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Opening Statement |
Good morning. Welcome to the Boardroom of the National Transportation Safety Board. I am Debbie Hersman, and it is my privilege to serve as Chairman of the National Transportation Safety Board. Joining me are my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind and Member Earl Weener.
Today, we meet in open session, as required by the Government in the Sunshine Act, to consider the December 7, 2011, helicopter crash of a Eurocopter AS350 outside of Las Vegas, Nevada. Let me recognize Member Mark Rosekind for his outstanding service as spokesperson for our on-scene investigative activities.
The crash happened minutes into a regularly scheduled "Twilight City Tour" that was to fly over Hoover Dam and Lake Mead as the sun set and the pilot would provide information about scenic landmarks.
Two couples were onboard: newlyweds from India and a couple from Kansas celebrating their 25th anniversary.
On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the families and friends of the pilot and four passengers who perished in this accident. We know that nothing can replace the loss of your loved ones, but we do hope this investigation will provide some answers to your questions.
Investigator-in-charge Bill English says this was a "traditional" investigation. In short, there were no modern investigative tools to help point the way … no flight data recorder, no cockpit voice recorder, no cameras, no air traffic control tapes. Nor were there any witnesses in the rugged terrain where the helicopter crashed.
Today, we will hear in detail about helicopter components and controls, about maintenance practices and personnel, and about fatigue and human factors. This painstaking, deliberate investigation pursued every clue and followed the evidence trail, which ultimately led to the hangar floor and maintenance operation.
This is not our first investigation involving maintenance issues; maintenance error has produced some of aviation's worst crashes, such as the 1979 DC-10 crash in Chicago and the 2003 Beechcraft 1900 crash in Charlotte, NC, that, together, claimed 294 lives.
In too many investigations we have seen the tragic results of human error, and we've long known about the safety challenges unique to maintenance - tasks performed at night (when our bodies are programmed to rest), long duty days, shift changes and interruptions, the disassembly and reassembly of complex systems, time pressures and more.
There's been considerable research on human factors and maintenance by leading aviation safety experts. James Reason and Alan Hobbs write in their book Managing Maintenance Error about certain aircraft maintenance situations and work pressures that can lead to the same kinds of errors no matter who is doing the job. These 'error traps,' they say, "Clearly imply that we are dealing primarily with error-provoking tasks and error-inducing situations rather than error-prone people."
Let's learn from this tragedy so that we can, first, determine what happened, and, then, most importantly, get to the life-affirming task of making clear and cogent recommendations to prevent future needless tragedies.
Our goal, as always, is to enable more people to live to enjoy the sunset.
Dr. Mayer, will you please introduce the staff.
