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FEDERAL AVIATION ADMINISTRATION

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4TH ANNUAL FAA INTERNATIONAL AVIATION

SAFETY FORUM

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SAFETY WITHOUT BORDERS-MEETING GLOBAL CHALLENGES

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THURSDAY,

NOVEMBER 29, 2007

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The Forum convened at 8:00 a.m. at the

Westfields Marriott Hotel, 14750 Conference

Center Drive, Chantilly, Virginia.

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TABLE OF CONTENTS

Opening Comments 3

Nicholas A. Sabatini

Associate Administrator, Aviation Safety

Federal Aviation Administration

Admiral Thomas J. Barrett 6

Deputy Secretary, U.S.

Department of Transportation

Robert A. Sturgell 18

Acting Administrator

Federal Aviation Administration

Giovanni Bisignani 27

Director General and Chief Executive Officer

International Air Transport Association

Plenary 1 Panel

SMS - Safety Management Systems 43

Captain Daniel E. Maurino

Coordinator, Flight Safety

and Human Factors Programme

International Civil Aviation

Organization, and various Panel

Members

Q and A with Plenary 1 Panel Members 94

Video Viewing/Captain Gene Cernan 116

Captain Eugene A. Cernan 116

Aerospace Consultant and President

Bombardier Aerospace/The Cernan

Corporation

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1 P-R-O-C-E-E-D-I-N-G-S

2 (8:07 a.m.)

3 MR. SABATINI: Okay. Welcome to the

4 4th Annual FAA International Aviation Safety

5 Forum. What a privilege to host so many aviation

6 safety professionals who do so much to make air

7 travel as safe as possible. It is a pleasure to

8 host an event made possible by the hard work of

9 FAA staff and the gracious support of our co-

10 sponsor, the Air Transport Association, and of

11 our international sponsor, the International Air

12 Transport Association, along with many other

13 sponsors. You will find them all recognized on

14 the back of your program.

15 This year we have more exhibitors than ever

16 before, and I know you will want to make the time

17 to see the exhibits which are on the first floor

18 in the Washingtonian room. The exhibits are open

19 today from 10:00 a.m. to 7:00 p.m. And because

20 you\'ve asked for it, we now have an email booth,

21 so please take advantage of that.

22 Yet we all know that the most

23 important ingredient in aviation safety is

24 people, you. We have an impressive array of

25 international safety talent here today, and we

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1 are looking forward to high level and provocative

2 discussions. To save time, we are introducing

3 our panelists in print. In your registration,

4 you will find a booklet with the biographies of

5 today\'s speakers listed in their order of

6 appearance on the program. If you have any

7 questions, there are FAA staff members on hand

8 who will be happy to help you. We are

9 documenting the proceedings and will make them

10 available.

11 We have provided headsets for

12 simultaneous interpretation. If you use a

13 headset, you are welcome to keep it with you and

14 take it to the break out sessions and to lunch.

15 Please be sure to leave the headset with us when

16 you leave the conference.

17 Most important, there evaluation forms

18 in your registration packet. Please take the

19 time before you leave to fill these out. We do

20 use these comments to plan future conferences.

21 Drop the forms in the box outside the room.

22 Now let\'s get to the reason why we are

23 all here this week, and that is to talk about

24 aviation safety. First, let me thank each of you

25 for what you do for safety. What you have done,

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1 what we have all done is nothing short of

2 remarkable. Look at what the aviation community

3 has achieved, the worldwide aviation accident

4 rate or hull loss per 1 million departures is

5 1.0. In many areas of the world, the rate is

6 even lower than that. One way to look at our

7 industry\'s safety record is this \-- airline

8 pilots are safer at work than when they are off

9 the job. This is a remarkable achievement.

10 Yet we face challenges, challenges

11 from growing demand, challenges from changing

12 business models, challenges from rapidly

13 advancing technologies. But perhaps the biggest

14 challenge and the best reason for us to come

15 together every year is working together for a

16 seamless and integrated global system. With

17 limited resources, it is even more important that

18 we learn now to work smarter, not just harder.

19 That brings us to our focus this week

20 on safety management systems. As you see from

21 the agenda, we\'ll be talking a lot this a week

22 about the critical importance of safety

23 management. Joining me this morning to kick off

24 this year\'s forum are the FAA Assistant

25 Administrator for International Aviation, Jim

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1 Filippatos; Air Transport Association Vice

2 President Operations and Safety, Basil Burimo;

3 Director General and Chief Executive Officer of

4 the International Air Transport Association,

5 Giovanni Bisignani; Acting FAA Administrator,

6 Bobby Sturgell; and Deputy Secretary of

7 Transportation, Admiral Thomas J. Barrett.

8 Now this morning\'s first speaker is

9 known for many things. He\'s known for an

10 illustrious and distinguished career in the

11 United States Coast Guard. He was instrumental

12 in improving maritime security after September

13 11, 2001, expanding Coast Guard support tot he

14 national foreign intelligence community,

15 supporting Operation Iraqi Freedom and for

16 smoothly transitioning the Coast Guard into the

17 new United States Department of Homeland

18 Security. Our speaker is also well-known for his

19 no-nonsense approach. Give him a problem and he

20 will put together the team and develop the

21 solution. It is now my honor and privilege to

22 introduce the Deputy Secretary of Transportation,

23 Admiral Thomas J. Barrett.

24 (Applause.)

25 VICE ADMIRAL BARRETT: Good morning,

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1 Nick. Thank you and distinguished guests and

2 attendees. I\'m delighted to be with you hear

3 this morning and have the opportunity to welcome

4 you on behalf of President Bush and my boss,

5 Secretary of Transportation, Mary Peters, to the

6 4th Annual International Aviation Safety Forum.

7 There\'s terrific attendance here. I think it\'s

8 over 400 from all parts of the world, over 35

9 countries at last count, I thought. I think

10 we\'re going to have the ICAO model here with

11 translations in about five languages.

12 And I know many of you have traveled

13 a long distance to get here with a common goal

14 and a significant challenge, if you will, to

15 achieve the lowest possible accident rate for

16 aviation and to constantly improve safety with a

17 remarkable to build on and to do both, as Nick

18 indicated, in the midst of incredible growth in

19 aviation globally and certainly domestically in

20 the United States, and in a system with

21 increasing complexity and challenges. Looking at

22 your program, for example, notice the

23 environmental issue that was mentioned earlier.

24 That\'s another challenge to take on. Growth is

25 another challenge to take on. Managing safety

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1 forward in the face of those challenges and

2 complexities is difficult. And I appreciate the

3 fact that you\'re here and are stepping up to help

4 do to.

5 You are, in fact, the best in the

6 world at this, certainly in this country. You

7 know how to ask the tough questions, the who, the

8 where the why and try and prevent the next

9 accident from happening. Aviation, frankly, in

10 the Department and I think across the world, in

11 terms of identifying risks and then getting on

12 top of them is a model for other forms of

13 transportation.

14 You know, President Bush asked me to

15 join the Department of Transportation. I first

16 came into the Department as the first

17 administrator, the Hazardous Materials and

18 Pipeline Safety Administration, PHMSA. I knew

19 safety was safety was a key part of my mission.

20 That\'s one of the reasons I took that position.

21 It\'s a key driver for the Department and

22 certainly for my boss, Secretary Peters. If you

23 listen to her enumerate her priorities, number

24 one is safety across all modes, and that includes

25 aviation. Second would be systems performance of

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1 transportation systems, and last would be

2 bringing 21st century solutions to bear on the

3 challenges we face. Twenty-first solutions

4 includes technology, an area we\'re all familiar

5 with, but also involves approaching different

6 ways of financing our transportation

7 infrastructure, different ways of bringing that

8 system into the 21st century. So safety, though,

9 number one.

10 So when I got here and started working

11 with PHMSA and certainly as Deputy, I sat down

12 with the safety professionals around the

13 Department and lead on that, really, is Nick,

14 who\'s up here with you this morning. I consider

15 him a mentor and part of that is because his

16 relationships and his dialogue is willing to

17 engage with all of you to kind of kick the tires

18 on these issues in a very smart way and drive a

19 system forward. You know, we talked about, and

20 what I talk about with him, is year in and year

21 out, how is it, how is it that aviation has been

22 able to lead other modes when it comes to

23 identifying risks and figuring out how to reduce

24 them. And we talk about some of the challenges.

25 You know, we have a history of

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1 looking, and it\'s necessary and important, but

2 what I call a little bit in the rear view mirror

3 at incidents and accidents and taking lessons

4 from that and applying them forward. But with

5 the growth we\'re seeing in aviation and other

6 modes of transportation, that\'s not good enough

7 anymore. We talk a lot of about what leading

8 indicators are out there. You\'re going to talk

9 today about safety management systems and safety

10 culture, how you get on top of incidents, prevent

11 them from happening without really having the

12 database out there or waiting for the data to

13 come up and show you. That\'s a tougher challenge

14 to identify the risks forward and get on top of

15 them without waiting for the incident. And we

16 can\'t really wait with the growth we\'re seeing,

17 certainly, in aviation.

18 I think one of the ways you get there,

19 and you\'re all here for this, is collaboration.

20 It\'s learning from each other, and in this case,

21 learning from each other globally. I think

22 that\'s a terrific opportunity and that\'s how it

23 gets done. I would tell you from my perspective,

24 and I appreciate this, you know, the test of a

25 healthy relationship is a willingness and ability

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1 to kick the tires on tough issues, to reach

2 consensus where you can but to get the issue on

3 the table. And I think sometimes there\'s a

4 tendency to just pat each other on the back and

5 tell each other, you know, kind of cumbyja, we\'re

6 doing well.

7 The healthy relationship comes, and I

8 hope you will see this in this conference \-- I

9 expect you will \-- from being able to put the

10 tougher items up on the table and share different

11 perspectives and different viewpoints and work

12 the problem forward. And I think that dialogue,

13 that dialogue is really encouraged in forums like

14 this. And I think working together on those

15 tougher issues will allow us to extend and

16 improve upon the safety record you\'re already

17 seeing.

18 You know, last year\'s record was

19 encouraging. Nick told you about the folks in

20 the cockpit being safer there than on the roads.

21 But the numbers \-- one accident for every 1.5

22 million commercial flights worldwide, that\'s

23 terrific. And a lot of you in this room rightly

24 can claim credit for that, and I just applaud

25 your efforts and I congratulate you. We want to

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1 build upon that record and take it forward. But

2 that\'s a terrific accomplishment and I don\'t want

3 to minimize that. You want to build on success.

4 That\'s what we\'re doing here.

5 And it\'s a terrific challenge. And I

6 know Bobby\'s going to talk to you about that in a

7 little while. Nick mentioned my background in

8 the Coast Guard, but I\'m sensitive to the

9 challenges you\'re up against from two

10 perspectives \-- one, I\'ll give you an example

11 that I use you\'re familiar with, Exxon Valdez was

12 a large oil spill up in Alaska, and if you think

13 that about that prior to the time that Joe

14 Hazelwood fetched the Exxon Valdez up on Bligh

15 Reef and you had that spill, there were over 860

16 safe tanker transits to Prince William Sound, no

17 accidents, no spills, no real problems so to

18 speak, and then you have the Exxon Valdez. You

19 run the numbers on that \-- and, you know, my

20 background is data driven systems perspective,

21 you know, transparency and partnership and

22 leadership, the type of things you\'re going to

23 talking about \-- but if you run the numbers on

24 Exxon Valdez and the tanker transits, what you

25 got was 99.9 percent success equaled an

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1 environmental disaster.

2 You\'re in an even tougher business.

3 Ninety-nine point nine percent success may not be

4 good enough when you\'ve got a couple of hundred

5 people in an aircraft. Okay? There\'s not a

6 margin for error there. So meeting that

7 challenge head on, figuring out how to work

8 toward that essentially zero defect, manage the

9 risk in a system that also has to take into

10 account cost and environmental issues and

11 complexity, moving millions of people around \--

12 27 million record-setting in the United States

13 over the Thanksgiving holiday \-- how to do that

14 is an enormous challenge. But I am confident

15 also that with the skill and talent in the room

16 here, as Nick said, the safety professionals,

17 that you\'ll find a way to do that and do it in a

18 prudent, smart way forward.

19 The other thing just intrigues me and

20 the other piece of Coast Guard background I would

21 give you, and I just offer it as something to

22 think about as your work these issues forward, I

23 was a Commander up in Alaska and am very proud of

24 Coast Guard aviators up there. There\'s a former

25 Kodiak Commander here in the room, Mont Smith.

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1 But what you have up there is you have some of

2 the worse weather on the planet. You have

3 enormously large distances for the type of

4 equipment they\'re flying and you have no

5 infrastructure really, very limited support

6 infrastructure. And yet day in and day, year in

7 and year out, they go out and they pull off some

8 incredible, absolutely incredible rescues and

9 missions. And thinking about how you get there,

10 and I certainly did all the time, the term that I

11 used and I think our Commanders and our crews

12 used, was kind of operational excellence.

13 And what it meant to me was how you

14 translate the concept, how you translate the

15 safety management system, how you translate the

16 culture, how you translate the parts management,

17 the maintenance, you know, how you translate

18 safety at large down to the hangar deck, into the

19 cockpit, in with the air crew, down on the hoist

20 with the rescue swimmer. Operational excellence

21 \-- what does it take, what does it actually take

22 to deliver the safety you want, the mission

23 performance you want when you\'re executing your

24 mission, on in this case, conducting your

25 business, and it\'s getting from here to there.

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1 That\'s the tough part. It\'s not having the

2 construct. It\'s getting it \-- get it migrated

3 out there operationally.

4 And I think the issues you\'re going to

5 talk about \-- and I looked at your agenda \-- I

6 really applaud it \-- I\'m just delighted to see it

7 \-- safety management systems, partnership, shared

8 values, system monitoring, you know, the feedback

9 loops, safety culture, Clean Skies \-- but how you

10 translate these concepts down to the day-to-day

11 on the hangar deck, in the cockpit to make these

12 things real. I also think safety, and you know

13 this, doesn\'t know any borders. This is a global

14 business. It doesn\'t recognize language and

15 cultural differences. And as Nick said a few

16 minutes ago, what we want is a system that\'s

17 seamless, that\'s integrated, that works globally.

