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NTSB Board Member Michael Graham on Safety Culture, SMS, and GA Risks
In this episode of NTSB News Talk, hosts Rob Mark and Max Trescott welcome NTSB Board Member Michael Graham to discuss the critical role of safety culture in aviation, the implementation of Safety Man...
NTSB Board Member Michael Graham on Safety Culture, SMS, and GA Risks
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Welcome to NTSB News Talk, where we talk about recent accidents from the past few weeks,
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newly released NTSB preliminary and final reports and other safety-related news.
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The views expressed on this show are really just the opinions of the hosts and not the aviation
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news talk network.
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This podcast is not affiliated with or endorsed by the NTSB, the National Transportation
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Safety Board.
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This podcast is for entertainment and education and is not a replacement for flight instruction.
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Now here are your hosts, CFI and award-winning aviation journalist Rob Mark and Max Trescott,
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CFI and author who's trained as an accident investigator.
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Welcome to NTSB News Talk, I'm Rob Mark.
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And I'm Max Trescott. Today we have a special guest joining us, that's NTSB board member,
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Michael Graham. I got to tell you, we were rather flatter that it was the NTSB that heard
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about the show and asked if we'd like to have Michael as a guest. And of course we said yes.
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And Rob, I understand you've actually met him before.
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I have met him a couple of times at the Textron Flight Ops office in Wichita.
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Both the times I believe I was on assignment with Flying Magazine to do something about one of
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Textron's airplanes. And of course before joining the board Mike spent more than two decades at
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Textron where he served as the director of flight operation safety, security and standardization.
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His role was implementing safety management systems across a wide range of the company's flight
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operations. Yeah and before that he had a background in the US Navy, he spent nine years there
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where he was flying A7s and FAA teams off of carriers. He was also a flight instructor.
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And of course he's very much a safety leader who's dedicated much of his career to preventing
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accidents and saving lives. That's true. And we're going to speak with Mike about the role of NTSB
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board members, the importance of safety management systems, and the challenges the board faces
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trying to implement some of those safety recommendations. We're also going to touch on lessons
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that all pilots can learn from Mike's career. Well, let's get started with episode 13. Here's
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our conversation with NTSB board member Michael Graham. Mike, welcome to the show. Thanks so much for
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joining us here today. Thank you for having me. Well, tell us a little bit about the role of an NTSB
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board member, both formally in terms of what you do and perhaps informally, aspirationally, what
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you're trying to accomplish through that role. First of all, most of the most people probably think
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investigators and I am a trained aviation safety investigator, but that's not really our role here.
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Our role is to basically fulfill our product at the end, which is our bigger investigative reports.
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And those are brought to the board to be deliberated upon as board members. So we're kind of like
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I like to refer to us as the Supreme Court of Transportation Safety. So it's kind of everything's
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presented to us and then we deliberate and vote on it. And each board member brings a different
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experience level and aspect or angle to each of the bigger investigations we have. So that's part
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of what we do. We do anything that has a recommendation on a report has to go through the
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reports to the board votes on the recommendations that go out. And that's our product. Others in
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our investigative report per safety study is our recommendations. We're not a regulator.
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So we don't do regulation. We don't do cost benefit analysis on our safety recommendations.
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We are here solely for safety. And once we get that recommendation out there, then I spend a
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lot of time advocating for our safety recommendations. And let's face it, we have more than just
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hundreds. I think we're in the thousands overall these years. So we go out and advocate as do a lot
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of our investigators and people here at the board do. And then on the bigger accidents, we actually
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will go with what we call the go team. And I have pretty much three functions as a board member when
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we go on a launch like that. One is we are the media spokesperson on scene. Two is
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we kind of work with the local authorities that have already responded and just thank them and
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help them through the processes. They basically hand everything over to us so we can start the
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investigation. So we're not the first responders, but we pick up after that. And then the other one
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is to meet with the victims family members, whether it's virtually or on site. We meet with them and
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kind of talk to them, express our condolences, obviously. And we talk to them about our process. And
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then we will give them the information that we're going to put out in the media first before we give
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it to the media. So that's kind of the role of a member. You mentioned the advocacy role. Tell us
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more about that. What are you personally trying to advocate and how do you go about doing that?
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To me, that's a big part of the job is advocating. So we want people to implement our recommendations.
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So how do we do that? First of all, who do we send our recommendations to? They go to any
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entity that if they implement what we ask will hopefully prevent that accident for happening
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again. So that could be the regulator, FAA in many cases. I think they get the majority of ours
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out there. It could go to a manufacturer, maybe an aircraft manufacturer. It could go to an
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operator. We've investigated an accident on a lot of associations that can get to all their
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membership. So we will go, we will go talk about the issues. We'll talk about our recommendations.
