tv Key Capitol Hill Hearings CSPAN August 30, 2016 7:26pm-8:01pm EDT
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join us thursday night at 8:00 eastern on c-span for congress this fall. national transportation safety board chair christopher hart is concerned on automatic pilot. he recently spoke here in washington. afterwards he took questions on a variety of safety topics, most of them from pilots and former pilots. this is about half an hour. >> i am just absolutely thrilled about the next speaker. he is extremely well-versed in the motto schedule with safety. i know you all know that's our motto. he has spent most of his career focused on transportation safety and today chris hart is the chairman of the national transportation safety board, a position he's held for over two
years now. he's actually served on the board twice, this stint since 2009 and back in the early '90s before moving on to the national highway traffic safety administration. chris is very familiar with aviation. he's a licensed pilot with commercial, mumt engine and instrument ratings and his family has a tradition of accomplishment in the field as well. in 1926 his great uncle, james herman manning, became the first african-american pilot to receive his pilot's license by the united states government. yep. [ applause ] please, a warm welcome for chairman chris hart. [ applause ] >> good afternoon. thank you for that kind introduction. it's an honor and privilege to
be here. i warned the captain that their number one danger of getting me up here is getting me to shut up because i'm an attorney. and my credo is never use one word when two will suffice. i'll do my very best. thank you for that kind introduction and for inviting me to speak on behalf of the ntsb. most of you know that the ntsb investigates accidents in, determines what caused the accidents and make recommendations to prevent the accidents from happening again. my remarks today come from the context of what we see as accident investigators. i want to talk to you today about automation. the good news is there's more automation. the bad news is there's more automation. airline pilots have a long history of transitioning to more an more automated operations. in fact according to a 2015 article in the "the new york times," boeing 777 pilots reported that they spent just
seven minutes manually piloting their flights in a normal flight and airbus pilots spent half that time. it can improve safety, reliability, productivity and efficiency but the problem is there is also a downside. all of you know first hand that automation is more pref lent in flight operations yet human pilots are still crucial to the process. to determine why that is, it's instructive to explore the theory of full automation and the present state of automation. completely manual automation is unambiguous. in both instances it's very clear who is in charge. when the automation is combined with human operators, it's not always so clear who is in charge and that's where things can get complicated. the theory of automation in the flight deck is if there's no pilot, there will be no pilot ar error. removing the pilot address four
issues on the ntsb's most wanted list, fatigue, distraction, impairment and medical fitness for duty. but this theory of removing pilot error by removing the pilot has several defects. the first defect is assuming that the automation is working by design. what if it fails. will be fail in a way that's safe? will it inform the pilot of the failure in a timely manner and will the pilot be able take control. the fatal accident in 2009 resulted from a failure of the automation that the operator was unaware of until it was too late. another e dpekt is the theory fails to determine what happens when the automated system has situations not encountered before. the automation may not be able to respond appropriately.
last but not least, removing the pilot doesn't remove other sources of human error from the system. humans are involved in designing, manufacturing and maintaining the aircraft. and this could possibly involve several aircraft and more difficult to find and correct. we investigated a collision of a people mover that resulted in part from improper maintenance. they took the driver out, took the driver error out but it still crashed. beyond designing, manufacturing and maintaining the aircraft, humans are involved in the system in other ways, for example, the pilots in other airplanes, air traffic controllers, wildlife has mittation. so each of these points of human engagement present additional opportunities for human error. but the most fundamental lesson we've learned is that introducing automation into complex systems can be very
challenging. the problems that we have seen thus far from increasing automation including increasing complexity, degradation of skills, complacency and potential laws of profession nalism. in the 2013 crash of aseen of 214 in san francisco, the pilots became confused by the plane's automatic system. the pilot incorrectly assumed that the throttles would wake up and maintain the desired speet. the plane came in low and slow and crash into a seawall while landing. this crash illustrated confusion attributable to the complexity of the automation but also the degradation of the pilot's skills to the extent that he was unable to complete a manual approach and landing on a runway on a clear day with negligible