18 You know, aviation history, and you

19 know this, is built on ideas turned into reality.

20 And we saw it last night in the museum. We\'ve

21 seen it repeatedly where you watched aviation

22 make enormous strides forward in very short, very

23 short time spans. And it\'s happening now in

24 safety. In the last ten years, we\'ve seen a 49

25 percent improvement in accident rates worldwide,

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1 49 percent. That\'s a huge, huge number. It\'s a

2 huge improvement. And I know there\'s a lot of

3 work behind that and there are challenges ahead.

4 And one of the challenges comes from

5 your success, from the expectations. Across the

6 globe we\'re seeing record growth and demand for

7 flight, demand for air travel and, frankly,

8 there\'s an expectation and an assumption that

9 that travel is going to be conducted safely.

10 Don\'t think twice about getting on an aircraft

11 anymore. And so the challenges as that grown is

12 maintaining and even improving on that record,

13 and that growth, if you will, leads to part of

14 the challenge you\'re going to deal with \-- busy

15 runways, loaded taxiways, crowded skies. It

16 means there\'s more risk, there\'s more opportunity

17 for confusion, for accidents.

18 And that\'s why recently here, over

19 Thanksgiving, the President and Secretary Peters

20 worked very hard with the aviation community, the

21 FAA and the Congress, and we\'re still doing that,

22 to develop short and long-term solutions to

23 airspace congestion. New York City \-- we\'re

24 working with airlines and airport operators to

25 craft measures to ease the congestion that,

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1 frankly, in the United States, causes three-

2 quarters \-- in the New York region \-- three-

3 quarters of the problems and delays we see across

4 the system. And I just encourage you to follow

5 that effort closely, and we are, because New York

6 is not an anomaly. It\'s kind of a harbinger or a

7 preview of what may come in airports, really,

8 around the world as that growth continues.

9 So over the long term, and you know

10 this, we\'re working with Congress. We need to

11 move away from a radar-based system to satellite-

12 based systems \-- the FAA terminology, next

13 generation \--to allow us to more safely handle

14 significantly more traffic. Significantly more

15 capacity is what we need in those systems. And

16 maintaining the safety record as we do that is a

17 significant challenge for us, particularly when

18 you consider how fast demand is growing.

19 So I just want to conclude this

20 morning, encourage you and let you get on with

21 the important work. I really do appreciate your

22 willingness, particularly those of you who have

23 traveled, to come here and participate in this.

24 We welcome your ideas. We encourage your

25 dialogue. I told Nick this morning, I have to

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1 apologize. I\'m not going to be able to stay and

2 listen. I would \-- I probably \-- I feel a little

3 humble being up here actually speaking to you. I

4 would much rather be in the position of listening

5 and learning from you, but I\'ll get some feedback

6 from Bobby and Nick after the fact.

7 But I wish you the best. We need you

8 to be successful and I\'m confident you will be.

9 So thanks very much and welcome again.

10 (Applause.)

11 MR. STURGELL: Well, good morning land

12 welcome to our 4th Annual International Safety

13 Forum. I see lots of old friends and also I see

14 lots of new faces this time. Our first

15 conference drew about 330 attendees from 15

16 countries. I think since then, every year we\'ve

17 eclipsed that mark and this year\'s included. To

18 me it\'s just a reflection of this industry that

19 it is a global industry and that we are all

20 pointing in the same direction.

21 I just want to start off by thanking

22 Admiral Barrett for opening things up. I think

23 he put the issue for us in just the right

24 context. Safety is a shared responsibility. As

25 you read the Admiral\'s biography, you can see

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1 that his view of safety comes from a little

2 different angle, the Coast Guard. Just for the

3 record, there are very few 30-foot swells in

4 commercial aviation, but even at that, the

5 message is the same. No matter where you are or

6 what you do, whether it\'s on a plane or a ship,

7 safety has got to come first. And I think safety

8 first is the best way for all of us to look at

9 this conference again this year. The message is

10 indeed the same.

11 The challenge, though, is a little bit

12 different for us in aviation. The question for

13 us in aviation is how to maintain the safety

14 record that\'s the envy of all transportation.

15 This is the safest period and the safest

16 generation in this history of transportation.

17 It\'s been called the golden age of safety, and I

18 think that\'s precisely right.

19 So how are we going to move forward?

20 How are we going to raise the bar? The answer to

21 that, I think, is simple to say but definitely a

22 challenge to implement. The answer is SMS,

23 Safety Management Systems, and the challenge I\'m

24 here to issue today is for each of the people in

25 this room to become activists for safety

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1 management systems. If your operation, your

2 organization or your nation doesn\'t have one in

3 place or isn\'t yet moving to develop one, that

4 needs to change. The challenge for you is to

5 return to your cockpit, your workplace, your

6 country and push hard for SMS.

7 Aviation no longer is in the business

8 of combing through the ashes and wreckage to find

9 the answers. SMS will give us the intelligence

10 we need for the problem reaches the headlines.

11 When it comes to the risk, I think all the low

12 hanging fruit is long gone. SMS uses hard data

13 to point us in the direction that we need to go.

14 We don\'t have to wait for something bad to

15 happen.

16 Before I talk more about SMS, I\'d like

17 to spend a moment framing up where we are today.

18 Aviation is safe. That\'s a given. But it\'s also

19 growing. Boeing and Airbus set sales records \--

20 \$65 billion dollars in firm orders in the first

21 two days of the Dubai Air Show. Dubai Aerospace

22 alone is buying 100 planes from each manufacturer

23 at a total cost of more than \$27 billion dollars.

24 We\'ve got a similar success story on our hands

25 with business jets. There was a time not too

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1 long ago when North America accounted for 80

2 percent of the bus jet purchases. Today the

3 demand from Europe, Asia Pacific and Latin

4 American is soaring. Projections for next year

5 point to deliveries of more than 1,300 business

6 jets worth a record \$22 billion dollars. That\'s

7 up from 506 deliveries worth 8.2 billion in 2003.

8 In terms of shear passenger counts

9 alone, the U.S. continues to set records every

10 year, and we\'re still expecting a billion

11 commercial passengers in the year 2015. Bottom

12 line, we\'ve got a rapidly growing aviation

13 environment \-- more people, more planes. And

14 with that comes the challenge of orchestrating

15 them from Point A to Point B. For each of us,

16 there\'s the complicating factor of resources that

17 aren\'t growing along with the upward spiral of

18 aviation. Make no mistake here, though, this is

19 not a commentary about tight budgets. Rather

20 it\'s an acknowledgement that each of us do not

21 have a blank check. It\'s an acknowledgment that

22 all of use need to adopt strategies to help

23 handle an upswing activity with the same level of

24 safety that we\'re seeing in today\'s golden age.

25 Here in the United States, fatal air

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1 carrier accident shave dropped 65 percent since

2 1996. That works out to one fatal for every 4.5

3 million departures. Internationally, as Admiral

4 Barrett pointed out, the numbers are dropping as

5 well. If the 1996 accident rate had remained the

6 same through last year, there\'d have been almost

7 3-dozen major accidents. The actual number of

8 fatal accidents was 11. Yet from an

9 international perspective, accident rates vary

10 considerably with some regions doing well and

11 some not so well.

12 So the point is that collectively, we

13 all still need to take a step up. And I\'m

14 including the United States in that group as

15 well. The safety management system approach will

16 enable us to do that. SMS enables you to keep

17 your eye on the ball every single day.

18 Ultimately, we don\'t want to just meet ICAO

19 minimums. Ultimately, our goal is to raise the

20 bar worldwide. No matter where you go, no matter

21 what flag\'s on the tail, from take off to touch

22 down, and all the points in between, we want to

23 ensure a consistent and high level of safety.

24 At its most fundamental level, a

25 safety management system helps organizations

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1 identify and manage risk. It does not wait for

2 something to happen. It doesn\'t rely on

3 anecdotal information. It is based on hard data.

4 Safety management systems help us manage risk far

5 better than we have, because it\'s a discipline

6 and standardized approach to measuring risk. We

7 can review past experience and address known

8 hazards. At the same time, we can look ahead and

9 rigorously apply safety risk management.

10 At the very core of the SMS is the

11 need to identify potential hazards and then

12 analyze risk. After that, the next steps are to

13 rank hazards and assess risk and then identify

14 mitigation options. It\'s a closed loop process

15 where identified risks are mitigated and the

16 mitigations are monitored to provide continuous

17 system safety. The FAA\'s air traffic

18 organization is adopting a safety management

19 system for its operational policies, processes

20 and procedures. And Nick\'s aviation safety

21 organization is moving to an SMS construct as

22 well. Last year they developed an SMS doctrine,

23 and now the group is moving to implementation.

24 The next logical step to enhance

25 safety is what I see as the evolution from

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1 inspecting safety to taking a systems approach

2 with SMS. What\'s important in this construct is

3 that SMS is being implemented in accordance with

4 ICAO standards that are themselves being changed

5 to apply a systems approach in aviation safety in

6 all aviation domains including air carriers and

7 airports. That\'s a fundamental difference for

8 the SMS approach. The process itself is

9 overseen. The burden is on the service provider

10 to ensure the safety of the products and services

11 it provides whether it is design and production

12 of aircraft, air carrier operations or air

13 traffic control. And this way, both regulator

14 and service provider can better target resources

15 based on risk.

16 Perhaps the best way to characterize

17 the safety management system is to say that it is

18 a structure of voluntary, non-punitive reporting

19 methods set up with an organization to foster

20 safety awareness all across the board. Even

21 small bits of information can point to a larger

22 problem before that large problem can become a

23 catastrophe. So that\'s the FAA\'s view of SMS.

24 What does it mean to you? Our recent

25 call to action here for runway safety is an

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1 example of using SMS principles. As you know, we

2 had a string of events that pointed to a problem

3 with our runways despite our continued success in

4 improving runway safety. They involved a variety

5 of factors \-- miscommunications, miss-turn down

6 taxiways, snow plows, missed turns onto active

7 runways, signage. There are more examples but

8 everyone gets the idea. Runway safety is a major

9 concern. When we issued our call to action, we

10 looked at 5.4 million records covering a 20-year

11 period, and we found 117 isolated instances of

12 flight crew confusion here in the United States

13 involving these types of issues. Our call to

14 action is addressing these issues as we speak.

15 Short-term actions such as enhancing runway

16 markings and improving pilot training are already

17 underway. And this was done cooperatively with

18 the industry.

19 We also completed a Universal Safety

20 Oversight Audit Program, USOAP, here in the

21 United States. I don\'t need to tell many of you

22 in this audience today about the comprehensive

23 nature of this audit, but I can tell you that we

24 learned a lot about ourselves in the process. We

25 learned that aviation safety\'s ISO certification

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1 has lead to great improvements and

2 standardization since the last audit in 1999 by

3 ICAO. We learned that our already safe ATT

4 system can be made even more safe if we could

5 develop formal agreements between other agencies

6 and if we work with airport authorities across

7 this country on common safety improvements.

8 What this shows is that even as our

9 safety record and oversight tools are first rate,

10 we still need to be more vigilant. Little events

11 that seem insignificant take on a different

12 meaning when viewed through the lens of the

13 bigger picture. It\'s all about continuous

14 improvement and SMS will produce that outcome.

15 And SMS isn\'t something that you pull off the

16 shelf when the need arises. It\'s got to be

17 maintained and ingrained.

18 So in closing, let me emphasize that

19 with SMS, everything is interdependent. The true

20 value comes when data are shared, not isolated.

21 There\'s no place in safety for secrets. The

22 challenge now is up to us. I encourage you to

23 make the most of the information you\'ll be

24 hearing over the next two days, and I thank you

25 again for making the trip to the United States.

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1 Thanks.

2 (Applause)

3 MR. STURGELL: You know, we\'re very

4 fortunate this morning to have with us the

5 Director General and Chief Executive Officer of

6 the International Air Transport Association, but

7 before going any further, though, I would like to

8 take the opportunity to thank IATA once again and

9 ATA for their general support of this Safety

10 Forum.

11 Before being named Director General,

12 he launched the first European airline-owned

13 online travel agency. He was also CEO of

14 Alitalia. In an industry that really depends

15 upon your ability to look down the road, to

16 anticipate what\'s coming, to be a visionary, this

17 man is known for superb instincts. He is focused

18 on safety and he also has the drive and insight

19 to make it happen. Please join me in welcoming

20 our distinguished guest, the Director and Chief

21 Executive Officer of the International Air

22 Transport Association, Mr. Giovanni Bisignani.

23 (Applause.)

24 MR. BISIGNANI: Thank you very much.

25 It is a real pleasure to be here, and

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1 congratulations again to the great FAA team for

2 organizing another very relevant event, an event

3 that continues the tradition started when Marion

4 from FAA always more engaged in international

5 arena. We are a global industry and this is a

6 valuable forum to discuss global solutions for

7 safety, our number one priority.

8 Since last year the financial health

9 of our industry has improved. For the first time

10 since year 2000, the industry will turn a profit

11 of \$5.6 billion this year after \$40 billion

12 dollars of losses, and that is good news. It

13 reflects instead tough leadership decisions that

14 improve productivity by 56 percent, produce sales

15 and distribution by 13 percent, and cut non-fuel

16 unit costs by 15 percent. The U.S. carriers have

17 gone from the industry sick man to the most

18 profitable. U.S. carriers will return this year

19 to profit, \$2.7 billion dollars as a result of

20 strict cost control and careful capacity

21 management.

22 Europe has had more stable profits,

23 \$2.1 billion this year largely as a result of

24 strong long- held markets, particularly for

25 premium traffic. Asian carriers have seen

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1 profits fall to \$700 million dollars, this

2 because of capacity expansions of 42 percent

3 since 2001 and this made years weaker.

4 For 2008, we expect even better

5 results, but the challenges are not getting any

6 easier, because the credit crunch throws a shadow

7 over the economic expansion that underlines our

8 good performance. Let\'s remember that airlines

9 are still \$200 billion dollars in debt, and we

10 could be heading for a downtown with little cash

11 in the bank to cushion the fall.