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We will work with them any way we can. And not just the board members, but we have a specific
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people at the board that work directly with like the FAA and help them better understand what we're
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asking for and then work through them implementing that and the long run. And sometimes these take,
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let's face it, they usually take years to get implemented. You mentioned that it can take years
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for implementation. I don't know what the backlog is of recommendations that the NTSB has made
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that have not been implemented. But is there a single thing that you think is the roadblock
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to implementation? Is it, oh my gosh, that'll cost the company or the agency or whatever,
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a great deal of money. And I don't know. I'm just curious if there's any regular roadblocks.
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It really depends on the recommendation. I mean, we tried to get positive train control
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in on trains for 50 years. And we finally got it in there. And to me, it's just in its infancy.
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We need to see the next change and the next software update for all these things. So we try not
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to leave them out there too long. But unfortunately, there's quite a few that have been out there a while.
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We know if they're implemented, they will make a big safety difference. So we will continue to push
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on some of them. Some we will just occasionally close out closed, unacceptable. But the more important
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ones and most of them are, we stick with them as long as we can. You were talking about trains.
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I mean, the NTSB works with other forms of transportation besides aviation, don't they?
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Yeah. So our biggest modal office is aviation safety because our statutory mandate is to
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investigate all civil aviation accidents. We don't quite have that in the other modes,
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but we have other mandates. They're a little smaller. But we do railroads. We do highway. And when
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you're talking seven and nine million accidents or crashes a year on the highway, we can only do a few
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when you look at those numbers. We do rail pipeline hazardous material, marine pipelines. So we kind
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of cover all the transportation. I understand that the NTSB no longer has the most wanted list of
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safety improvements that they did for years. If you would tell us why that's changed and go
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ahead and take a moment and tell us the top five or six things that you would like to see
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implemented in aviation from a safety improvement standpoint. Yeah, that's a good point. I think
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a lot of us felt we maybe out grew the most wanted list. We thought we were going to replace it
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with something a little different and that just never happened. But here's the thing, all board
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members advocate for everything when you come down to it. But let's face it with our backgrounds
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and everything being different. We tend to migrate towards things that we may have a passion over
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or a pet peeve towards. And I tend anything in aviation obviously, I'm going to try to get my
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my hands involved with a couple things. I mean, probably the biggest one that I was pushing
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was SMS for part 135. And more than just 135, we were looking for repair stations, the part 21,
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the manufacturers. We got most of it, most of the air tour operators, not quite everybody. We didn't
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get the repair station. So that was a big one. And the other part I know we're probably talking
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about a little bit is the scalability of SMS. That's always been the big deal out there, right?
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So we got it coming. And I think that's great. So that's one of the bigger ones I do. I love technology.
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I think technology can be an engineering control to prevent some of these accidents we have out there.
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So I tend to lean towards a lot of that kind of technological fixes. And I also got involved
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in the highways with connected vehicle technology. And I think that has an incredible safety
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potential down the road. In your previous role when you were at Textron, Mike, I don't remember you
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were involved with the demo pilots and safety and something. But tell us a little bit about what
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you did at Textron and how that helped you decide to become an NDSB member. Good question, Rob. Yeah,
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you're I was the director of for all the flight ops safety and security. And we had standardization
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in there too. So we had so many different types. We had three separate production flight test
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groups. We had a demo group. We had a training group that did training with piston engines, aircraft.
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We had a defense group. We had the engineering experimental flight test group. And then we had a
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basically a management company also for some of the customers. We managed aircraft for them.
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So I oversaw all the safety and security of those operations. So I pretty much implemented. We had
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an SMS in various pockets throughout each of those flight operations. We tried to kind of bring
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it all together. And under one person and I had I had a person in each one of those flight
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departments that reported directly to me kind of like the NTSB. We were kind of an independent,
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but working within the organization so we could take a good look at what's going on from the
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risk management point of view. So this was an opportunity to come to the board to do this on
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a national or international level. And then with all the other modes. So I couldn't say no to this
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offer. So I'm curious because I know former chairman Robert Sommelton, I've always curious
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when you hear about this, I mean, did you see an ad in the paper that said NTSB wants board members
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or it sort of passed around in the safety world that says, Hey, you know, Mike Graham might be
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a good guy. We should talk to him or I'm just curious how it works. Let me just rephrase that. Rob
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wants to know how he could become an NTSB board. Well, it's unfortunately it is a political process
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to do it. You've got to get a nomination. Actually, my path was back in early 2017.
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I was at the Air Charter Safety Foundation Safety Symposium. And I was part of that board of
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governors with that foundation working on charter security and or safety programs. And Robert
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Sommelton did a presentation and spoke to us. And in afterwards, we were chatting with them. And I
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was with I remember Brian Burns, who was the president of the organization there. And a few
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or the other board members. And Robert was saying, you know, Hey, I'm going to the White House right
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now. I'm going to talk about trying to become the chairman. And he goes, you know, we do have two
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openings on the board. And then he took off. Well, that night we were all sitting around at dinner
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going, you know, and he had made a mention like, you know, it'd be really great to have somebody from
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your part of the operation with business aviation and charter, you know, on the board and have
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their perspective. So we're sitting around that evening at dinner talking and going around the
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room and guys were like, Oh, I've never I couldn't do that job. I couldn't and that came to me. And I
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said, you know, I think I could do that job. And I'd really like it. So I tried to get a hold of my
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senators. And they didn't want to have anything to do with me. My congressman took it and ran with it.