wind. the policy emphasized the full use of all automation and did not enclur manual flight. our investigation experience has shone that the challenge of complacency can arise with pilots operate aircraft with more automation. it becomes more pronounced the safer an operation becomes. the more the pilots become accustomed to automation safety, the more concerted effort it take to keep the pilots engaged. there can be too much of a good thing. in addition to complacency, query whether too much automation when it's working properly can undermine professionalism. many subway systems that with have in our country today, many of them the system is largely automated so that the automation takes the train out of the station, maintains speeds and adequate distance from other trains, stops at the next
station in the right place and then opens the door. so the only thing the operator does is close the doors. the only function of the operator, close the doors. so when the operator's only function is to close the doors because everything else is automatic, does the operator love his or her work and enjoy the pride of accomplishment or will he or she just be there to get a paycheck. if the paycheck is the primary objective, what does that do to professionalism. unlike the problems that occur when the automation fails, this problem occurs when the automation is performing correctly. our investigations of automation related accidents revealed two extremes. on one hand the human operator is the least predictable and most unreliable part of the system. on the other hand the human operator is the most adaptable part of the system when failures occur. the crash landing of united flight 232 in sioux city, iowa. as you probably remember, the
tail mounted enjoin failed sending fan order parts through all three of the airplanes hydraulic systems. we've seen that crash as it was filmed through a chain link fence and it wu truly incredible that without hydraulics, the pilots were able to maneuver the aircraft to an airport and very few pilots were subsequently able to do that in a similar later when it wasn't life threatening. but these pilots did it in real time and it's more incredible that more than 60% of the passengers and crew survived. also the amazing land in the hudson river. that flight crew had never been trained to glide an airliner. they had never been trained to land in the water and never been trained to land without power. despite that, captain sullenberger were able to save the day by quickly and calmly
assessing the determination, determining that a ditch in the hudson river was a best course of action and executing the ditching successfully. some of you may not be aware that there was an automation aspect to that landing in the hudson. captain sullenberger planned to pull the nose up to the upper alpha limit during the flare. unbeknownst to him, the airplane's software stopped his nose up command 3.5 degrees short. consequently the vertical impact speed wu higher and the rear fuselage was breached in a way that the flight attendant was injured and water entered the plane. automation that was intended to improve safety and comfort hindered the most adaptable part of the system, the human pilot. the crash near buffalo new york in 2009 was a case of the human pilot was the most unreliable and unpredictable part of the system due to the pilot's
unattention, he caused the stick shaker open pusher to activate, whereupon he responded inappropriately and caused an aerodynamic stall and crash. so inappropriate that he was pulling instead of pushing, pulling with 95 pounds of force. faa records indicate that this pilot previously received four certificate disapprovals one of which he did not disclose and further the training records indicate that while he was a first officer he needed additional training after three separate check rides. how many chances do you have to fail before you shouldn't be in the front of an airplane. in this case the pilot how should not have been in the front of the airplane but the filters failed. another tex book example of the human as the most unreliable part of the system was air france flight 447 from rio to paris in 2009. but in that instance those pilots were set up to fail in a number of ways. after air france 447 reached his
cruise altitude over the atlantic and began approaching distant thunderstorms, the captain left the cockpit for a rest break, giving the control to two less experienced pilots. with the super cool watt frer the nearby thunderstorms, the heaters were overwhelmed, causing them to become clogged and the loss of airspeed called the auto throttle to fail and the pilots had to fly the plane manually. and the pilots responded inappropriately to the loss of the systems, stalled the airplane and crashed into the ocean. several factors played a role in this crash. to begin with, the tubes did not effectively provide redundancy because they were all taken it by the same cause. in addition the pilots had not experience thd type of failure before each in training and they were unable to figure out in the
moment what went wrong. the error messages that the pilots received did not help them determine the case, in effect which is the failed systems that needed airspeed information in order to work. had the pilots known that the cause was the loss of airspeed information they may have known to revert to what we all have trained to do in that situation, which is pitch and power. the pilot flying did not communicate he had pulled husband stick back and the pilot monitoring didn't ask. and the pilot monitoring did not know that the pilot flying was pulling back on the stick. finally, automatic pilots are mandatory at cruise altitudes so as you know so the pilots had never flown at that altitude in training or in the similar later and had no stall recognition or recovery at cruise altitude. the tubes have frozen before in that type of airplane but the pilots in the previous encounters responded successfully. consequently the fleet and the accident airplane was scheduled