12 At the same time, cost control is

13 getting more difficult. Labor is now 23 percent

14 over cost. With profitability, their

15 expectations are high. Already we see strikes

16 from France to Japan and management must be

17 tough, reminding them that there is no free

18 lunch. Fuel is now 28 percent over cost and the

19 bill that we are paying this year will be \$132

20 billion dollars, and there is no good news on the

21 horizon. So running an airline continues to be a

22 tough, tough business.

23 Safety, our number one priority, is

24 also a growing challenge. And without public

25 confidence in safety, we don\'t have a viable

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1 business. And with an industry that is growing

2 at 5, 6 percent a year, we must reduce the

3 accident rate just to keep the same absolute

4 number. Our targets are much more ambitious,

5 like cutting the accident rate in half over the

6 last decade. We achieved that and 2006 was our

7 safest year ever. But this year looks like it

8 will be a big step backwards. Preliminary

9 results for 2007 show an accident rate at .9

10 taking us back to 2002 levels.

11 Some areas are doing well, very well -

12 - zero accidents in the Middle East and North

13 Africa. IATA\'s work with Russia and CIS helped

14 to turn the worst safety record of 2006 into zero

15 accidents so far. Europe and North America also

16 saw improvement. North Asia saw its perfect

17 safety record come to an end with one hull loss,

18 but at .72, it\'s still better than the global

19 average. And China still has zero accidents so

20 far.

21 So what is the problem? It is

22 concentrated in three main areas \-- Brazil, where

23 some tragic accident pushed the Latin American

24 hull loss rate to 2.52. Asia Pacific \-- accident

25 in Indonesia increased the accident rate to 3.27.

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1 In Africa, a more dispersed and under related set

2 of accidents increased the accident rate in that

3 area from 4.3 to 6.04. Let\'s remember that we

4 are a global industry and flying must be safe

5 everywhere.

6 We established transparent and

7 effective partnerships with Brazil and Indonesia

8 to help them improve their situation with

9 practical measures. The issues are similar in

10 Africa. We are opening an office in Nigeria and

11 effectively working worth the government. And we

12 recently signed an MOU to further develop our

13 cooperation. But the problem crosses more

14 borders, so we are working multilaterally to help

15 airlines to move forward on their agenda.

16 Said by ICAO Safety for Africa

17 Conference, the common theme in our technical

18 approach to safety is cooperation, cooperation

19 between industry and governments. We are in this

20 together. A safe industry is our shared

21 responsibility. And the conference theme of

22 today, as Bobby or Nick mentioned, is \"Safety

23 Without Borders - Meeting Global Challenges.\"

24 And today I will summarize my address

25 \-- three strategic areas where cooperation is

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1 critical \-- auditing, safety management systems,

2 and training and qualifications. And I will say

3 some words about environment, our biggest

4 political and technical challenge today, because

5 our approach to all three is business-like based.

6 Based on what? On transparency so that we

7 clearly understand what we need to achieve, on

8 accountability so we understand the targets and

9 how we are going to achieve those targets.

10 But let\'s start with auditing. As you

11 know, the IATA Operational Safety Audi, IOSA, is

12 a key part of a 6-point safety strategy. That

13 covers everything from operations to cabin safety

14 to training. IOSA is changing our industry.

15 Over 175 airlines are on the public registry

16 covering 80 percent of scheduled international

17 traffic. Our member airlines, I can assure you,

18 are fully committed to safety-based practices.

19 IOSA is now a condition of IATA\'s membership.

20 IOSA is the global standard for airline safety

21 management. It has nearly 1,000 standards that

22 are transparent and freely available to any

23 commercial airline in the world, IATA or non-

24 IATA.

25 By working with regulators, IOSA

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1 standards combine the highest level of ICAO

2 standards, FAR, and industry-based practice.

3 While we constantly improve the IOSA standards,

4 there are other challenges. To make sure they

5 are implemented consistently and effectively, we

6 are taking a very businesslike approach with

7 targets and a strong quality assurance program.

8 IOSA has three target deadlines for IOTA\'s

9 members \-- end of 2006, to commit to an audit;

10 end of 2007, to complete the audit; end of 2008,

11 to close findings and join the register. If a

12 carrier has failed to meet any of those

13 deadlines, they are simply out of IATA. Ninety-

14 seven point five of our carriers met the first

15 deadline, and on January 1st, I terminated six

16 carriers that did not.

17 But naturally, as you may understand,

18 our goal is not to reduce our memberships. We

19 want to have all our members on board. That is

20 why our partnership for safety program provides

21 assistance to airlines with gap analysis to find

22 weakness and develop action plans. The program

23 is active in Africa, Latin America, Russia, in

24 CIS and Asia-Pacific. Already, 70 airlines

25 underwent a gap analysis and realignment of our

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1 international airline training fund allowed to

2 fund 29 safety-related training courses in 2007.

3 More broadly, 25 awareness seminars around the

4 world brought IOSA and SMS to over 700

5 participants including airlines, manufacturers

6 and governments.

7 Why governments? Because it is an

8 effective tool to enhance your safety oversight

9 programs and a growing list of governments make

10 use of IOSA. The FAA was supportive since the

11 beginning. Let me express our strong

12 appreciation to Nick Sabatini for his passion,

13 his commitment and what he is doing and has done

14 for safety. The latest commitments are from

15 Costa Rica, Turkey and Mexico where IOSA is now

16 part of the national regulations of those

17 countries. To be frank, the list is growing too

18 slowly. The airlines is committed. There is no

19 cost for governments and the results are clear.

20 So I hope that with your support, we will have

21 many more countries on board helping us in these

22 efforts.

23 In the meantime, we are applying our

24 IOSA experience to ground operations. Good

25 initial work has been done FSF and Boeing. I

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1 reported last year that we were developing the

2 IATA Safety Audit for Ground Operations, ISAGO,

3 because while improving safety, our goal is also

4 to reduce the number of redundant audits and the

5 \$4 billion dollars that ground damage costs the

6 industry each year.

7 The standards are nearly complete and

8 the testing has started, so we plan to conduct

9 the first audit in early 2008. As regulators, I

10 encourage you to use ISAGO as a tool and help us

11 to develop and strengthen the standards, because

12 an effective auditing is also critical to safety

13 and working together is the only way to deliver

14 the best results.

15 Safety Management System, SMS, is

16 another good, great example of where we need to

17 work together closely. ICAO did good work in

18 developing the concept to take a systematic

19 approach to safety culture by aligning the entire

20 organization of the airline beyond safety and

21 operations. IATA incorporated this SMS thinking

22 through the IOSA audit effectively making it a

23 requirement for all IATA airlines. Now it\'s time

24 to dig a bit deeper.

25 Although we all agree on the concept

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1 in are implementing as best practice, there is no

2 goal for global standard to guide us or targets

3 to monitor our progress. And SMS has the

4 potential to be wonderful tool to align our

5 safety efforts but we must agree together to a

6 global standard that is measurable, and I will

7 closely follow your discussion on this topic that

8 I\'m sure will be very important this afternoon.

9 Another important issue for safety is

10 training and qualification, because our five to

11 six percent growth per year brings other

12 challenges. Just look at the house in New York

13 where a politician failed to invest in

14 infrastructure. We are working closely and

15 effectively, as always, with the FAA on a

16 solutions. But another major challenge of growth

17 is availability of qualified personnel, and it\'s

18 a problem all around the world. All our airlines

19 are having big, big trouble in addressing this

20 issue. Because there are 16,000 planes on the

21 manufacturers order book, to fly them we must

22 produce 17,000 new pilots a year. And the

23 question is how do we train and qualify them

24 while continuing to improve safety. Already, we

25 are seeing the first signs of strain. We\'re

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1 still worrying tendencies. No standards for

2 training and qualification and human factors are

3 cropping up in more accidents. It is time to

4 ring the warning bell.

5 We must rethink pilot training and

6 qualifications. Why? Because today there are no

7 global standards or training concept or

8 regulations, not even a shared standard between

9 IOSA and the FAA, and this must change. IATA\'s

10 training and qualification initiatives has five

11 goals \-- to raise awareness of the looming

12 crises, to coordinate a global approach to

13 solutions, to maintain and improve essential

14 standards and to increase the pool of pilot\'s

15 candidates and improve training capacities.

16 To achieve this, we must work with

17 regulators together to develop global standards,

18 harmonize their implementation and support them

19 with effective oversight. I will be frank. We

20 failed with foreign operations specifications.

21 We cannot afford a similar mess with training.

22 It is too important. The first test will be the

23 multi-crew pilot license, MPL. Pilot training

24 has not changed in 60 years. We were flying the

25 DC-3s. We now fly the 380s. We are still

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1 thinking box with an emphasis on flight hours.

2 ICAO revised Annex 1 to allow for a competence-

3 based at initial training. We can produce better

4 pilots more efficiently by focusing on real

5 multi-crew working conditions and making better

6 use of simulators.

7 Some areas are moving fast,

8 particularly those areas with a strong tradition

9 of initial training. Europe was an early

10 adapter. In the last month, the first four MPL

11 graduates graduate from Denmark. Australia and

12 China are on board and Japan and Canada are not

13 far behind. The U.S. has been a bit more

14 cautious. With 5,000 out of work pilots to date,

15 the need for more efficient training seems today

16 a bit distant. But with growth, that will change

17 quickly. This is an issue that we all face, so

18 we must work together to deliver a global

19 solution that supports improved safety and

20 sustainable growth with better trained pilots.

21 The last point I want to raise is

22 environment, another issue of sustainable growth.

23 We all know that aviation is 2 percent of global

24 carbon emission according to the Nobel Prize

25 winning IPCC. Efficiency gains will limit our

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1 global CO2 contribution to 3 percent by 2050. So

2 aviation is and will remain a small part of the

3 big problem of climate change. But our carbon

4 footprint is growing and that is not politically

5 acceptable for any industry.

6 IATA has a four-pillar strategy to

7 address climate change \-- invest in technology,

8 build and operate efficient infrastructure, fly

9 planes effectively, and once we have achieved all

10 of that, let\'s consider also economic measures

11 from tax credits for re-fleeting to offset

12 programs and emission trading. This strategy is

13 producing results, concrete results. We share

14 the roots \-- best practices ensure management and

15 better operational procedures. IATA achieved up

16 to 15 million tons of CO2 savings in 2006. And

17 airlines are committed to doing even more to

18 achieve a carbon-neutral growth in the medium

19 term with a long term goal of a carbon free

20 future.

21 Climate change is a global solution

22 and it\'s a global problem, so we can only achieve

23 this if governments support a global solution.

24 We took our strategy and goals to ICAO recently,

25 at the last assembly, where all member states

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1 endorse the IATA strategy and I particularly

2 expressed my appreciation yesterday to Secretary

3 Peters who led a strong U.S. delegation and to

4 our great friend, Jeff Shane, for sharing a

5 difficult and important debate. But one of the

6 biggest satisfactions was at the U.S. acceptance,

7 not just of the strategy but also of our fuel

8 efficiency target to achieve 25 percent

9 improvement by 2020.

10 The biggest disappointment was Europe.

11 They supported the global strategy, yes.

12 Appreciate it. But they\'re taking a unilateral

13 approach to emission trading. That is

14 irresponsible and politically motivated.

15 Moreover, it does nothing to improve

16 environmental performance. The Chicago

17 Convention and IATA fully supports any challenge

18 by states at ICAO, WTO or elsewhere.

19 Let me be absolutely clear. Our goal

20 is to improve the industry environmental

21 performance with a target of zero emission and

22 economic measures will not achieve that goal.

23 Only technology can bring us to a zero emission.

24 Some potential building blocks for a carbon-free

25 future are here today \-- solar power, bio-fuel,

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1 fuel cells, and the manufacturers community

2 backs this vision from Airbus to Boeing, GE,

3 Pratt & Whitney and Rolls Royce, all our fuel

4 suppliers. I personally had meetings with all of

5 their CEOs and they\'re all supporting and we\'re

6 all engaged in this great, great important

7 achievement. But nobody has all the answers

8 today for a zero emission.

9 But let\'s remember that we went from

10 the Wright Brothers to the jet engines in just 50

11 years. And today, 50 years after that, we are a

12 safe, global, mass transportation system for 2.2

13 billion passengers. With commitment and common

14 goals, I am convinced that our carbon-free future

15 is absolutely possible. We are a great industry

16 built by turning dreams in to reality supporting

17 today 32 million jobs and \$3.5 billion in

18 economic activities. We are putting our

19 financial house in order.

20 Also, many challenges are ahead of us.

21 We have achieved amazing results in safety. Nick

22 mentioned some. But every accident is a tragedy

23 and the preliminary results for this year remind

24 us of the need for constant vigilance everywhere.

25 Our common goals is an industry that is safe,

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1 secure and environmentally responsible. The only

2 way forward is to work together as we are doing,

3 as partners with transparency and targets. Thank

4 you very much.

5 (Applause.)

6 MR. SABATINI: Thank you, Giovanni.

7 You have certainly provided us what we have come

8 to expect from you \--incisive and informative

9 comments and certainly a very compelling global

10 perspective. Thank you once again, Giovanni.

11 So we\'ll now take a 20 minute break.

12 Actually, maybe a little longer because you\'re

13 supposed to be back at 9:35. Do listen for the

14 chimes and we\'ll see you back here. Now unlike

15 last year where the break was right out these

16 doors, it\'s downstairs, so I encourage you to, as

17 you take your break and engage with your

18 colleagues, do walk through the exhibits and take

19 a good look there. I think we\'ve got some

20 exciting exhibitors there and exciting things to

21 see. So we\'ll see you back here shortly.

22 (Whereupon, off the record at 9:04

23 a.m. and back on the record at 9:41 a.m.)

24 MR. FILIPPATOS: Good morning,

25 everyone, if we could take seats and get started

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1 with the first plenary, that would be terrific.

2 And also, if Randy Babbit is in the room, there\'s

3 a message for you at the desk. Welcome to

4 everyone here and especially to our guests, our

5 colleagues who are able to come internationally.