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And his staff worked and worked. It got it took about a year to get the White House's attention.
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And then I went through a couple phone interviews, finally got invited to come and interview with
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the presidential personnel office. And I was like April. So I'm on year two. And then I don't hear
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anything back until August of that year. And they say, okay, we're going to take your package to
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the president. And we'll let you know at the end of the week, well, the next morning they called
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me and they said, he said, you're the one. So you still can't tell anybody. And I had to go through
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the vetting process. And by the time I already I got the nomination, that was in basically finishing
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up year two of the process. And it took another six months to get a confirmation hearing and then
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get another six months to get confirmed. So mine was a three year process probably longer than anybody.
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So it's a long road. But I just felt this is where I was being led. And it's been great. I just
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had a confirmation hearing to be reconfirmed a week and a half ago. And I'm hoping the Senate moves
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it through here sooner or later. And is that the main part of the reconformation process? Is that hearing
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or are there other hurdles that you need to go through to get reupped for another five years?
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You bet. So yeah, you get to go through the hearing. You do all the prep work by going to the
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senator's office and either talking to them themselves or their staff. And then after the hearing,
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you always get extra questions for the record, which I finished up about a week ago. And we'll just
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see how long it takes to get moved out of committee and then go to the full Senate.
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So if it took three years for you, I'm thinking it's probably going to be at least four or five
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years for Rob to get through the process. Yeah, yeah, they'll have to re-enominate them every year.
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Okay, you guys are just trying to get under my skin. And you know what? It's not going to work because
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I am rock solid here. But seriously, when you first got to the board, what was it like? I mean,
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do you go through the new board member training syllabus or what happens?
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But even or not. Yeah, you kind of do. You go to all the different motor offices and you get a big
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brief on what's going on, how they do their job, all the big investigations going on that they're
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working on. You go through every office, you go down to research and engineering and look at
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the lab and see what they're doing. You go through media training for you to have to do press conferences
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on a launch. You just go through your transportation disaster assistance or family assistance.
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You go through some training with them. It's all excellent training. And the big part of it is
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what you bring to the board. Everybody goes, well, how do you deal with decisions in railroads
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or in marine? And it's like, I just use all the tools and experience I had in aviation. All the
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safety management systems work everywhere. So why aren't all the other modes required to do it?
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Or if not required, why haven't they implemented it voluntarily? So I just take it from that
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standpoint in my whole aviation career and experience all the way through the Navy and then
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managing air safety investigators from texturon aviation that were party members to these investigations
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here at the board. And you've brought up SMS before and something I really want to hear from you
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about. The big challenge that I see is that we have a couple hundred thousand pilots that fly
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single pilot. Some of them do professionally. Most of them do it,
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advocationally, they're just doing it for fun on the weekends and so on. Any ideas that you can
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suggest how they can borrow some ideas from SMS and kind of scale them down to the individual
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single pilot who's not part of a company with a safety office and have an exposure to the kind
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of safety culture that you experience both in the Navy and at texturon? That, well, you know,
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gets into the scalability question, right? How can't you do it? One of the big things we push for
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here at the board, I personally pressed for was scalability for the small guy and every, you know,
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I know a lot of the different associations out there were pushing back on the SMS mandate
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because of the scalability question and I totally understand why, you know, you just can't say,
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hey, do a big part five for a small operator or a single pilot operation. So coming out of a
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air tour helicopter accident that we had done over in Hawaii, we were going to reiterate our part
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135 SMS recommendation to the FAA and one of the recommendations I pushed for was a scalability
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aspect out of the FAA. Give some guidance to the small operator, the single pilot operator,
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what they expect SMS to look like for that person. And I'll be darn it in only two years
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after they came out with the SMS mandate for part 135 and some of the other operations.
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Part of the AC, I think it was 120-92 delta in the appendix G was a like a spreadsheet of guidance
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of what an operator at the small scale or single pilot operator should do to implement that
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portion of the SMS and it's all broken out by sections under each of the four foundations of
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SMS. So amazing, they did it in two years and I think it's really good guidance. So I'm excited,
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the FAA jumped on it and I think they did a pretty good job. So we'll see of course we've got
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a couple of years to let it has to be mandated by that time. Okay, and I haven't heard of that
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particular AC so we'll include a link in the show notes so people can find that. That's great,
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that kind of guidance is available. Talk a little bit about safety culture. For example,
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when you were in the Navy, it's a very different environment but I think a probably a very positive
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one where you may have a squadron of kind of self-reinforcing norms and teamwork to try and push
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for safety. What did you learn from that experience and are there ways for single pilot operators
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and they're not operators, they're just single pilots, yeah. There are ways for them to
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use some of what you learned in the Navy. Oh, that's a big question. Yeah, at the squadron,
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I mean you lived with these people for six months at a time on the ship so you really got to
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know each other. You interacted daily, hourly, with just about everybody in the squadron, not just
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the pilots, the mechanics and all the different ordinance men and the people doing the admin work.