for the installation of more robust heaters but an immediate emergency replacement was not considered to be necessary. increasing automation reduces the workload of the human operator so when all is going well, automation brings unparalleled safety, reliability, productivity and efficiency. however when something goes wrong or something unexpected happens, a human pilot can save the day with much needed adaptability. the challenge is how to read the benefits of the automation while minimizing its potential downsides. let me suggest that one of the best ways to accomplish that goal is through collaboration. for the past two deck sides the aviation industry has been demonstrating the power of collaboration through c.a.s.t. which you have been participating in. aviation in the u.s. has become amazingly safe. the last crash was the 2009 krsh that i mentioned befr and the last fatal crash of any airplane
in the u.s. was the 2013. much of the industry's safety record is attributable to collaboration. in the early 1990s after the accident rate had been declining, the accident rate began to flatten on a plateau. the faa was predicting that the volume of travel would double in the next 20 years. so if the volume doubled while the accident rate remained the same, the public would see twice as many airplane crashes in the news. joe public counts the number of events. so that caused the industry to do something that to my knowledge has never been done before or since in in other industry at an industry wide level. and they pursued a voluntary collaborative industry wide approach to improving safety. this occurred largely because david henson, the administrator of the faa realized that the way to get off the plateau was not were regulations but figuring
out a better way to improve safe fi in a complex aviation system. the voluntary collaborative process brings all of the players, the airlines, the manufacturers, the pilots, the air traffic controllers and the regular later to the table at the same time to identify the safety issues, second, prioritize those issues, realizing that they're going to identify more than they have resources to address, third, solve the problems that they prioritize and fourth, evaluate whether the interventions are working without causing unintended consequences. this process has been an amazing success. it resulted in a reduction in the aviation rate on which it was stuck by more than 80% in less than ten years. this occurred despite the fact that the plateau was considered to be exemplary. the process also improd not only safety but also productivity which flew in the face of conventional wisdom that improving safety generally hurts
productivity. in addition, a major challenge of making improvements in complex systems is the possibility of unintended consequences, yet this process generated very few unintended consequences. the success occurred largely without generating new regulations. what an amazing win-win success story this has been. the moral of the story is that everyone involved in the problem should be involved in developing the solution pun this is relevant because collaboration means that the designer of the automation should bring the pilots in to the design stage long before the test pilot leaves the ground in a new airplane. the regular later should meet with the pilots and controllers regularly to obtain operational feedback. in turn the feedback can be used to improve training. can be used by the manufacturers to improve the design and by the air traffic controllers to
improve operations as proper. pilots can help industry anticipate and correct problems related to the critical area of interaction between themselves and their automated systems. the ultimate human interface allows the pilot to play his role as the most adaptable part of the system while minimizing the pilot's impact as the most unreliable part of the system. will airlines rch will completely automated? >> we've seen several news stories recently about increasing automation in cars. but accidents such as the land in the hudson are the reason why, in my view, we will not see complete automation in airlines anytime soon. meanwhile if the industry hopes to continue improving safety it must continue to enhance its understanding of the human automation interface through better collaboration. thanks for the opportunity to be here. and if i have time to take questions i would be more than happy to do that. thank you for allowing me. [ applause ]
>> thank you. >> thank you. >> do we have -- this is your time. what an incredible opportunity. please, if you have any questions. i know i have my accident investigation team out there as well. this is your time, gents. anybody have any questions? as you all decide on that -- i think i see one coming. is that jeff? are you making your way down there? action investigation board lead. chairman. >> thank you. >> thank you. >> thank you for coming. >> thank you for having me. >> i'm jeff, the chairman of our accident board here at airline pilots association. the previous panel talked quite a bit about the dangers of lithium ion battery shipments. i'm wondering if you can share comments on how the ntsb is