6 We are grateful to have you here and appreciate

7 the opportunity to talk about these issues with

8 you. Of course, we\'re going to begin with the

9 first Plenary now \-- Safety Management Systems,

10 so a key issue, if not the key issue of this

11 conference. I am very pleased to have Captain

12 Dan Maurino as the moderator, and I\'m going to

13 turn it over to him Officer Slaughter that he can

14 go ahead. I\'ll quickly introduce the panelists

15 and then get the dialogue started. Thank you

16 again for being here.

17 CAPTAIN MAURINO: Thanks, Jim. Good

18 morning, everybody. I would like to start off by

19 expressing my personal appreciation to the

20 Federal Aviation Administration for this

21 opportunity to moderate a panel with a membership

22 of the caliber of the membership of this panel.

23 (Whereupon, off the record at 9:42

24 a.m. and back on the record at 9:44 a.m.)

25 CAPTAIN MAURINO: Anyway, again, thank

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1 you very much to the Federal Aviation

2 Administration for this opportunity. Let me

3 align the flight plan we discussed with the panel

4 members, for you this morning. We\'re going to go

5 through a brief identification of each panel

6 member. We are not going to go into

7 introductions. You have the bios in your books.

8 Then each panel member will have an opportunity

9 to make a brief statement kind of to fire up the

10 discussion, very short couple of minutes.

11 And then we\'ll move over to the actual

12 debate that we intend to present as a kind of

13 professional cross-fire situation keeping in mind

14 that there are no right or wrong answers. It\'s

15 simply presenting perspectives that hopefully

16 will assist you in furthering your endeavors

17 regarding SMS in your organizations. And we\'ll

18 try and spare the last 20 minutes or so of the

19 session to open up the floor for questions. So,

20 that\'s the flight plan.

21 So let\'s proceed with the

22 identification of the membership. On my extreme

23 far left, Captain William Yantiss. Bill is the

24 Vice President, Corporate Safety Security Quality

25 and Environment with United Airlines. To his

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1 right, Merlin Preuss. Merlin is the Director

2 General of Civil Aviation with Transport Canada.

3 To Merlin\'s right is Captain Peter Griffiths,

4 Director General for Civil Aviation for the

5 United Kingdom Department of Transportation. To

6 Peter\'s right is Randy Gaston. Randy is Vice

7 President for Fight Operations with the

8 Gulfstream Aerospace Corporation. To Randy\'s

9 right is Mickey Cohen. Mickey is the Vice

10 President for Operations and Engineering with the

11 AAR Cooperation. And last but not least, Mr.

12 Nicholas Sabatini. Nick has already been

13 introduced. He\'s the Associate Administrator for

14 Aviation with the Federal Aviation

15 Administration.

16 So what we have here represents the

17 regulatory side of the house in Nick, Merlin and

18 Peter. We have the flight operations, including

19 air side of the industry, with Bill; the

20 maintenance aspect with Mickey; and then the

21 corporate executive aviation in Randy. So we

22 have a pretty good spread of membership.

23 So let\'s start with the opening

24 statements. Nick?

25 MR. SABATINI: Thank you, Dan. First,

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1 let me say that it\'s an absolute honor and

2 privilege to be here with my distinguished

3 colleagues on this panel. We\'re at a critical

4 junction in aviation safety, and aviation safety,

5 that safety equation is an evolution of where

6 we\'ve been to where we can each continue to

7 evolve to. And we\'re teeing up this conversation

8 as a global conversation so that there\'s clear

9 understanding of what it is that we\'re saying

10 when we talk about SMS.

11 In reality, in my own personal

12 experience, if I\'ve talked to 10 people, I get 10

13 different versions of what they believe SMS is.

14 And I will tell you this. For one, it is not a

15 panacea. It is built on a framework of a good

16 quality management system. It is built on a

17 framework of good regulations that establish

18 standards. And for those of you who are looking

19 for a off the shelf box where you reach in and

20 pull out the SMS magic, it doesn\'t exist. What

21 it is is a business approach to managing risk,

22 and that\'s what we\'re going to have a

23 conversation about. And the break out sessions

24 will address each of the four pillars that form

25 the foundation for safety management systems.

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1 CAPTAIN MAURINO: Very good. Thank

2 you very much. Mickey?

3 MR. COHEN: As we look at the airline

4 industry today and we continue our evolvement of

5 the maintenance organizations moving into third-

6 party providers, it provides a different

7 challenge for us that are doing the maintenance.

8 We\'ve had a lot of systems in place, a lot of

9 programs, and what SMS is doing for us is

10 bringing together all of these programs and

11 making it a system that we utilize within the

12 company, and we analyze and we make

13 recommendations and changes, and we address it

14 just as if we had a financial miss as we go

15 through daily business. So we treat safety and

16 quality no different than we would anything in

17 our financial model.

18 What\'s important to us as we become a

19 third-party provider is the partnership that we

20 have, not only with our customer but with the

21 regulatory folks, international and the sharing

22 of information. In our company, we have put

23 together system where we have information sharing

24 of every quality escape, every incident, customer

25 issues, and employee issues and we shared among

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1 all of our facilities. And it\'s carried right

2 through out corporate organization. This comes

3 down from the top of our organization and is

4 supported with our chairman. And we have taken

5 it throughout our entire system.

6 CAPTAIN MAURINO: Very good. Thank

7 you very much. Randy?

8 MR. GASTON: Thank you. First, I\'d

9 like to express my appreciation to be able to

10 participate in this forum. For the business

11 aircraft community, the challenge is try to get

12 our hands around how do we set a model for that

13 community to have something that we can count on

14 that addresses safety, not just a safety program

15 but some type of safety management system. The

16 predominant model for all my flying career has

17 been safety programs, which is really nothing

18 more than a reactive response to something.

19 Something happens, you come up with another rule

20 or response to try to minimize that.

21 But the thing is it\'s really not data

22 driven, so what we\'re really trying to do is we

23 come up with a system that allows you to have

24 information to come in to be able to make

25 intelligent decisions on how you want to try to

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1 manage risk.

2 Two years ago, we embarked on having

3 a safety management systems within our flight

4 operations. We have about 100 pilots. We do

5 everything from flight tests to corporate flying

6 to production and corporate transportation. So

7 we said, how do we get our hands around this to

8 define whether we\'re actually safe or not. And

9 so the fact that we really never had any real

10 issues as far as accidents, that was not the

11 question. The question really was how do we know

12 we\'re safe. And so what we did is that we went

13 through the process of getting ISBAO standard,

14 International Standards Business Aircraft

15 Operations. The idea was to get a Good

16 Housekeeping seal of approval on ourselves. So

17 we\'ve already had one external audit, and next

18 month, December 11th, we\'ll have our second

19 external audit.

20 In the process of the second audit, I

21 asked a rhetorical question. I said, well, you

22 know, we\'re spending money doing this, can you

23 tell me what we\'re going to get out of this? Do

24 we need to continue doing this. And the answer I

25 was looking for was yes, but I wanted the

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1 rationale. And it simply said this \-- is that we

2 need an external forcing function was it. We

3 need an external forcing function, because we

4 have all these other things that are demands on

5 our time. And what that would do is it forces us

6 really to do the job that we have to do all the

7 time.

8 The safety management system is a data

9 driven system. It likes to be fed. All right?

10 And that\'s the only way you can be able to make

11 good rational decisions. And so to have a good

12 safety management system, it has to be data

13 driven. So, that\'s the system that we\'ve

14 embarked on. That\'s the one we\'ve been \-- we

15 feel we\'re successful with, and through our \--

16 the different committees that we\'re involved

17 with, our owners, operators, we try to get them

18 to adapt the safety management system process.

19 CAPTAIN MAURINO: Very good. Thank

20 you very much. Peter?

21 CAPTAIN GRIFFITHS: Thank you, Dan.

22 It's a great pleasure to be here as one of those

23 irresponsible Europeans \-- we heard that earlier

24 \--

25 (Laughter.)

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1 VICE ADMIRAL BARRETT: \-- to be able

2 to come and talk to you about management of risk,

3 which we obviously have got wrong, so that\'s a

4 great advantage for us. However, I think safety

5 management systems, having been involved with

6 them for so long in airlines as well as from a

7 regulatory framework and working across many,

8 many cultures, the key to it is the people

9 themselves. People are not only the generators

10 of risk, but they\'re also the victims of risk.

11 And we have to go make sure that whatever

12 frameworks are put in a global environment deal

13 with effective cultures with those people,

14 pursuing the causes of safety risk, pursuing

15 activities that we find are causing problems,

16 promoting safety and promoting toolkits that we

17 can use within that safety management system that

18 work for that environment and to prepare plans to

19 mitigate some of those risks. So a four-tier

20 approach of effective culture development.

21 And those come out as outcomes. What

22 we\'re looking for is constant outcome which

23 improves our safety performance. And that is

24 part of a constant improvement program. They\'re

25 difficult to regulate. When I look at it from

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1 the other side of the fence, having been an

2 airline operator for quite so many years, now I

3 sit the other side of the fence as the

4 gamekeeper. It\'s actually very difficult to

5 regulate. We have to find methodologies to do it

6 so that we can work together with the industry

7 and management through partnership approaches

8 between the regulator and the industry to get

9 those required outcomes.

10 When I look at the UK aviation system

11 of irresponsible managers, we now have 221 AOCs

12 in the United Kingdom. I don\'t think that

13 there\'s probably anybody in the room that is not

14 touched by UK aviation. We have in our top three

15 operators over 600 aircraft operating worldwide.

16 We have 19,000 commercial pilots and all of those

17 fall within the state safety management system

18 which then feeds into regulatory programs into

19 other states. So I think the challenge for us as

20 we look at global safety management systems, is

21 making sure that all of those people participate,

22 all of those people feed in information into our

23 system sensory net, as some airlines have called

24 it, and feed information into the thinking

25 element which results in the arms and legs of our

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1 regulation which pushes us forward towards our

2 goal of constantly improvement.

3 CAPTAIN MAURINO: Very good. Thank

4 you very much. Merlin?

5 MR. PREUSS: Thanks, Dan. And my

6 thanks to the FAA for the invitation to

7 participate in this panel. I\'m going to take a

8 little different tact than the previous panel

9 members and talk about it strictly from the

10 government perspective, if you like. So there\'s

11 three points I\'m going to try and make here

12 briefly. We took the formal safety policy

13 decision to implement SMS in 1998. About four

14 years later, we regulated the SMS into the

15 business aviation sector. In 2005, we regulated

16 the airline business which means the AMOs that

17 support the airlines and the airline industry

18 itself, 20 passengers or more, what Nick would

19 call Part 121,. I believe. We are now coming to

20 the end of the three-year implementation period

21 of that particular regulation.

22 Hot on the heels of that is the

23 regulations for our major airports and air nav

24 system providers, so this is all coming in to

25 place systematically and relatively slowly. The

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1 requirements that we have, and as Nick said,

2 there\'s 10 people in the room, 12 opinion of what

3 SMS is, our SMS has to a few more bells and

4 whistles on it than what ICAO has published, but

5 that ICAO core is part of what we have.

6 The point I\'m trying to make here is

7 this is a long path for regulatory authorities.

8 It is not, as Nick said, an off the shelf

9 solution. So first point, it\'s going to take

10 time for a regulatory authority to get their head

11 around this and put it in place.

12 The second thing and parallel activity

13 that we put in place in Canada was the equivalent

14 of a safety management system in the government,

15 in Transport Canada Civil Aviation, absolutely

16 necessary in our view. Again, it has its

17 difficulties, but the only discernible difference

18 between what we\'re asking industry to do and what

19 our own system does is our system applies to

20 everything we do, whether it\'s finances or human

21 resources, and the second difference is I don\'t

22 have the performance indicator called profit.

23 That\'s all the differences there are between the

24 two systems in Canada.

25 So, what I'm saying here is the

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1 regulatory authorities need to walk the talk if

2 they\'re going to be able to maximize the benefits

3 of SMS and the industry. The last point, and this

4 is really scary, if you\'re organized to deliver a

5 forensic type approach, which we all were and

6 perhaps some of us still are, including Canada in

7 many areas, that organization we have found to be

8 ineffective inefficient in implementing SMS in

9 industry and implementing our own risk management

10 framework inside.

11 So you can look forward to a

12 reorganization quite blankly. So in Canada, no

13 doubt, we\'re preventing all these things. We are

14 experiencing a government agency the perfect

15 storm. It is not for the faint hearted. Thank

16 you, Dan.

17 CAPTAIN MAURINO: Thank you very much,

18 Merlin. I\'d like to add at a personal level that

19 beyond the Canadian government, Transport Canada,

20 in terms of SMS, at a personal level, I have yet

21 to find a more passionate person about SMS than

22 Merlin, as an individual. Bill?

23 CAPTAIN YANTISS: Terrific. I\'d like

24 to focus representing the airlines on a couple of

25 points. One is we could not agree more that a

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1 safety management development and implementation

2 in an airline to change our culture, we call it a

3 journey. In fact, it\'s probably a journey that

4 never ends. Our start actually, for us at

5 United, was in a very unusual and unexpected

6 area, and that was actually our co-chair

7 relationship.

8 We discovered that when the FAA \--

9 after several accidents, the FAA asked the

10 airlines to develop a standard and a

11 certification process for all of our coach

12 airlines that we were going to put our passengers

13 on. Well, obviously this is good business for

14 the airline, because if we\'re going to put our

15 passengers on another carrier, and soon we\'ll be

16 co-chairing with over 60 airlines, so I am

17 required in my position, and Hank Krakowski, my

18 predecessor, to do the same thing \--is write a

19 letter that states that our co-chair partner

20 meets the same essential standards as we do at

21 United and that the airline meets all the ICAO

22 standards. That presented a unique challenge to

23 U.S. carriers, and this is maybe one of the times

24 that a legacy carrier actually got out front.

25 So we recognized that we needed to

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1 create a global standard that the regulators

2 would accept as well as all airlines, and we

3 started off on a project under the sponsorship of

4 IATA to implement a safety management system and

5 a global standard for co-chair airlines. Now

6 what\'s quite interesting about this is that the

7 organization or management standard of IOSA is

8 actually based on the Transport Canada

9 fundamental five elements, which is organization

10 and management, which is safety policy;

11 documentation system so that it creates some

12 fundamental framework for the organization to

13 operate and be consistent; a safety system of

14 some kind with individual components; a quality

15 system and emergency response.