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And I think as far as culture goes, you just got to have really good open lines of communication
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and you got to be open to being critiqued. That's the one thing I learned in the Navy. You're not
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going to learn by sitting in a bubble or anything like that. And the fact that every landing I did on
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the ship was graded. That really opened you up to, you know, okay, how well did I do? And it was
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a big deal. And you worked really hard at getting better because the top 10 were recognized every
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deployment. And you know, when you're talking about 200 pilots, 10 people getting recognized for
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the best landing grades, that's a big deal. And my first deployment, I was nowhere close.
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Go ahead, Ron.
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Well, and I always, when we travel on the airlines, people always say, oh, that was good landing.
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Oh, man, that landing was awful. And we wonder where this philosophy came from of airline passengers
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being focused on the quality of the landing. It came from the Navy, didn't it? All these years
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ago, I've been wondering where it came from. And you guys are grading each other. They're all
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I had no idea. No, I had my second deployment, full deployment. I ended up getting a top 10 patch
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for that. So it was a big deal. So in a sense, perhaps pilots should be looking to grade themselves,
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take notes, figure out how to improve, was certainly giving flight instruction. Or when I was
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taking it, for example, when I did helicopter training a couple years ago, took copious notes,
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and I found that beneficial. Did you do that kind of thing? And do you recommend that?
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Oh, absolutely. And in the Navy, we did, we probably had a minimum, we two hours before the flight,
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we started a brief and usually brief for about an hour. If it was a bigger strike or something like
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that, it was probably longer. And then after the flight, you came back and you debriefed, I mean,
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you debriefed everything. I see in civil aviation, I just don't see that very often. If you could
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do something at the end of a flight, sit down and just critique yourself a little bit, you know,
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how do you do that when you're the only one flying out there in your operation? So there's ways
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of doing it. Sit down and say, you know, what went well? What didn't go so well? What would I do
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different next time and why? But also say, okay, this work really well. How can I make that help me
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fix this or something like that? Other things too is have somebody else come in and critique you
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ever so often or fly with you. I just say, hey, what do you think? Am I doing okay? Did I miss something?
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You just got to be open to being critiqued a little bit. That was probably the hardest thing
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to learn in the Navy that they're going to look at every aspect of your flight. You know, we would,
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when we trained to go on deployments, we would have these what they call tax tech pods on the aircraft.
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And we could go back and sit in a big auditorium and watch the whole thing. And they could be
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into your aircraft and look at just about everything you were looking at or hopefully you were looking at.
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So yeah, just an ultimate critique of your flying abilities. But you knew it was all so you could
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get better. And we have so many people in general aviation that are, let's say they're in it because
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their ego is so they have a big ego and they can't imagine themselves not doing everything
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perfectly. I mean, of course, now, you know, being critical of yourself, it's going to be a little
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tougher with somebody that has a personality like that. Would that be correct? Oh, absolutely. And
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when I learned in the Navy, first of all, there's no perfect people out there and there's no perfect
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operation. I haven't found it yet and I never will. So we are always talked about correct and
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correct in the Navy. We were always striving for perfect knowing that we'd never get there.
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But you wanted to get as close as you could and it was always having to make corrections to get
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it right. And then a lot of times you'd have to correct while you were doing it. So I think people
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need to look at that. They need to use the data that they may have out there too, right? Some of these
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maybe small flying a small piston or something like that. I mean, with ADSB data out there now,
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you can go back and track and look at what was my approach to be was I, you know, was I stabilized
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coming in or engine monitoring, you know, simple little things you could look at down the road or
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other operators that you fly in and out of the airport. You know, you got any issues with me. Did
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you see what happened over there? You got anything that could help me out handling this? I mean,
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just be really open to whatever. Well, speaking of data, tell us a little bit about the G8 dashboard
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and how pilots might be able to help that with their flying. Thank you for asking me about that.
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Our data group working really hard to make. We have so much data out there from all the accidents
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and safety reporting and safety recommendations and safety studies we've done over the years.
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And if you go to our website, there's there's a G8 dashboard out there. And the one that we have
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out there right now is from 2012 to 2021. And it's a great dashboard. You can look into every,
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whether every mode, you know, 91, 121, it'll give you what's the most dangerous phase of fly?