advocating for safer shipment of batteries. >> we've been pursuing that on quite a few fronts, not only the shipping of car go but the batteries that we're all bringing into the cabin in our iphones and ipads. it's a problem that's going to get worse until we activity do something about it. in order to give you more e details i would have to refer you to some of our guys. paul, you heard him at the panel this morning, he's forgotten more about hazardous material than i ever knew. i would be happy to refer you to some of our guys who do that. >> thank you. >> thank you. >> mr. chairman, thanks for coming. always a pleasure to hear you. >> thank you. >> i've been in the industry for 28 years now. when i first came in the conversation in the cockpit was we are three pilots and we'll never have two. now as the new generation begins to come into the industry, i
wonder if that conversation is we have two, will we have one. i wonder what you're hearing about that and what your thoughts are. >> that's an interesting question. we go where the accidentsare. we don't want to be prescriptive. if we prescribe something and then there is an accident, then our objectivity is compromised. it's hard to know in advance. we go where the accidents are. and if we see problems arising? we've got plenty of accidents with two pilots and whether or not they're kmoocommuting. we don't have a prediction on that. we'll be following that closely to see what kind of trends developing. if we see trends going the wrong way, we're going to jump on it. >> back of the room i see one. >> so we've had a question come in via text message. you talked about automation. in a perfect world, there would be a comprehensive of initial and recurrent training for both automation and basic stick and
rudder skills for airline pilots. based on ntsb research analysis, what do you believe the appropriate balance for today's pilots would be? and looking forward, do you envision that changing? >> that's a good question. i hear too much emphasis on training and not enough emphasis on design. in 447, i saw the media intensively blame the pilots. and to me this is not just a pilot issue, it's a design issue, it's a system issue. part of the reason they had never flown manually at that altitude is because in order to accommodate more air lanes, they removed the opposite traffic from 2,000 feet to one thousand feet. when they did that, they said i don't think humans can do that reliably there is a system issue that played a role in the fact they had never flown this airplane han yuli. it flies very difficultly at cruise than when you're take off at landing. here they are at night in coffin corner with 225 passengers behind them trying to figure out in the moment for the first time
how do i fly the airplane manually at 37,000 feet. so to me there is too much emphasis placed on training. train sag crucial part of it to be sure. and training both on the automation and on stick and rudder skills to me is crucial. but to me we also need to put a lot more attention on the basic fundamental design. and i know the manufacturers have done that after this occurred. i know both boeing and airbus have responded in big and significant ways to 447. but the point is this is where the collaboration is so important to bring back the fact that when you bring the pilots in to work early in the design phase, to work these kinks out before this airplane ever comes out of the hangar, that to me he is a far more important and effective way to improve safety than more training, more training, more training. >> thank you. rip torn, chairman of the air traffic service group for alpa. appreciate your coming out here today. >> thank you. >> one of the issues that has come up on our radar from the
international as well as the domestic flying side recently is visual procedures. approach, go around. second basic maneuver we learned flying after a visual takeoff is a visual landing. are you all seeing a trend, especially in the g.a. world with problems with that? and is that an area of emphasis that is popping up on y'all's radar at the board there? >> i'm not sure if i understand your question is what the problem? i'm not sure i understand the problem. >> for having accidents and incidents during visual approach and approach landing and go-around segments of operations. >> well, the visual operations have created a number of challenges. and one of the ones that we've seen in terms of like the possibility of mid-air collision is when there is a go-around and the pilots have to execute that visually, but he is up 18 degrees and can't see what is near him.
and that other airplane on the intersecting runway there is that sort of unknown who is really in charge here. is this supposed to be a visual maneuver or does the air traffic controllers have to play a role in keeping these airplanes apart. that's one problem. in addition to that we've seen the asiana type of problem where if that accident had been 200 1/2, we'd not be here talk it because it would have been done with autopilot and would have been done successfully. we've seen a lot of issues associated with visual operations. ironically, the 214 is an example where that would not have been an accident if it was 200 1/2. >> does that address your question? >> is that a trend we're seeing an increase of? or higher than normal? >> i don't know if we have enough data yet to identify whether it's a trend. that's a good question. i'll have to look into that and get back to you. >> thank you. >> thank you. >> lindsey fin nick, retired old pilot. first of all thanks for all you and your colleagues do on our behalf.