16 Now when we published the original

17 IOSA standard, we knew the world was not ready to

18 call it an SMS, so what we did was call it

19 organization and management. It\'s fundamental

20 management 101 and then a safe airline and a

21 well-managed airline is a safe airline, and it

22 produces a consistent, efficient product. And

23 that certainly is our goal. So as we published

24 the standard, we didn\'t call it an SMS, but we

25 recognized this was the first space for the

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1 airline industry and we can be a part of that.

2 And each of the three alliances sponsored this

3 effort to develop a initial standard that met

4 all of Dan\'s ICAO requirements, included all of

5 the best practices that we could find on the

6 planet and made those options and suggestions and

7 developed guidelines for implementation.

8 That was our first exposure to SMS and

9 I\'ve had a chance to audio about 50 airlines and

10 to measure airlines against the standard, and

11 those have been some wild experiences. I had one

12 CEO that actually threatened to throw me off the

13 property along with our team because we were

14 measuring their organization against this

15 standard. And they said, we don\'t want you here,

16 we don\'t like this standard.

17 And it was really obvious at that

18 point we needed a global system, a terminology

19 and an approach that we could all agree on. We

20 are a global industry. We need to get out of the

21 regional mentality and create this common ground

22 under with ICAO, the regulatory agencies, the

23 airlines, the employees and the entire

24 infrastructure. So the work that and the

25 discussions we\'re having today are immensely

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1 important to the industry.

2 CAPTAIN MAURINO: Very good. So I

3 think that each of the statements provide like a

4 springboard for further questions to progress the

5 panel. And I\'m going to take them in no

6 particular order. But these are certainly

7 issues. The statements have identified issues

8 that we certainly need to deal with at a very

9 general level at least.

10 Nick addressed the question of

11 different perceptions about SMS is or is not and

12 the fact that it is perceived as a solution to

13 all the problems in aviation starting with

14 identification of safety risks on the one side

15 and ended up with unwanted pregnancies on the

16 other, a situation which is not unlike the

17 situation aviation faced in the late 80\'s with

18 aviation human factors. And I think that at this

19 point in time, if you ask a person to clearly

20 articulate what is an SMS, you would see the same

21 thousand-year stares that you would see in the

22 80\'s if you ask a person to articulate what is a

23 aviation human factors.

24 So question for the panel \-- would an

25 international standard or standards identifying

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1 the functions that an SMS should get involved in

2 and the outcomes of those functions, would such

3 standards help clarify misperceptions and

4 misconceptions? Do we need an international

5 standard? Anyone want to take this one? Peter?

6 CAPTAIN GRIFFITHS: Yes. I think

7 having worked in other countries with different

8 cultures, one of the aspects of trying to get

9 over safety standards and safety programs is I

10 was constantly asked what to do; where is it;

11 what can I touch here; what toolkit have I got to

12 go and actually manage this. And yet when you

13 talk about some of the concepts of safety in a

14 global environment, some of them may have trouble

15 with the language, some of them may have trouble

16 with some of the concepts. They\'ve got their own

17 beliefs, mechanisms and their own values.

18 But what you find underlying all of

19 that is there is a concept of safety and a

20 standard will help them be able to choose the

21 believes and value systems that they\'ve got to

22 translate that into the standard that we\'re

23 looking for globally. So I would strongly

24 support a standard that looks at outcomes, and

25 give those countries that need it, the ones that

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1 we were hearing about from Giovanni \-- we\'ve had

2 some accidents recently \-- to be able to give

3 them the toolkit that shows them how to move

4 their systems or believes and values into

5 something which will enhance safety in their

6 countries.

7 CAPTAIN MAURINO: Very good. Nick?

8 MR. SABATINI: I\'d like to give that

9 a shot. I would offer that \-- so I\'ll use the

10 U.S. as an example to illustrate the point. I

11 believe that you cannot simply walk in lockstep.

12 What works best is if you established principles,

13 basic principles that are embodied as attributes

14 in the design and construct of a safety

15 management system. It is based on a good quality

16 system where, as an industry, we are very

17 experienced and very good at saying this is the

18 quality of my product, and we have in place

19 quality management systems. The evolution from

20 just quality is to also manage safety, say this

21 is my safety outcome.

22 Randy mentioned data. I will tell you

23 that data is the lifeblood of safety management

24 systems. It absolutely is dependent upon sharing

25 of data so that we can understand no only what

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1 happened but why it happened. And when you

2 understand that and you have data, you can do the

3 analysis to look at your risk areas and determine

4 the safety of your operations by identifying the

5 risk and applying mitigations or elimination of

6 that risk, whatever the case may be.

7 So I would say that we look at a

8 regulatory structure as the safety standard, the

9 training, the maintenance, the operation. But

10 how safe is the operation? And that\'s the

11 challenge for us is to put in place, number one,

12 a mindset that manages safety from a system

13 design at the local entity, certificated entity,

14 whether it\'s a repair station, whether it\'s an

15 airline or some other certificated entity and

16 then raise it to a national level so that there

17 is an understanding of what the system is doing.

18 Using the United States as an example, what is

19 each individual air carrier doing? They

20 understand that but it needs to be rolled up to a

21 higher level so you have a national understanding

22 of what is going on from a system perspective as

23 well as tying into a global perspective. That\'s

24 the interconnectivity that\'s required.

25 So I think it\'s outcomes. What do we

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1 want? Performance based.

2 CAPTAIN MAURINO: Merlin.

3 MR. PREUSS: Just to follow on with

4 what Nick said, I\'m fully in favor of a

5 international standard, performance based. I

6 think that\'s the only way to promote that type of

7 regulatory framework.

8 On a slightly different tag, one of

9 the things is starting to show up with our system

10 as we put it in place is the effect it has on our

11 relationships with other regulatory authorities.

12 The SMS regulatory framework being performed in

13 space brings with it a different surveillance

14 model. If you have an international standard

15 that\'s clearly based on performance, it will be

16 much easier to create those equivalent levels of

17 safety so that the international agreements that

18 you have, whether it\'s with repair stations or

19 with airlines flying over your country, it\'ll be

20 a lot easier to create those equivalencies.

21 What we have right now is an audit\'s

22 an audit\'s and audit. Everybody understands

23 that. The results of the audits, you take the

24 box and you\'ve got some satisfaction that you

25 have the equivalencies. Once you move off into

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1 the SMS world, those equivalencies are harder to

2 determine if you\'re using a forensic approach.

3 So, yes, international standard. Yes,

4 performance based.

5 CAPTAIN MAURINO: Pat, with your alert

6 can you \-- does that involved, say, a significant

7 shift in the way that we kind of monitor each

8 other so to speak \-- it might involve \-- from the

9 perspective of the industry, because we\'ve heard

10 the regulators so far. Randy or Mickey or Bill,

11 any input here as users of the system.

12 CAPTAIN YANTISS: I\'ll take a shot.

13 I have long, for years, recognized the value of,

14 as an international aviation community, being on

15 the same page so that we can communicate and look

16 at the industry holistically rather than

17 operating in regional silos. We\'re all

18 operating in each one another\'s air space. We

19 have, obviously, global air traffic control

20 challenges.

21 But when we look at partnerships with

22 MROs, and we\'re exploring and SMS relationship

23 with one of our MROs as we speak, we see that

24 we\'re all tied together and that as MROs develop

25 safety management systems, or what I prefer to

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1 call safety and quality management systems, along

2 with all of our other air carriers, to ensure

3 that we understand the same standard.

4 We are basing as an IATA carrier all

5 of our expectations on ICAO requirements as a

6 foundation. We build on that with best practices

7 for airline operators, and these best practices,

8 over time, become requirements as we raise the

9 standard globally. And it allows us, I think, to

10 utilize the synergies, if you will, to address

11 safety globally. It's just not a regional issue.

12 We all operate globally in one another\'s air

13 space.

14 And IOSA was designed, for the first

15 time, to get a standard on paper \-- a, to get the

16 airlines thinking about safety and quality

17 management systems but also to get something on

18 paper where the regulators could see it other \--

19 as a different standard with ICAO and best

20 practices all in one volume. And as Giovanni

21 indicated in his presentation, there\'s over a

22 thousand standards. We continue to add best

23 practices.

24 It\'s not a panacea. Because if

25 someone is IOSA registered just means that they

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1 meet that standard. It doesn\'t always mean that

2 it\'s done as well as it could be. But it is one

3 approach to standardized airlines and to give

4 this fuzzy SMS discussion some specificity,

5 granularity and so that we can touch and feel and

6 understand it. And I think that\'s its real

7 value.

8 CAPTAIN MAURINO: Very good. Okay.

9 So I suppose that we could safely assume that we

10 have one first conclusion out of the panel, and

11 that is that we indeed need some kind of

12 international standard which aligns the functions

13 and the deliverables of an SMS. And, oh boy, I\'m

14 so happy to hear that, because the way that ICAO

15 communicates with its membership is through a

16 device that is called state letter, and we have

17 indeed developed one such standard for an SMS

18 framework which will be communicated through our

19 membership through one state letter which is

20 going to be distributed for comments on the 7th

21 of December. So I\'m glad to hear the replies

22 that we\'re going to receive from at least three

23 members of our communities. Are you guys crazy?

24 So now it was mentioned Randy, I

25 believe, in his opening statement that SMS is a

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1 data driven approach to the management of safety

2 risks. Somehow Mickey brought the data question

3 in by saying we need to deal with the management

4 of safety along the same lines that we deal with

5 other organizational processes, financial

6 management, human resource management and so on

7 and so forth. I think that it was alluded,

8 again, to the notion that data, it\'s the

9 lifeline, the blood of SMS \-- simply because

10 we\'re talking about management, you cannot manage

11 what you cannot measure.

12 The question is how do we protect the

13 sources of safety data or the sources of safety

14 information so that we can access the data on

15 safety risks? Because prevailing legal systems

16 throughout the world are first concerned about

17 punishing and then the rest. So we need data.

18 Are we going to be able to access that data in

19 the prevailing environment? And if not, what can

20 we do? Who wants to give a first stab at this

21 one? Nick?

22 MR. SABATINI: Well, here in the

23 United States, and we certainly recognize that

24 that is a significant concern globally in terms

25 of the protection of the data. And for each

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1 sovereign state, there are different judicial

2 systems, but I can best talk about what we have

3 here in the United States. The United States

4 Congress has given the FAA the statutory

5 authority to protect that data which is

6 voluntarily provided in both the safety and

7 security arena. And we have programs that are

8 identified as those programs through which you

9 may participate and provide the FAA with data

10 that is gathered every day by the people

11 operating the system.

12 And just to give you a sense of

13 perspective of how critically important it is for

14 us to work together with industry, I\'ll give you

15 some statistics. Before we had programs, like

16 ASAP, the Aviation Safety Action Program, and

17 before FOQA and before COSP, what we knew is that

18 we were gathering data through the FAA\'s own

19 efforts. Now that we are receiving terabytes of

20 data, we have a sense of perspective in the sense

21 that we were only gathering about 5 percent of

22 the data that exists in the universe of safety

23 data. The other 95 percent is in the hands of

24 the people who operate the system every day.

25 It is absolutely essential that that

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1 information be shared with the regulator in a

2 non-punitive environment where we not only

3 understand what happened but why it is happening.

4 And that presents us data that can be translated

5 into usable information. And it absolutely needs

6 to be protected. So we have a good system in the

7 United States. It\'s not perfect but I would

8 encourage other sovereign states to consider that

9 kind of an approach. Certainly, we continue to

10 learn from each other, but it is absolutely

11 critical that data, if we\'re going to continue to

12 provide the public the expectation that we have

13 created that flying from A to B is almost

14 guaranteed.

15 And yet we know, as a safe operation,

16 that it\'s guaranteed to be from A to B safe, we

17 know that risk is always greater than zero. And

18 if we\'re going to serve that public well, then we

19 have got to have the flow of information freely

20 given without fear of blame or punishment.

21 CAPTAIN MAURINO: Any perspective \--

22 okay, Merlin, yes, sure, go ahead.

23 MR. PREUSS: Just a slightly different

24 perspective. We\'re making some amendments to our

25 Aeronautics Act to provide some of the

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1 protections that Nick has alluded to. And

2 believe me, in our Parliamentary committees, the

3 whole idea of the government hiding data from the

4 public was really a sore point with our

5 Parliamentarians and with the media that were

6 following this.

7 So the way that we\'re trying to

8 approach this \-- and of course, it\'s a given that

9 what we want is a blame-free reporting

10 environment \-- the approach that we\'re taking

11 here is the individual who\'s making the reports

12 is going to be fully protected. The FOQA data is

13 going to be fully protected up until its de-

14 identified. So the trick here is that once it\'s

15 de-identified. the impact it has on the person

16 making the report is it\'s not reduced to zero,

17 but it\'s pretty much reduced to zero if you\'re

18 very cautious about how you do that.

19 And we\'re hoping that that will allow

20 the blame-free reporting environment to flourish

21 while at the same time meeting the needs of the

22 public for access to information.

23 CAPTAIN MAURINO: Do Exhibit have a

24 perspective from the irresponsible Europeans?

25 CAPTAIN GRIFFITHS: Yes. I was told

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1 the irresponsible Europeans have no view on this.

2 We take this particular issue quite seriously.

3 You\'ve seen a lot of activity within the European

4 arena on whistle blowing legislation, on Safe

5 Harbor provisions for data. And I think there

6 are many airlines in Europe that have led the way

7 on ensuring that data protection systems are

8 there through confidentiality requirements,

9 through making sure that unions have the right

10 interaction with not only the regulators but also

11 the companies. But ultimately, the

12 accountability for that data sits at the very top

13 of the company.

14 We often talk about human factors and

15 how it\'s pilot error and many other things. How

16 many corporate errors have we made in the

17 boardroom? How many accidents have actually

18 occurred because of decisions that are taken in

19 the boardroom? So that human factors approach

20 moves all the way through the reporting systems

21 of the company, right up to the very top level,

22 to ensure that everybody understands that we are

23 all prone to error, we are prone to risk, and

24 therefore we should manage our risks accordingly.