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What's the leading defining event? What was the leading cause of each accident or the total,
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you know, what's the biggest cause of accidents we have out there in GA or 135 or 121. And we're updating
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that right now for things after 2021. But we're working with the data really hard. Aviation,
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we've always had a big database, but we're doing that with all the other modes now too. So I think
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we've got at least 10 years worth on all the other modes and we're trying to go back and get as much
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in there as we can. So it's really good to go. I use it before I go out and speak and just kind of
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see where we're at and let the industry know. So it's worthwhile to take a look at. Are there any
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particular accident types that you want to mention that pilots are kind of getting themselves
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into again and again and again? Oh, yeah. Where do you begin? Unfortunately, we've seen no new accidents
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out there. I think the one I've spent some time on since I got here that still just kind of
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amazes me a spatial disorientation. And there's a big difference between fixed wing and rotor wing
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out there. When you look at the rotor wing community, a lot of them, if they do have an
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instrument rating, they don't have a lot of instrument time. And when I'm talking small amount,
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I'm talking like less than 10 hours or if somebody who's had been in there 25, 30 years flying,
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you know, a lot of it is VFR only with them. And if you continue to flirt with weather sooner or
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later, you're going to get yourself in the weather. And if you're not ready for it, unfortunately,
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the outcome is not good. If you look at that, we're talking maybe 5 to 10% of our GA accidents
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or our spatial disorientation accidents. But the problem is over 90% of those are fatal when they
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do happen. And a lot of it is in the fixed wing too. We've seen it all the way up through part
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121. We've had people get spatial disorientation. The Amazon air outside of Houston that went into
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Trinity Bay in 2019. The first officer with pilot flying got spatial disorientation. And the
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captain didn't get in there and quick enough to take over and then fully take over the aircraft.
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And they put it in the water killing both of themselves and a jump cedar. So I came from a background
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in the Navy where we spent a lot of time. But when we started flying, they made me a really good
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instrument pilot. And I understand why now. Also for trying to get aboard the ship, you have to
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be a really good instrument pilot. And if you want to get good landing grades, you better be using
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your instruments very well. But with that, we went through a lot of labs and simulation to
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get a feel for all those spatial disorientation issues out there. So you know what they felt like.
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So when you got in the aircraft and had that happen to you, you knew exactly what you had
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and you got on those instruments. I mean, that's the big thing. You got to be not just
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current, but you need to be proficient in instruments out there. I think that'll that would
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alleviate a lot of these accidents. And if you're not an instrument pilot or you're not current
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or proficient, don't go flurting in the weather or near the weather. While you were talking about
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the GA dashboard, I went up to the NTSB site and how would I find the GA dashboard from the website,
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main page or maybe that's something we can I probably type it in the search in the search.
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See if that'll work for you. I will include a link to it in the show tonight. So that'll help.
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And you brought up technology and certainly there was a lot of discussion of technology
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during the DC, midair collision discussions. Talk a little bit about the importance of technology
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and where you'd like to see a GA in particular headed with technology. That's a big question.
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I always look at technology as a way that they can assist the pilot. If you're way behind the
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airplane, you're probably not ready for the next level of automation or technology out there. But
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you know, there's a lot of capability out there. We got ADSB out now. It would be great to see
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more ADSB in if properly implemented. And that's my big thing is you've got to implement it
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correctly with warnings and cautions to get the attention of a pilot when needed. Also, you can
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get in a lot of weather looking at our recommendations today for ADSB. It's all banned. ADSB in has been
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for uncontrolled airspace that's highly congested. So air tours in Alaska, air tours in Hawaii,
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in other Alaska 135 operations has been we've been asking for it up there. But we haven't
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asked for it in congested airspace. That may be different after the DC, midair, but we'll see what
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comes out of that. But I think it has a lot of potential for us out there. Just talking about the
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GA pilot, I grew up in the Navy with angle of attack. Angle of attack was everything. Our emergency
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procedures were not, if we lost an engine, accelerate to this speed. It was accelerate to
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on speed AOA is what we called it. Take numbers out and just a site picture is what you wanted.
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I think AOA, angle of attack would really benefit a lot of GA pilots, given them a better understanding
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of what their aircraft is capable and when they're maybe starting to get outside the envelope a
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little bit, I know I was able to explore the whole envelope of the aircraft in the Navy. You
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can't always do that in general aviation. But if you get a better feel for what your envelope
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of your aircraft is capable of and when you're starting to hit those margins looking for those
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indications out there, I think that would be helpful and I think technology could help out there.