it really is appreciated. >> thank you. >> the board, as you know, has worked many accidents. unfortunately too many in which the pilots' failure to follow procedures or inability to follow procedures has been inch indicated. from my perspective, too often the board's response if they make a safety recommendation in that regard, it's the pilots should be more disciplined, they should be more -- there needs to be perhaps better training. and as far as i know, there has been no specific recommendation where the board has recommended or directed either the regulator or the airline or airlines industry to have a closer look at how cockpit procedures are developed. and i think the data is now there that if appropriately mined would show or strongly suggest that defective procedures from a human cognitive capability point of view are somehow causal or enabling deviations to occur from these procedures.
so what i'd like to see or get your response on, could the board be a little more specific? to me it seems like a no-cost effort to perhaps encourage a closer look at s.o.p.s that were introduced conceptually 20, 30 years ago, and s.o.p.s have been great. however, i think we need to take that next step. can i have your perspective on that? >> thank you for the question. i'm a big believer that if we see procedures repeatedly not being followed and we know that the people who aren't following are highly trained, competent proud professionals who aren't just people like like to ignore rules, they're people like to get the job done, then that means it's time to look more intensively at the procedure and see if the procedure is inappropriate for the circumstance. i can't cite chapter and verse. i know there are several instances where we did look at the procedures where we said this is creating a problem rather than solving the problem. one that comes to mind was way back in detroit when they tried to take off without their flaps
and slats. and we looked at whether the checklist procedure, whether that checklist process was appropriate and whether that was creating a disconnect that caused this problem. i'd have to refer back for details on specific instance, but i know there have been instances when we have said this was not a -- this was a noncompliance with the procedure, but the proceed year itself was defective and the procedure needs to be reexamined. if this many people raaren't do. we revisit the approach procedures and say we need to rethink. this i know that when united airlines was looking at a lot of instances of flap overspeed. and they went to the pilots and why are you putting the flaps down too fast. the pilots said because the controllers are bringing us hot and high and we got to do something to get rid of the energy and then it's going to be a lose-lose because we're back in the system, more time in the airplane, delay for the passengers, et cetera, et cetera. let's revisit the procedures. he went to faa and said your air
traffic controllers are put:00 my pilots in a position where they have to do what they shouldn't in order to land successfully the first time, which is putting the flaps down too fast. they found lo and behold they were appropriate for dc-6s and dc-7s, but not so good for jets there have been instances where the procedures have been implicated as opposed to people just following the procedures. i would have to get back to you to give you some specific instances. i am aware. i'm a strong believer when i see procedures repeatedly not followed, that means it's time to look more intensively at the procedure, not just the people. i'm a strong believer in that, and yes we have done that when the occasion warranted. >> thank you. >> thank you. >> time for one more? >> action and analysis. >> chairman hart, thank you for coming and sharing your knowledge and expertise with us. jeff perrin, also run the accident analysis prevention group for alpa national. with the advent of cell phones and efbs, is the board starting
to see a trend in distractions among pilots leading to accidents or incidents? by these electronic flight bags or other external electronic devices? >> i was just saying at lunch that we now as a board unfortunately have fatal accidents in every mode of transportation because people are doing what they shouldn't be doing. most of the time that's texting. the worst one is a railroad accident where the engineer in chatswor chatsworth, california killed 25 people, including himself. we have accidents in every mode and yes, the trend is definitely going in the wrong direction on that one. that's why it's on our most wanted list. distraction is on our most wanted list. we're seeing it everywhere, and it's getting worse. >> thank you. >> anybody else? any more from the back? good to go? done. okay. >> thank you very much. >> chairman, thank you very much. >> my pleasure. [ applause ]
c-span created by america's cable television companies and brought to you as a public service by your cable or satellite provider. on lectures in history, george washington university professor chad heap teaches a class about the origins of the gay rights movement. he describes how participants found common ground with the black power movement, anti-war protesters and other groups fighting against the status quo of american cold war society. he also talks about different groups within the gay rights movement which are often focused on more specific issues like removing the ban on lesbians and gays from holding governmental jobs. his class is about an hour. >> so welcome back to class.