25 So by putting the accountability right

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1 at the very top of the company, very top of the

2 regulatory trees and ensuring that we have a full

3 and free dialogue within those confidential

4 provisions I think is essential to good SMS

5 management, and it helps us develop pictures of

6 outcomes that we can support.

7 CAPTAIN MAURINO: Randy?

8 MR. GASTON: Yes. I think without the

9 protection of data, you\'re going to have a hard

10 time advancing safety beyond a level that we\'re

11 seeing today, because the only way you\'re going

12 to get to the point now, where we\'re going to

13 address the random human error, actually, the low

14 level of accident rates to go ahead and make any

15 kind of material difference is that you\'re going

16 to have to have a lot more data to look at that.

17 When we try and look at this in a global way

18 relative to the Gulfstream fleet of aircraft, how

19 do you get all the people in that to participate

20 in a, let\'s example, a FOQA program, because we\'d

21 like to have all that information?

22 But the question \-- the first thing

23 that comes from operator was well, we want this

24 protected. So, you know, the first thing we do

25 is we explore ways to protect information. In a

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1 way, it\'s naive to think that the information\'s

2 not there anyway. It\'s because the ultimate

3 failure is when you have the accident and, of

4 course, you\'ve got flight data records and

5 cockpit voice recorders. You haven\'t protected

6 anything.

7 What it allows you to do with a FOQA

8 program and gathering data, it allows you up

9 front to start looking at behavior. If you look

10 at what\'s \-- what happens is in accidents as

11 you\'re looking at the human side of it, you can

12 address the accident rates either through

13 technology or you can do it through looking at

14 the behavior side of it. Safety management

15 systems primarily look at behavior.

16 When I talk about looking at data, the

17 quantity of data you need is the type of data

18 that you see from a FOQA program. We are making

19 some headway within the business community to

20 introduce people to that concept and acceptance.

21 We\'ve had people do pilot programs and they have

22 readily embraced it. But if you ask the

23 community how many would sign up for FOQA today,

24 you get a mixed response. But then when you give

25 them the sense that \-- how the information can be

**73789a6a-b28d-4172-a102-5e2392f88277**

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1 used and it\'s protected, you get a lot more

2 people to go ahead, and they\'re willing to sign

3 up for it.

4 CAPTAIN MAURINO: Now the question

5 would be, at a really personal level, and this is

6 really a personal level, there is this notion

7 that protecting data or sources of safety data,

8 it\'s like it is impossible, because we\'re dealing

9 with legal systems and legal systems cannot be

10 changed. Is that true? Have legal systems never

11 been changed in the history of the humankind when

12 a society has perceived there are dangers here

13 and present to that society and therefore it

14 changed and a human-made device was necessary?

15 Do you guys feel that this legal obstacle is such

16 an obstacle or is it a lack of requisite

17 imagination by our part to properly present the

18 case to lawyers and politicians?

19 MR. SABATINI: I would offer that it

20 is an incredibly challenging endeavor to

21 undertake to change a political system that is

22 embodied in its judicial and legal system, but

23 the force that is at play here today in this

24 global community is that as Merlin pointed out,

25 we can no longer live in the forensic world. As

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1 difficult as it was in years past to improve on

2 engine reliability, to improve on airframes, crew

3 resource management, the introduction of

4 technology like EGPWS, we learned hard lessons

5 the hard way. And as difficult as that was, when

6 you look back in history and what we\'ve been able

7 to accomplish to bring us to where we are today

8 is the safest it has ever been. Looking back,

9 that was easy work. The hard work is ahead of us

10 and that is the compelling case, for the global

11 community recognize that if \-- when the system is

12 going to grow as it forecasted to grow, it is

13 critically important that we work together,

14 regulators and the industry in a construct such

15 as SMS where you must have a collaborative

16 relationship. The flow of information must be

17 free flowing.

18 And I would offer this. You\'re going

19 to sit in on four breakout sessions, and we have

20 talked about standards and I guess that\'s part of

21 the conversation that needs to take place \--

22 well, what is a standard? Is a standard a

23 regulatory standard or is it a principle? We

24 espouse the idea that in an SMS construct, there

25 are four fundamental principles. You wish to

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1 call it a standard, I\'m okay with that. But it\'s

2 not so much the standard. It is the outcome that

3 we expect. What is that outcome? It is a safe

4 operation. But we\'ve got to define safety. That

5 is the difference in terms of where we\'ve been

6 and where we\'re going today.

7 If you look at what we\'ve done at the

8 air carrier world starting in the United States

9 in 1998 where we introduced the air

10 transportation oversight system, you\'ve basically

11 asked those air carriers to redesign their

12 organizations in such a way that there was in

13 every person who had a responsibility that that

14 responsibility was clearly written and that it

15 was documented and that that person had the

16 authority to execute that responsibility and was

17 held accountable and that there would be in place

18 procedures for that person to execute, that

19 there\'d be controls in place to assure that those

20 procedures were executed in the proper manner,

21 that there were metrics to determine that what

22 was designed was, in fact, delivering the proper

23 product.

24 And last but certainly not least, of

25 the very complex nature of an air carrier \-- now

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1 there are many other complex organizations \-- but

2 we have our most experience in the air carrier

3 world, an incredibly complex organization, the

4 interface, the point being from the front office

5 of the flight deck to the person who is at the

6 end of the boon de-icing the airplane that the

7 training be such that it was consistent in

8 everyone understood it. But that was just the

9 first step in system design.

10 All it did was identify risk. And you

11 targeted your resources to identify \-- to treat

12 that risk. But it doesn\'t actively promote the

13 management of risk. It\'s understanding that risk

14 and once you know what that is, it\'s to manage

15 that risk. That\'s why we talk in terms of at the

16 very top of the organization, you must have the

17 commitment from senior leadership, and that

18 leadership must establish the policy and what

19 they expect in a safe operation. They have got

20 to put in place procedures that assure \--

21 basically, we refer to it as safety assurance.

22 And then, of course, the determination that those

23 controls that you have in place are, in fact,

24 producing what you designed that system to

25 produce, so you have risk management and what you

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1 do with risk management and mitigate those risks.

2 And last but not least, all these

3 processes are executed by humans. I would offer

4 that unless those processes exist in a culture of

5 safety, you will never make the kind of progress

6 that we absolutely need. So there are the formal

7 programs which are ASAP and FOQA and the other

8 programs that we have. But you don\'t need ASAP

9 and you don\'t need FOQA in a company. There are

10 tons of data that are accruing and available

11 every single day that doesn\'t have to be reported

12 in an ASAP world within the company. That

13 information needs to be shared and you don\'t need

14 formal programs and you don\'t need to change a

15 judicial system.

16 CAPTAIN MAURINO: Peter and then

17 Mickey.

18 CAPTAIN GRIFFITHS: I think one of the

19 things that we have to recognize is that we\'re

20 regulators. I mean if I listen to my colleagues

21 in the industry, they tell me that we\'re

22 constantly writing the law and we\'re constantly

23 changing it. So if we\'re listening to the

24 industry and they want us to do something about

25 it, and they want us to actually put in those

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1 provisions, and it\'s not beyond the wits of the

2 regulators to put it in, and he\'s talked about

3 the data approach, putting together a package

4 that says you must do this if that data is

5 overwhelming, and it is \-- Giovanni put a really

6 good speech together which showed what the

7 industry have achieved over the last 20-30 years.

8 That has been built on protected

9 systems, on safety management processes, on

10 confidentiality of the data. It also shows that

11 the industry is one of those industries which

12 everybody looks up to. Before I joined the

13 Department of Transport, I was working in the

14 marine industry to put a safety management system

15 in on a cruise line. They all admire the

16 aviation industry. So we\'ve got elements in

17 there that are really good, and if the industry

18 says that they need protected systems, then we

19 must look at that, and we must try and devise the

20 law so that we recognize what the lawyers want to

21 do but at the same time protect those elements of

22 the industry which we know and love so well to

23 ensure that we\'ve got it.

24 CAPTAIN MAURINO: Mickey?

25 MR. COHEN: I think the protection of

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1 information even goes deeper. We\'re talking at a

2 fairly high level here of the reporting coming

3 from the companies, but where we\'re really going

4 to see the benefit from a safety system is at the

5 lower levels of the organization from the people

6 that do the job every day. And you need to put

7 in a just culture system where they don\'t have a

8 fear of reprisal, and you put that system in and

9 it doesn\'t start working tomorrow. It takes,

10 quite frankly, years to get the confidence of the

11 people in leadership teams within the companies

12 to be willing to come forward, because it\'s those

13 little things. We catch them at a higher stage.

14 If we can get the information at a

15 lower stage and share that information, we can

16 have a much better benefit from it. One of the

17 things we have done at our repair stations is we

18 have put in an enterprise reporting system. As I

19 mentioned before, an employee can put something

20 in that he perceives to be a problem, and he

21 won\'t be persecuted for it. He could ask for a

22 response. He can do it anonymously. We put in

23 hotlines that they can call and report things.

24 As a customer has a problem with an aircraft that

25 we have produced, we will take that, put it in

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1 and all of these things get analyzed.

2 And then as we come up with a fix for

3 it or a resolution for it and most of the time

4 it\'s going to be in your procedures. In the

5 maintenance world, most of the errors are done

6 because we have got a procedure that has a fault

7 in it, and we develop those procedures. We test

8 them. And a lot of the times, people just go

9 along with them until there\'s something very

10 significant that happens.

11 But if we can get them to identify it

12 and we can convince them to bring that

13 information forward, and that\'s what we share

14 internationally, it would just be a tremendous

15 system and we\'d all benefit from it.

16 CAPTAIN MAURINO: There is this common

17 expression that nobody knows better how a system

18 really works than the people who make the system

19 work. They will tell you know how the system

20 should operate by the book but how the system

21 really operates divergent from the book. And I

22 think that in an ideal SMS government, the

23 information that we\'re talking about should be a

24 mix of that lower level information, as you

25 categorize it, and the information that an

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1 organization normally has access to, that Nick

2 was alluding to before. So any other

3 perspectives on this one? Bill?

4 CAPTAIN YANTISS: If I may just add a

5 couple of thoughts. One is the issue of trust.

6 As we gain more experience with safety and

7 quality management systems, we have our

8 associations typically represented by one of

9 their leaders at the table in an ASAP program.

10 We have a regulator. We have a company

11 representative. That\'s really provided an

12 opportunity to develop trust so that we can get

13 sensitive issues on the table and start talking

14 about risk.

15 And we have found that our

16 experimentation of working collaboratively with

17 the FAA, for example \-- let me just chase that

18 rabbit if I may \-- has proven very positive. We

19 understand the FAA\'s goal is to ensure, as an

20 airline, our oversight group, wants to help us

21 identify risk and ensure that we\'re providing

22 safe transportation. Obviously, we want to do

23 the same thing. So from that perspective, we\'re

24 pulling on the same rope, but we\'re using a

25 different set of tools.

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1 We have found that with the new air

2 transportation oversight system and trying to

3 align that with the IOSA Safety Management

4 System, the new advisory circular on safety

5 management systems, if we align all of these,

6 then we\'re bringing the FAA and our employees and

7 the associations or the unions together at the

8 same table working the same issues and getting

9 those perspectives. And those three different

10 perspectives for the same discussion are really

11 great. If we bring our safety representatives

12 from the airlines pilot association to the table,

13 they bring a onsite experience and perspective to

14 the table that is really invaluable.

15 So I guess trust as we move forward in

16 safety management systems, if we\'re going \-- I

17 guess my worst fear is not knowing what those

18 risks are. So the objective that I have in our

19 airline is to create an atmosphere where we\'re

20 open and candid and transparent with the

21 regulator. We actually go out and audit the

22 airline jointly with the FAA. They have access

23 to all of our audit reports. They share their

24 inspection reports with us, and therefore we

25 stand a greater chance of identifying weaknesses

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1 in the system because we\'re now sharing data and

2 we trust one another, and that\'s been a gradual

3 process.

4 And then similarly with the

5 associations \-- The associations are very, very

6 sensitive about a punitive environment. And with

7 our ASAP programs, we currently have four, each

8 with a different association, each with a

9 different culture, each with a different set of

10 guidelines and rules to develop that trust

11 between the company, the representatives. And

12 we\'re now negotiating with another association

13 for ground employees. I consider this the Mount

14 Everest of challenges, because it\'s a challenging

15 environment, high turnover, a culture in most

16 airlines have somewhat of a punitive nature, so

17 we\'re looking to change our corporate culture,

18 and we call that a just culture for the

19 management team \-- but creating that trust, and

20 all of us to include the union representatives,

21 in this case the IAM, going to school for SMS and

22 having a common language.

23 So really, if we have the employees,

24 the airline team and the regulators talking the

25 same language and understanding each other\'s

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1 challenges and ensuring trust with that data,

2 okay, and so that either the airline is not

3 dragged through the media and embarrassed for

4 sharing sensitive information or weaknesses in

5 the airline system. I can be very embarrassing.

6 So if we\'re headlined in the media as an airline,

7 the last thing I want to do is share deficiencies

8 in the airline.

9 So that, I guess, the element of trust

10 for all the players is very important to success.

11 MR. SABATINI: If I may, I\'d like to

12 add, I think, a very important point to what Bill

13 is saying. He did a magnificent job of

14 describing what is taking place, in his case, at

15 United Airlines and the associations and the

16 various organizations that are working with him

17 in that construct. From a regulator\'s

18 perspective, that is local in nature. They know

19 absolutely what is going on to the extent that

20 they have information at that local area. And so

21 there\'s United, there\'s the other carriers \--

22 American and US Airways, etcetera, and they all

23 know what\'s going on locally.

24 And in an SMS construct, the next

25 level is to \-- it\'s about system design. It\'s

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1 taking safety management systems to the next

2 level, to a national level and we\'ve got the

3 beginnings of that with what we are now referring

4 to as ASIAS, the Aviation Safety Information

5 Analysis and Sharing System, where it takes that

6 local information, de-identified and protected,

7 etcetera and loads it up into data that flows

8 into this capability to identify those risk areas

9 and apply the intervention, identifying areas of

10 vulnerability. So easier said than done, but

11 nonetheless, that\'s the track we\'re on.