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And I was kind of surprised during the DC midair collisions to learn that ADSB in was not available
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for the type of regional airliner that was involved in that particular accident. Certainly my
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experience has been that other forms of traffic displays are inferior to ADSB in. Just talk a
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little bit about the hearings in general. Were there any aha moments for you or any moments of
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frustration with what you were hearing from the witnesses? I think I struggled with a lot of what
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came out of air traffic control and I can't speak to the investigation because it's an
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active investigation. But there's a lot of factual information we are trying to get out of a lot
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of different groups, RME, ATC. I think there may have been some frustration with maybe what's going
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on in air traffic control. And a lot of it's tied up with next gen hasn't happened. We've been
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talking next gen for what well over 20, 25 years at least. And they're working with a lot of
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outdated stuff out there, a lot of equipment, under staffing. There was frustration. There was
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frustration to hear a controller saying, hey, we asked to change the flow rate in four years
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ago and we were told, no, it's not going to happen too bad. That was frustrating. Hearing
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shouldn't be adversarial. So I saw some of that a little bit that upset me. We're there to just
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get factual information. And sometimes people get on their soap locks a little bit. It happens
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at every hearing, but we're not there to draw conclusions. So that's where you probably sense
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my frustration a little bit. Yeah, I saw at times where it looked like you wanted to say something
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and held back. And all I can say is great that that's part of your character that you're not going to
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react emotionally to something. But the entire thing was very eye opening just to learn probably
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10 major factors, any one of which, if it had been different, could have changed the outcome.
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My sense was that everybody who testified would say that they were doing their job. And yet somehow
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the job didn't get done. Yeah. Well, I don't want to draw any conclusions because it's still an
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act of investigation. Everybody's trying to do their job. And I think we're going to find out
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it's not just one thing. Every accident, it's not one thing. Everybody wants to focus on this or
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that. It's not going to be that it's going to be a combination of things. It's like the Swiss
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cheese model, right? James Rees and Swiss cheese model. It's going to be several of those operational
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layers of protections broke down or they just became so porous that it happened. I see a lot of
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complacency lately. And when you're managing risk, it's not a one and done thing. It's a constant
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process. And I think we're going to see this that, you know, I think there was a lot of signs out
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there that the potential of this accident was going to happen sooner or later. And nobody
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stepped in to stop it from their end. And like I said, it's not just one end. It's going to be
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several ends, I think. Yeah. I think there's a feeling of the part of some people that simply because
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an accident hasn't happened in the past is not evidence of a safe system. Absolutely. Nobody's
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perfect and no operations perfect. So the potential is always there. And you got to, it's a constant
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process to be looking for that next little hazard that next little risk that you didn't see or you
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didn't uncover. That's the hard part of safety. Yeah. And I think early on, I used to think that
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one could work hard enough to get to a safe state where you were then going to be perfectly
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safe from then on out. And what I realized is, no, we all operate in an extremely dynamic
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environment. And so things are constantly changing. So even if you've mitigated all of the risk
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you identified yesterday, we've got new risk today. Absolutely. You nailed it.
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Well, what are some of the challenges that the agency is facing today? As you look ahead,
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challenges at the board. Well, first is the potential of a government shutdown here in the next
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day or so. That weighs on people. One is our agency. We have a grown in the last 20 or 25 years
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like most agencies has, but our mandates have. So we're just trying to get to a reasonable size.
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So we, one, we can get enough investigators out there. So we don't burn our people out with too
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many investigations. Two is we'd like to knock down the amount of time it takes to get a report
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out on an accident investigation. So we just, we need a few more people out there. And that's
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goes for all of our modes. And we, we had some commitment by the, the hill with a larger budget
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to do that, unlike most organizations right now or agencies. So we're just trying to work to,
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to get to what the right number of people is to be able to not only get the job done, get it
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accurately done. That's, that's the most important thing. But get it done in a more timely matter.
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And I've seen job postings in the past for NTSB. Are you hiring that one? Where do people go? And
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what kind of people are you looking for? I think we're always open for new people or for more people.
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I haven't looked in the last few weeks, but I think USA jobs is always out there. That's another thing
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that the hiring process in the federal government is a very lengthy process. I would love to see that
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shortened. I don't think that would work in the private sector. I know it wouldn't work for me
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where I was working before coming here. But we're always looking for good people that are, you know,
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passionate about what they do and just fully committed to, to, to the mission.
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Well, you brought up earlier ADSB. Do you think there might be any further expansion of the mandate?
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For example, it seems like ADSBN could have been extremely valuable in the DC mid air.
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Yeah, we've been, I think like I said, we've been asking for it in uncontrolled airspace in
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certain areas. It would, it would make sense. I think if you look at a lot of the,
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the new technologies coming out right now for like airports that don't have radar or gray and
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ground radar, like Austin, Texas, where we had the FedEx, almost land on top of the Southwest
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airlines, they're put in what they call SAI, I think it's surface awareness initiative,
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where they're using ADSB to put up a display where everybody's at. The only problem I see with
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that right now, and I'm sure the FAA is going to take care of this, is you need alerting, like you
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have with the radar systems at the major, the bigger major airports. So you need something there to
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caution or alert the oral and visual alerting to let the controller know and that, you know,
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the separations too tight now, got to do something about it. And then a few weeks ago, I went out
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and looked at one of the avionics manufacturers using that same ADSB technology and putting that
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system into the cockpit directly. So you don't have to worry about the middle man of the air
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traffic controller, letting you know, kind of like what T-CAST was many years ago when we started.
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Get it right to the cockpit right away so they can do something about it right away with the
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proper warnings also with that. And I know at least two avionics manufacturers are working on that.
