orders to require that the
communication status of aircraft be included in the information
exchanged when responsibility transfers from controller to controller.
FAA orders are also being amended to require the usage of available
methods to provide a visual indication to controllers of the
communication status of an aircraft. The revised orders are currently
in coordination and will be effective in the third quarter of FY 2010.
In addition, training was developed based on the NWA 188 incident
highlighting radio communication status and notification procedures
when communication is lost. This training was implemented in February
2010.
The FAA is researching the feasibility and options for providing a
visual indication of the communication status of aircraft to controller
displays. We expect to complete the research by September 30, 2010.
______
Response to Written Question Submitted by Hon. Byron Dorgan to
Margaret Gilligan
Question. Administrator Babbitt's Call to Action took a number of
important first steps to address the safety risks that came to light as
a result of the crash of Flight 3407. The DOT IG, however, recently
noted that many of the Call to Action initiatives have fallen behind
the FAA's self-imposed deadlines. Further, the DOT IG has criticized
the FAA for failing to impose clear deadlines or milestones for the
implementation of the voluntary programs by air carriers and labor
unions. What is the FAA currently doing to make certain that the Call
to Action initiatives do not fall behind schedule and are implemented
in the near future?
Answer. We have already completed a number of the initiatives
developed through the Call to Action meetings. Specifically, the FAA
has completed a two-part focused review of air carrier flight
crewmember training, qualification and management practices. The FAA
inspected 85 air carriers to determine if they had systems to provide
remedial training for pilots. Based on the information from these
inspections, the FAA has finalized a Safety Alert for Operators (SAFO)
with guidance material on how to conduct a comprehensive training
program review in the context of a safety management system (SMS) and
publication of this SAFO is imminent. A complementary Notice to FAA
inspectors will provide guidance on how to conduct surveillance.
We have also obtained commitments from air carriers and pilot
employee organizations for voluntary implementation of best practices.
With respect to voluntary programs such as Flight Operations Quality
Assurance (FOQA) and Aviation Safety Action Programs (ASAP), the Call
to Action has encouraged greater participation. Since we launched the
Call to Action initiative, the FAA has approved 12 new FOQA programs.
Three air carriers that had no ASAP program have now established them.
Four more air carriers have established new ASAP programs for
additional employee groups.
Since the issuance of the final report on the Call to Action, we
have also published an ANPRM seeking recommendations from the public on
enhanced certification and training requirements for pilots who fly
passenger aircraft. In addition, the FAA has continued to consult with
pilot employee organizations on practical ways to facilitate transfer
of experience, or mentoring, in a structured way. We have also
completed a survey to follow up on the results of our focused
inspection initiative. This survey revealed additional improvement in
the number of carriers who have remedial training programs. At the
beginning of our efforts, 15 carriers had partial remedial training
programs and 8 had none, but as of last week, 93 of the 95 carriers
with active certificates have complete remedial training programs and
the remaining two have partial programs.
To ensure that we continue to follow through on the Call to Action
initiatives, we have very aggressive time frames for the two rulemaking
projects. The draft Notice of Proposed Rulemaking on Flight Duty and
Rest is currently in executive review. Although we have not met our
target timeline, this rule is being developed on an extremely expedited
schedule with the utmost commitment from the rulemaking team.
Similarly, the supplemental NPRM on crew training requirements has been
drafted and is in the review process.
______
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to
Margaret Gilligan
Question 1. The First Officer of Colgan Flight 3407 earned a base
salary of around $20,000. The salary of Captain Sullenberger, the
veteran pilot of U.S. Airways Flight 1549, also known as the ``Miracle
on the Hudson,'' was cut 40 percent in recent years, forcing him to
take a second job. Given all of the responsibilities that commercial
pilots shoulder, do you consider low pilot pay a safety issue?
Answer. The FAA's role is to set the standard that pilots must meet
in order to fly for a commercial air carrier. Although we do not
presently have data regarding a correlation between aviation safety and
pilot pay, on October 16, 2009, the Department of Transportation,
Office of Inspector General (OIG) announced that it planned to begin a
review to identify and assess trends in commercial aviation accidents
including correlations between pilot experience and compensation. We
look forward to the OIG's findings and will review the results of this
audit.
Question 2. Regional airlines operate half of all domestic
departures and move more than 160 million of our Nation's passengers
each year. If we are to have one level of safety for both regional and
major network carriers, shouldn't the pilots of regional carriers be
trained and compensated at the same level as pilots for major network
carriers, particularly if they are flying identical routes?
Answer. The FAA holds all airmen certificated at the commercial
pilot level and all airmen certificated at the airline transport pilot
level to the same regulatory standards whether they work for a regional
or a mainline carrier. As discussed in the response to question five,
although we do not presently have data regarding a correlation between
aviation safety and pilot pay, on October 16, 2009, the Department of
Transportation, Office of Inspector General (OIG) announced that it
planned to begin a review to identify and assess trends in commercial
aviation accidents including correlations between pilot experience and
compensation. We look forward to the OIG's findings and will review the
results of this audit.
Question 3. One airline has a program where pilots that commute
long distances to their duty station are provided with free air travel,
as well as hotel accommodations at their assigned station. This is in
stark contrast to the First Officer of Colgan Flight 3407, who had to
commute from Seattle to Newark flying stand-by on a ``red-eye'' flight.
In the wake of the Colgan crash and other fatigue-related incidents,
what should airlines be doing to provide a stable, predictable commute
and proper accommodations for their pilots?
Answer. Each air carrier has a responsibility to establish
commuting policies and guidelines appropriate to its individual
operational environment. However, the greater issue at hand is that of
professionalism. As supported by the Aviation Rulemaking Committee
(ARC), which provided recommendations on how the U.S. should modify its
existing fatigue rules, each air carrier is responsible for ensuring
that it does not use a fatigued crewmember. Likewise, crewmembers have
a professional responsibility to use a rest opportunity for sleep, and
to be fit for duty.
Question 4. The Captain of Flight 3407 failed five proficiency
tests before he was hired--a fact he never disclosed to Colgan. At what
point should the FAA revoke a pilot's license for failing proficiency
or training tests?
Answer. The captain of Flight 3407 was disapproved on three flight
checks prior to his employment with Colgan (initial check rides for
instrument rating, commercial single-engine land, and commercial multi-
engine land). He was also disapproved on his initial check ride for an
airline transport pilot certificate while employed by Colgan. Colgan
training records show that, during his service as a first officer, the
captain needed additional training on certain procedures in the Saab-
340 aircraft he was flying at the time.
The FAA does not revoke pilot certificates for failure of
proficiency checks or training events. Given the number of training and
checking events that occur during the course of a normal professional
flying career, one or more check ride failures is not in and of itself
a reason to revoke a pilot's certificate. However, the FAA has
encouraged airlines to conduct a full review of a pilot applicant's
records in order to make an informed decision. The FAA also encourages
airlines to make a trend analysis on failure elements. The repetitive
failure of a single crewmember, or the failure of several crewmembers
during proficiency or competency checks, may indicate a training
program deficiency.