12 CAPTAIN MAURINO: But in any event, I

13 believe that there is absolute consensus in the

14 panel that the question of data and the

15 protection of the data is essential. And I think

16 that we could close up this portion of the

17 discussion by paraphrasing something that Acting

18 Administrator Sturgell said in his remarks,

19 something along the lines there is no place for

20 secrets in safety. And I think that that pretty

21 nicely sums up what we\'re trying to discuss

22 there.

23 We have about ten minutes before we

24 opinion up for questions, and there are two

25 additional issues that I like to see if we could

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1 discuss. I loved something that Merlin said \--

2 regulatory authorities need to walk the talk.

3 Now we keep saying SMS is a change in company

4 culture and blah-blah-blah-blah-blah-blah-blah.

5 What about the Civil Aviation Authority? I mean

6 how do we change the intellectual mindset of the

7 workforce that have been used throughout their

8 entire work experience to enforce and move that

9 workforce toward a situation of cooperative

10 development? And the question, I guess, goes

11 primarily directed to the three regulators in the

12 panel. How do we bring the inspector on board.

13 Merlin?

14 MR. PREUSS: With great difficulty.

15 CAPTAIN MAURINO: With great

16 difficulty.

17 MR. PREUSS: As we go through this

18 process, in Canada actually implementing this

19 framework and also changing some aspects of the

20 Act to allow us to maximize the benefits of SMS,

21 we\'re running into resistance from really only

22 two places. One is our internal pilots

23 inspectors union for the things that you\'re

24 talking about. And the other one is one of the

25 unions that\'s dealing with flight attendants. So

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1 I know you participated in our Parliamentary

2 committee, but one of those sessions had our two

3 major pilots unions basically at the same table

4 with the internal union, and the two external

5 pilots unions saying this is the best thing since

6 sliced bread. Here\'s a couple things you better

7 look at so you get it in right. And a complete

8 opposite thing happening with the internal

9 government union.

10 The way that you try and achieve that,

11 I would suspect, is to start with the whole idea

12 of integrating risk management into everything

13 that you do. Now we\'ve trained our inspectors

14 over the last five or six years. I\'d be very

15 surprised if you could come up with a problem

16 where our employees won\'t talk about solving the

17 problem by doing the risk analysis. They haven\'t

18 been able to consistently take that knowledge

19 about how they do business and apply it to this

20 new regulatory framework.

21 So I think the key here, a lot of it

22 has to do with education. It\'s not about

23 changing the results of your work so much as it

24 is about the way you try and get those results

25 which is more, on a risk management approach,

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1 identify the hazards, work in partnership with

2 the industry and bring that forward. But it goes

3 back to trust. Until that trust is developed,

4 we\'re going to continue to see resistance from

5 our own workforce. It is a work in progress.

6 CAPTAIN MAURINO: So what you\'re

7 saying is the message would be we\'re not trying

8 to change the outcomes.

9 MR. PREUSS: That\'s right.

10 CAPTAIN MAURINO: We\'re trying to

11 change the processes that you engage into \--

12 MR. PREUSS: Easy to say, hard to do.

13 CAPTAIN MAURINO: Yes, I suppose.

14 Peter?

15 CAPTAIN GRIFFITHS: Excellent. That

16 was me just thinking I got rid of the

17 irresponsible label, but it looks as if it\'s been

18 pushed back again as the irresponsible

19 regulators. I think there\'s a great deal that

20 regulators can do in order to move forward with

21 the SMS concept. If SMS is good for the

22 industry, it\'s good for the regulator, too.

23 And I would highlight it with an

24 example from the UK CAA. One airline in the UK

25 grew so rapidly, but one of the big questions \--

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1 and it was a question that was quite used not

2 just about that airline but a number of different

3 that were approaching from the United Kingdom \--

4 it was a question of fatigue management. And

5 fatigue management is actually a bit of a dirty

6 word within the aviation industry and one which

7 gets into very personal levels of commitment fro

8 companies to protect people as well as

9 commitments to insure that that data is kept

10 under control. Nobody in any airline industry

11 wants to go out and say that their pilots fall

12 asleep, but we know that it happens, and when

13 you\'ve got the right framework that you can work

14 together with your regulator and your industry

15 and bring data out that shows that these are

16 problems, you can come up with an effective

17 solution.

18 So if you take Randy\'s point earlier

19 about data drives everything, that particular

20 airline put together its FOQA system, its quality

21 system, its pilot checking process, its human

22 factors programs, its reporting programs and its

23 confidential reporting systems, plus it did some

24 fairly intrusive tests on its pilots. It tested

25 their cognitive performance before and after

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1 flight. It checked their physical standards. It

2 checked how often that they came to work having

3 had a really bad night out on the town and things

4 like that. You\'re getting into very personal

5 areas, areas where the unions are very sensitive,

6 and quite rightly so.

7 But at the end of the day, all of that

8 data was being shared with the regulator. It\'s

9 about the management of risk, so we went on what

10 Mick has called the \"journey\" of change within

11 that environment. We took some very clever steps

12 to move in towards a much more free and open

13 regulatory process, a risk manage process where

14 the regulator itself took an SMS approach towards

15 dealing with our airline and ensuring that they

16 met the standard. So they knew what the outcome

17 was.

18 So I think we, as regulators, can

19 definitely take that step if we\'re willing to do

20 so. We need to make sure that there\'s right

21 controls and processes in place in order to

22 protect all of the individuals. But it is a step

23 worth taking. It\'s a step which joins on that

24 journey towards our goal of a global safety

25 management system but also an assurance that

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1 every flight is safe.

2 CAPTAIN MAURINO: Nick?

3 MR. SABATINI: We\'re all familiar with

4 Professor Reasons. In his book, managing the

5 risk of organizational accidents, he goes on to

6 say \-- while he doesn\'t specifically address

7 regulators, but he talks about large

8 organizations, he goes on to say that

9 organizations like ours can unwittingly be

10 contributing to accidents. How so? By the way

11 we behave. And if you subscribe to that, and I

12 do, then I would say this. If you\'re going to

13 bring to the regulator, in our case, 6500 people

14 in our safety organization to adopt and

15 internalize for themselves why we need to behave

16 in a different way, then you have got to make a

17 compelling case for that change.

18 You can issue all the edicts that you

19 wish. Human nature and time has proven that

20 edicts don\'t last. If you want real change

21 within a culture, then you must be able to

22 describe a compelling reason for that change.

23 And we took on that challenge and we\'ve been on

24 this journey for about four years now. And it

25 brought us to a place where we said, one, let\'s

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1 apply to ourselves the same rigor and the same

2 discipline that we apply to industry. While we

3 don\'t require ISO-9000, but it is a methodology

4 many in the industry have adopted for themselves.

5 And we are not an ISO-9001 certified

6 organization. And we have voluntarily imposed

7 that upon ourselves. And we have also imposed

8 upon ourselves the rigor and the discipline of

9 safety management systems.

10 So it can be done. I will tell you,

11 and I agree with Merlin, it is very difficult.

12 But I would caution that if you\'re going to do

13 that, it cannot just be an edict \-- this is what

14 we\'re going to do but rather be successful in

15 describing that compelling reason for that

16 change. Because fundamentally, we\'re talking

17 about a culture change.

18 CAPTAIN MAURINO: All right. Very

19 good. I said two questions, but I really lied to

20 you, because we\'re coming to the 20 minute point,

21 and I\'d really to open the floor questions. And

22 in any event, I can ask those questions from the

23 floor this afternoon in the panel that Nancy

24 Graham is going to moderate. So at this point in

25 time, with 20 minutes to go, we would like to

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1 open the floor for questions any of the panel

2 members.

3 MR. HUETTNER: Yes, hello? I\'m over

4 here. Charlie Huettner representing Naverus

5 today. Most of the discussions thus far on SMS

6 have been on what\'s happening today in today\'s

7 aviation system. And as we all know, the

8 performance-based aviation system of the future,

9 NEXTGEN here in the United States, and named other

10 ways around the world will be transforming the

11 aviation system rather dramatically over the next

12 few years.

13 How do you see SMS being involved and

14 integrated to ensure that as we move to a

15 different aviation system, a more performance-

16 based system, that we don\'t, in a sense, create

17 new issues, new safety issues and identify them

18 early on?

19 CAPTAIN MAURINO: Who\'d like to take

20 that one? Merlin?

21 MR. PREUSS: I guess I can start off.

22 When you talk about what Nick was talking about,

23 what he refers to as ISO and other processes he\'s

24 put in place in terms of managing the risks on

25 behalf of the organization, because I agree

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1 totally with Nick, the regulator can cause as

2 many problems as they can solve, in this

3 particular case, if that was presented to us in

4 Canada, and it will, because that stuff is all

5 integrated with our border being the way it is

6 and the control system the way it is, we would be

7 asking those people that are implementing that

8 new regime to identify the hazards ahead of time

9 and tell us how they\'re going to be mitigated or

10 eliminated. And then whatever residual risk is

11 there will have to be dealt with.

12 So it\'s process-based approach and

13 that, frankly, is how we do business today in

14 Canada. If you\'ve got something new coming in,

15 if NAV-CANADA comes to us and says, we\'re going

16 to try \-- we\'re going to put ADS-B in place.

17 That\'s fine, go ahead and do that. But before

18 you\'re going to get the go ahead, we need to see

19 from you the hazards that you think are out

20 there, the risk management process you\'re going

21 to follow to eliminate or mitigate those risks.

22 So I think we\'re sophisticated enough to deal

23 with those things as long as we follow what we\'re

24 referring to now as the SMS approach.

25 CAPTAIN MAURINO: Bill?

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1 CAPTAIN YANTISS: From just an

2 airlines perspective on where we think we\'re

3 going. An airline, as I think we mentioned

4 earlier, is an incredibly complex animal, many

5 moving parts. It\'s amazing it works as well as

6 it does when you consider the number of

7 activities that are going on simultaneously.

8 Just push back an airplane. The carriers \-- and

9 we just had a discussion this week with Air

10 Canada comparing notes on how to move ourselves

11 forward and integrating all of these management

12 systems in an airline. And when we look at an

13 airline, we\'re looking at 30 or 40 management

14 systems. Safety is one. Quality is another.

15 And we\'re looking at security management systems,

16 obviously with a different regulatory agency.

17 Environmental safety systems, occupational safety

18 systems \-- all of these \-- and this is the

19 airlines challenge, okay \-- and the regulatory

20 agencies can tell us these elements need to be in

21 place, but our big challenge as an airline is how

22 to organize our work, our leadership team roles

23 and responsibilities, how do we get this done.

24 And one of the things that we

25 recognize with a team under IATA was rather than

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1 communicating to our senior leadership a SMS,

2 let\'s talk to them in terms they really

3 understand, and that\'s an integrated airline

4 management system of which safety is a

5 fundamental foundational piece of which

6 everything else is based. But on the other hand,

7 how do we get there and how do we organize. And

8 we, through this discussion, a team, some of

9 which are in the audience today, created a

10 document called \"Integrated Airline Management

11 System.\" And this, we think, to answer the

12 gentleman\'s question, is where we, as a group of

13 airlines, are moving forward \-- United and Air

14 Canada have what we call an integrated airline

15 management system and it\'s a work in progress

16 that\'s evolving.

17 But one of the pieces that you need is

18 that as being data rich and information poor is

19 that we have implemented an operational risk

20 management board, Risk Analysis Board, RAB if you

21 wish, and we meet monthly. And all of the

22 directors who have a database \-- what is that

23 database telling you in terms of risk \-- we bring

24 it together once a month. And then once a

25 quarter starting in February, we\'re getting

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1 together with the associations, all of our

2 unions, the leadership on safety, the regulator,

3 all the principals, our senior leadership team,

4 the officers, and we\'re going to T-up from each

5 database a risk. What is the leading risk of the

6 quarter? What are we doing about it? It\'ll be

7 action oriented.

8 And this, I think, is where we\'re

9 taking into the next phase risk identification,

10 analysis. So we get the employee perspective.

11 We get the regulators perspective, and we get the

12 airline leadership team perspective. We bring

13 all of that intellectual capacity in one room to

14 talk about one issue. And it\'s for 15 minutes

15 for each \-- for our director of quality, for

16 example, and maintenance will have 15 minutes,

17 short, succinct, direct \-- what are we doing

18 about this issue, and then measure results. That

19 is a work in progress. But I think, as an

20 airline, this is where we can go.

21 Then there\'s element of risk and this

22 is a new enterprise risk management system. So

23 we now have a risk tolerance committee for the

24 enterprise. And that\'s not exactly where the FAA

25 or the regulatory agency is, where the SEC is,

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1 but it\'s the senior leadership. And this is

2 enterprise risk. Operational risk is handled by

3 the COO., and this is what I am doing with our

4 staff. But there\'s two levels and in this

5 document, what we tried to do was show the

6 differences between the two risk analysis and

7 management systems. One\'s focused on operational

8 risk and all of these elements or modules, ASAP,

9 FOQA, and all of those are modules, audits, and

10 all the measurement systems. And then we have an

11 enterprise risk system that is manage by the CEO.

12 So this is an effort, and a work in

13 progress, to sort out these activities so that

14 our leadership team and the airline can

15 understand it\'s granular. It\'s a little bit more

16 specific, granted it is a work in process.

17 CAPTAIN MAURINO: Very good. Any

18 further questions? Yes?

19 MR. MERCKX: Good morning, my name is

20 Erik Merckx. I\'m working for EUROCONTROL.

21 Unfortunately, that\'s based in Europe as well.

22 We\'ve been working with our member states for

23 quite a number of years now to implement a safety

24 framework, and within those member states, we

25 have the air navigation service providers, and

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1 for the last four years, we\'ve been doing almost

2 on an annual basis a measurement of what we call

3 their maturity as a mis-maturity. And of all

4 these service providers, there are quite a few

5 who are fairly matured. When they are mature, it

6 takes about five to ten years before they reach

7 that level of maturity, and some of them still

8 have a fair way to go.