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So I think we could see those technologies being fully implemented to hear within the next
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couple of years, two or three years definitely. Yeah, I'm frustrated when I read about some
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collisions that have occurred. For example, one in our area, the California Nevada border,
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in which some aircraft was a DSB equipped with ADSB out, but chose to turn it off because he
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didn't want to people know where he was, which was silly. He ended up in a minute air collision is
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that it just seems to me that there are so many opportunities with ADSB out and ADSB in and that
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the more we can implement those technologies, the safer we're going to make the system.
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I agree with you. I think it will make it a safer system. And we're going to have to go through
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some of the growing pains of putting new technology out there. I mean, I look back at T-CAS
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and how it was very immature when it started, but look what we ended up with. We had an accident
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or two and then it got better and they made the software better. And I think it's a pretty good
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system now as we can see it has limitations like in the DCA mid air. You know, below a thousand feet,
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you can have resolution advisories because if somebody gets a fly down command at 300 feet over
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the water, that's not going to work. So we'll see that limitation already. So like everything,
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technology is great, but every one of the technologies out there has limitations. So what other
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system can help with that? That's what I'm always looking for. What's the next thing that can help
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with that limitation? I had a chance to visit the NTSB train center out there and I guess it's
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in Virginia. I think it was. It was. Or it is, I guess. No longer. We closed it down.
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Okay. Well, I wondered about that because when I was out there, Robert Samoa was still chairman,
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and he showed us the TWA 800 rebuild, which I thought was the most incredible thing I had ever
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seen in my life to have a big wire cage that was the shape of the airplane. And they figured
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out how to put every single little bit of metal back together the way that they found on that
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airframe. So where do you know, where did that TWA 800 mock up or whatever you call rebuild?
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Where did that go? Did it just get box somewhere? No, it was permanently destroyed. So you will never,
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you will never find a piece of TWA 800 again. Other than I think there's a piece or two at the
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safety center Boeing that they asked to have is as a permanent muse kind of a museum or safety center
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for their personnel when they trained a new employee, which we did. So the rest of it, it kind of
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outweigh out grew it. It was very dated, but it was incredible for the time we had it. But
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we talked to the families of TWA 800 and let them know what our plan was and they were in agreement.
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We had some special ceremonies for them before it was destroyed. But yeah, it was incredible.
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When I got to the board, I had been through there several times and I went out there multiple times
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myself. I took people out there, told them the story, and then you go out and get to see it in
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person. It just puts a big lump in your throat and it does. It really does.
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I'm curious during your time at Textron in a safety management role, you must have felt challenges
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trying to get the attention of leadership about various safety issues. What kind of experience
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would you share with people who are in safety roles today as to how they get the attention of
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management and how they provide leadership not from the top, but from lower down within the
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organization and the mentorship of things that they should be trying to do in their careers?
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That's really good. Sometimes they're always trying to put a cost figure on what is a cost to
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do safety. I had to do my own cost benefit analysis even though that's not what we do here at the
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board on safety initiatives. Then the long run, everything I did was just pennies. It's only
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cost pennies to do in the grand scheme of things. I had great leadership most of the time that
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understood that and they led from the top down and they supported it. But I would also say,
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don't cry wolf every time either. There's little things you can do to take care of some little
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nagging problems that you may have and some of those just require some time and effort.
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But if you're crying wolf all the time, you're going to turn off the top right away, right?
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They should know when you come in the door and you close the door behind you and say, hey,
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we got an issue boss. They should know, hey, I need to put everything aside and listen here.
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And if you're running in that door all the time, you're going to turn them off right away.
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And I'm guessing a lot of what you can do is just working person to person and having the
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interpersonal skills to work with your colleagues and understand what their issues are and communicate
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those issues. Talk about that a little bit. It's not just coming up with things that cost money.
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It's actually a very human interaction issue as well.
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It's a complete engagement. You got to engage every single employee out there and let them know
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that you understand if they don't let you know what's going on at their,
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we're not going to know what's happening. We can't fix it, right?
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So you need to make, I always said I had the title of safety, but honestly,
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every person in that operation was the safety officer. And if they didn't let me know,
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I couldn't help fix it. And then you had to earn their trust too, right? If they didn't trust you,
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they weren't going to tell you. So everything that brought to me, you had to give them feedback on,
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you know, whether, hey, we're investigating it, what the results are. If even if you didn't do
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something about it, you had to let them know that you weren't going to do anything and why.
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And I think that's where you earn a lot of respect that, hey, I took what you gave me, but
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it's a scheduling issue. It's not really a safety issue at this point or something. But the
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communication is the biggest thing with everybody. You got to, when you're asking for reports from
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people, confidential reports, and you're able to share information back without exposing anybody,
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protecting an amen with T. That's a big deal. And if they can see that their reports are being
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addressed, it opens up a lot of other people I found. People would come back and say, hey,
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you know, I saw you, you put out, I would do a ASAP talk sheet, aviation safety action program
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talk sheet. And I put out just kind of general, you know, everything was de-identified. You can
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tell who or what, but had put it in. But somebody go, you know, hey, I read that thing and that happened
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to me last month too. And it's like, well, then maybe you should report it. Maybe it's a bigger deal
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than we know. So when you give people feedback or given the information and everybody gets the
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information, the identified, it goes a long way. And I think that's why my program was very successful
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while I was there. Do you have any stories of people who were not interested in participating in
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the program, but later you were able to somehow sell them on the idea in some way? Well, I kind of
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already alluded to that a little bit. I mean, you're always going to have the naysayers. You're
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always going to have the people that are never going to want to report. And you want to get the
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largest percent you can. But I actually, it was one of those that when I put out the talk sheet,
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it basically said what happened. They came back to me and said, you know, that happened to me too.
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And I just didn't think it was that big of a deal. And they were completely sold on the program
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after that. The other one was we had a handful of former airline pilots.
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Yeah, some were regional pilots and some were the bigger guys. And when they saw we put an ASAP
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program in, they bought into it right away because they knew they knew what came with that. And
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they were able to really sell it with everybody else out there. And then to expand on that,
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when we started sharing that data with the Sias, the aviation safety information analysis and
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sharing group, that opens up that database to your operations. So now you can look at
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at that time, we weren't doing flight data monitoring. But I was able to look at all the
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de-identified data for all the aircraft that had flight data monitoring where all the airports that
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we went to and see what the big top five safety issues were there. So that opens the door.
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The more you share your data, it's all de-identified, the better off you're going to be because you
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can be able to look at the big gamut of aggregate data. And I am a huge proponent of that.
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Well, sometimes it's just the little stuff as well too. I think sometimes we think that all
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only the big things need to get reported. But is there a role for a little tiny nitsy things to
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be reported as well because they could have some unintended consequence?
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No, that's a good point. Yeah, even the little ground things that happen, right? That you don't
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hear a lot about. Just like we had a power cart and a hanger that had a loose wire on it.
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I don't think anybody would have known about it except for the person that usually used that
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power cart, but they reported it. And I found out that nobody was helping them out. And once we
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get things fixed in a couple hours, so it says a little winds like that that ground personnel
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will buy into or a mechanic or something like that. You want to get those folks involved too in
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the program. Well, as we start to wind up here, Michael, thank you so very much for your time
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today. Rob, any final thoughts before we go with Mike? No, I just think this was so interesting to
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hear some of the inside scoop of how the board works. And I'm really glad you were able to join
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us today, Mike. I'm really glad that you invited me on and I really enjoyed it. And it's always
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great working with you, Rob. I know it's been a while. But in Max, I've listened to your podcast
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before. So it's great to be part of it. Thanks so much for joining in. Will you come back and join
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us again someday? Absolutely. And, Arra, thanks to the NTSB for reaching out to us and
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arranging to have Michael Graham on the show. And I got to say one of the things that really struck
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me was about Mike's comment about his experience in the Navy. He said, what I learned in the Navy,
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there were no perfect people out there. There's no perfect operation. I haven't found it yet. I never
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will. And he also talked about how they tried to correct and re-correct. He said they were always
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striving for perfect knowing that we'd never get there, but you wanted to get as close as you could.
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And I have certainly in the past tried to have perfect flights. And I always fail, but I feel that
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by doing that, it just makes me a better pilot. And I encourage people to consider doing that as well.
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What I thought was really interesting about Mike's conversation was him mentioning his time in the
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Navy and that the people on the ship grade every single landing of every single pilot, every single
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time they fly. Can you imagine Max if somebody was standing at the end of the runway,
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watching everything you do not because they thought you were bad, but just to say, hey, that one was
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only an eight out of 10. Boy, that really is a lot of pressure. And actually, I think there's
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a lot to that. So for example, there's an app for the Sirus Pilots. There's another one for the
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TBM pilots in which they actually have their landings compared to everybody else who's using that app.
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And I think that kind of what's called gamification where people are striving to do better and
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better actually is a really positive thing for pilots. That's a really good point. And I think
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we ought to talk about that someday in depth. Indeed. Well, hey, this has been great, Rob. By the way,
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can I do anything to help you with your application? Seriously, I would love to have that job, wouldn't
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you? It's a funny thing because people have always asked me what else I've always wanted to do in my
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life other than all the colorful jobs I've had. And you know what? One of them was to be an NTSB
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accident investigator. I always wanted to do that. I am terminally curious. And my wife says I
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would have been perfect for the job. I suspect so. Well, Rob, great talking with you. We'll see you
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again soon. You bet you'll see him, Axe. This podcast is not affiliated with Or Endors by
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the National Transportation Safety Board. The views expressed are the opinions of the hosts
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and not of the Aviation News Talk Network. The show is for educational and entertainment purposes
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only. It's not a substitute for flight instruction, official NTSB guidance, or you know. Common Sense.