9 Now the ones who are mature, we see

10 that they are very far advanced in the way they

11 measure their performance, and I think that comes

12 back to a comment made earlier this morning, that

13 perhaps the best way to follow this up is by a

14 performance-driven system. However, what we also

15 see is that when people do measure their

16 performance, it is not only in terms of

17 accidents, it is not only in terms of incidents,

18 but let\'s start measuring other things, things

19 such as how many trainings have been planned; how

20 many of those trainings have really been

21 followed; refresher training; are competencies of

22 people measured; if there is a change in the

23 organization or in the system, is there a safety

24 assessment done; is safety really on the agenda

25 with the board \-- one can see that from the

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1 minutes, etcetera.

2 So it is a whole set of data below

3 incidents and accidents, and that made basically

4 the difference between matured and non-matured

5 organizations. Now my basic question is how far

6 do you want to go in terms of setting a global

7 standard? Where is the line, the thin line

8 between how much of that you want to put in as a

9 regulator or you want to trust that to the

10 accountability of the organization in charge?

11 That\'s the question. Thank you.

12 CAPTAIN MAURINO: That\'s indeed a very

13 European question.

14 (Laughter.)

15 CAPTAIN GRIFFITHS: I can see it will

16 come to an irresponsible European to answer.

17 (Laughter.)

18 CAPTAIN MAURINO: Did I say that?

19 CAPTAIN GRIFFITHS: I can see you

20 looking at me, Dan. Thanks. I sat on the

21 Provisional Council of EUROCONTROL, so I share my

22 colleague\'s view on systemic maturity. It\'s a

23 great way forward. But the difference with all

24 of these things is measuring the iceberg of risk

25 that we see. There\'s a lot of things that are

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1 above the line, the activities that we see on a

2 day-to-day basis. But it\'s the interactivity of

3 all the material that\'s going on below the

4 waterline which is actually causing the problems.

5 And I think Europe is probably one of

6 the best ways of demonstrating what happens when

7 you bring together so many different cultures

8 with so many different views which contrast with

9 each other and occasionally compete with each

10 other, and sometimes we have an occasional war

11 with each other just to try and work out who\'s

12 got the best one.

13 So it\'s really important that as we go

14 through these changes and, in particular,

15 EUROCONTROL has got some really big challenges

16 ahead trying to bring together the states that

17 operating, lots of different ANSPs. I mean

18 there\'s 68 ANSPs just in the UK alone. That\'s

19 before you start looking around the European

20 theater.

21 Those standards are really important

22 and they\'ve got to be driven by performance

23 outcomes, and we\'ve got to be able to inform

24 those systems and change them really quickly.

25 I went to a Provisional Council

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1 meeting recently, and I was quite surprised at

2 how advanced they were, but it created one

3 massive risk. One of the big risk that they face

4 is how do we close the gap on the growth of the

5 airline industry. And we go back to the previous

6 is these are the challenges that we\'re facing as

7 regulators. How do we close the gaps between the

8 systems that are being developed now? How do we

9 make sure that we risk manage that as we move

10 forward and bring that all together as one

11 holistic program which takes the industry on just

12 that one pace more?

13 CAPTAIN MAURINO: Good.

14 MR. TRAINER: David Trainer with the

15 Boeing Company. Nick made it sound like SMS is a

16 system that is an overlay to an existing quality

17 management system already in place. Does this

18 mean that SMS is a \-- could be a premature step

19 for a country or airline that\'s Category 2 or

20 blacklisted? Is there a walk before you run

21 aspect to this implementation?

22 MR. SABATINI: I didn\'t mean to have

23 it sound like it\'s an overlay system but rather

24 it\'s an attitude. It\'s a management attitude.

25 It\'s about how you, in your small company or

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1 large company, are going to manage safety just

2 like you manage finances, just like you manage

3 quality, etcetera. But there are some good

4 foundational blocks that you can build upon and

5 take advantage of, so that\'s what I was trying to

6 communicate, David, that\'s it\'s not just one more

7 thing we\'re going to add. I would like to

8 encourage you all to think of it as evolutionary.

9 It\'s the next step forward on what we already

10 doing very, very well.

11 CAPTAIN MAURINO: Good.

12 MR. GADZINSKI: John Gadzinski with

13 Southwest Airlines Pilot Association. I\'d like

14 to challenge the panel because what I\'ve heard a

15 lot of is that SMS is a data driven system, and I

16 go back to Frank Borman after the Apollo I pad

17 fire who said, we knew that there were risks out

18 there, and we were looking for them. What we

19 lacked was we had a failure of imagination. And

20 my challenge to you is that it\'s just as

21 important to know what questions to ask as it is

22 to know what to do with the answers.

23 And a good example is you have to ask

24 the question why did it make sense to put three

25 guys in a capsule filled with 100 percent oxygen

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1 and bolt them shut and have them flipping

2 switches. And I ask myself the same question \--

3 why does it make sense to ask an airline pilot to

4 land a commercial jet with his breaking pressure

5 going to 3,000 pounds but his anti-skid system

6 pressure only metering out 300 pounds and to ask

7 him to give a breaking action report?

8 Those things \-- those kind of

9 questions can\'t be \-- don\'t jump out at you from

10 a FOQA program or an ASAP program unless you have

11 somebody in that SMS process who places a high

12 degree of importance on using education and

13 creativity to know what kind of questions to ask.

14 Thank you.

15 MR. SABATINI: You know, I would offer

16 a caution. I think your point is well taken, but

17 humans historically, and I believe it was Albert

18 Einstein who said, if I only knew the right

19 question to ask. We are very good at asking

20 questions post accident and it\'s very difficult

21 to come up with the right answer, and I think

22 almost impossible to come up with the question

23 that\'s going to provide an answer to prevent

24 something from happening.

25 I think the best solution is the kind

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1 of culture that causes that information to flow

2 upward to be addressed by that community, whether

3 it\'s the broad community, a safety community or

4 whether it\'s a small company, a large company,

5 the regulator, etcetera. So that\'s a challenge

6 for all of us.

7 But the issue of questions is one that

8 we\'re very good at answering post, and that is

9 one of the main drivers for getting into a safety

10 system that encourages the reporting of what is

11 going on in the system whether you are in a

12 formal program or not and whether it\'s going to

13 be reported to the regulator because it is in the

14 regulatory structure or whether it is strictly

15 operational within the organization itself. So

16 questions pre-accident are very, very difficult

17 to get the right one.

18 CAPTAIN MAURINO: Merlin?

19 MR. PREUSS: I agree with Nick it\'s

20 very difficult to get the imagination up front,

21 but there\'s a couple of things that can help us

22 along the way I think. Implicit in the

23 implementation of an SMS in any operation would

24 be the concept of developing a risk profile.

25 That would be the first opportunity that you

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1 would have to be imaginative in your questions.

2 A whole bunch of what ifs. Identify all the

3 hazards you can, take the next step and ask the

4 question what if.

5 Implicit also in a well functioning

6 and effective SMS would be the root cause

7 analysis where you do not stop at band-aid

8 solutions. That mule mated with that aircraft

9 because that mule driver wasn\'t properly trained.

10 We\'ll retrain him or her. I don\'t think so.

11 That is not a sufficient answer if you\'re going

12 to have your SMS functioning to its maximum

13 capacity. Why wasn\'t the training done? What

14 was wrong with the training? What was the

15 attitude of the person on that mule that day?

16 If you do those two things \-- take a

17 look at risk profile from the beginning of your

18 operation and be diligent about finding out

19 exactly what\'s causing the errors that show up, I

20 think you\'re going to go a long way to trying to

21 get the fact that you can\'t be imaginative every

22 time in every situation.

23 CAPTAIN MAURINO: Bill?

24 CAPTAIN YANTISS: I think as an

25 airline, we\'re really good at collecting data.

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1 But we\'re challenged with having the tools, the

2 right kinds of databases in order to fully

3 understand and appreciate what it\'s really

4 telling us \-- to pull out those risks. And as

5 Merlin says, regarding root cause analysis, this

6 is a work in progress \-- a, for tools, training

7 people to do that, particularly line managers who

8 see this day in and day out.

9 And I think that\'s one of the

10 opportunities for a safety management system is

11 teaching our line managers, wherever they happen

12 to be, you know, whether it\'s a cabin, cockpit or

13 on the ramp or in maintenance, to identify those

14 risks as they\'re occurring. So for a ramp, for

15 operations, for example, threat and error

16 management, what are the threats. We teach

17 cockpit crews. Why don\'t we do it with the rest

18 of our employees. Okay, and that work is gaining

19 traction globally with ISAGO as on piece of that

20 initiative.

21 We had to divert, just to give you an

22 example, into Samoa with a 747, would the flights

23 fire a warning line due to \-- we had a load of

24 bees \-- yes, buzz, bees, you know and with some

25 dry ice to keep the bees cool. Well, we ended up

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1 with divert. And international diverts into a

2 location where there\'s very little support

3 intuitively seemed like a lot of risk.

4 So what we did was assign a team for

5 root cause analysis and risk assessment between

6 quality and safety people, because they have a

7 different set of tools, different set of

8 perspective, and they end up writing a 50-page

9 report on this thing with about 10 different

10 action items. There were risks that we had not

11 envisioned once they had debriefed everyone.

12 So you take a benign \-- you know,

13 there had been hull losses going into diverts.

14 You know, if there had been bad weather, a series

15 of aircraft malfunctions such as the enhanced

16 GPWS doesn\'t work, you may end up with a hull

17 loss. This we had good news. They landed

18 safely. But were identified significant numbers

19 of opportunities for improvement through good

20 root cause analysis.

21 Now we don\'t do that on every event,

22 but it does, as very illustrative of the value of

23 this type of working, doing it collaboratively

24 with the FAA, the associations, and our company

25 management team. Once again, that partnership

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1 working together.

2 CAPTAIN MAURINO: All right. Very

3 good. So we\'ve come to the end of the time

4 allocated for this panel. We have one minute.

5 One more question? One more question, okay. One

6 more question, please?

7 MR. KRIEGLER: Yes. Jacob Kriegler

8 with JetBlue Airways. Everyone is clearly n

9 agreement on the benefit and need for effective

10 SMS systems. My question is how we make sure

11 that all the different types of operators,

12 whether it\'s cargo or commercial or business,

13 really where the rubber meets the road, have the

14 tools and resources and education, both human and

15 technology, to bring about the outcomes that SMS

16 targets?

17 CAPTAIN MAURINO: Who\'d like to take

18 that one? Randy?

19 MR. GASTON: I\'ll start off that\'s a

20 good question on that, because if you look at

21 just information coming in, how are you going to

22 manage that. And as an example, when we looked

23 at a kind of a universal FOQA program, as an

24 example, we had to say, okay, what third party is

25 going to manage that. Okay, how is that

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1 information going to be distributed? You know

2 that you couldn\'t move forward unless you had all

3 those elements in place, so it\'s a difficult

4 task. But the parties that are out there that can

5 do that are there whether they\'re a third party

6 entity or that entity can exist within the

7 structure of an airline. An airline can do it

8 because it has the critical mass to do that in-

9 house. It can have the programmers that look at

10 the data and put that data out.

11 Now on the business side, if you\'re

12 looking at \-- just take, you know, one individual

13 operator that out there has the aircraft, and he

14 has a pilot crew, and he\'s asking himself how do

15 I assure that I\'m a safe operation. We have

16 people that are managing flight departments that

17 are attorneys, okay, because they\'ll find

18 somebody who\'s going to be the management head of

19 that group.

20 So the question is that \-- and this is

21 a real world example \-- the attorney comes to us

22 and he says, look it, I don\'t know really much

23 about managing a flight department, but he says I

24 \-- but I know to ask a lot of questions. And so

25 he wants to be able to assure his management that

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1 he has a safe department \-- taking it down at the

2 lowest level.

3 There is a mechanism for those people

4 to be in a FOQA program. There is a method for

5 them to be able to have data. All right? But

6 the problem then is is that when you have a very

7 small operation, when you get your FOQA data,

8 it\'s not a big mystery. Okay. So that\'s a

9 challenge for them to figure out how to go ahead

10 and do that.

11 But you also have quite an intimate

12 relationship with those people, because you\'re

13 flying with them all the time, so you get a real

14 sense all the time of their behavior. So there

15 are standards across the board. We\'re all faced

16 with the same issues in the flying environment

17 and that data. So whether it\'s an airline or

18 it\'s just an individual operator, there are

19 mechanisms there that can provide you really the

20 same answer.

21 MR. COHEN: You know, there\'s one

22 other mechanism that really needs to be

23 addressed, and as you listen to all the

24 conversation that\'s been going on, we\'ve been

25 talking about collecting data, but we\'ve spent

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1 very little time talking about feedback. And

2 without feedback, the data will dry up. And we

3 have seen that in every program I\'ve been

4 involved in and everybody you talk to, so it\'s

5 ultimately important to make sure the feedback

6 gets there so that the source keeps producing the

7 data.

8 CAPTAIN GRIFFITHS: And we\'re just

9 about to see yet another revolution in the

10 aviation industry with the advents and

11 implementation of VLJs or Very Light Jets, and I

12 think we\'ve had a little bit of discussion here

13 about corporate safety management systems. I

14 think the thing that we have to recognize from

15 the question that we got from our colleagues at

16 JetBlue is it\'s not just corporate aviation

17 that\'s out there, and commercial aviation. It

18 will be other people who don\'t have the benefit

19 of long training, who don\'t have the benefit of

20 FOQA data systems and other mechanisms. Each

21 individual is a risk manager in their own right.

22 If you look at Jim Reasons; work, \--

23 that was a really good example of causation. And

24 then if you look at John Adams\' work who was

25 working within the road industry within the

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1 United Kingdom, he suggested that every person,

2 be it a 5-year-old child right way through to the

3 old-age pension, there is a risk manager and they

4 learn along the way. And I think it\'s very

5 incumbent on us when we implement these systems

6 to make sure that the risk management is

7 understood across the board by single operators

8 right the way through to the very biggest

9 carriers, whatever we put in place, that it

10 addresses risk management across the board.

11 So again, we\'re back to performance

12 driven outcomes rather than just prescriptive

13 management.

14 CAPTAIN MAURINO: Very good. So now

15 I do believe that we have indeed come up to the

16 end of our allocated time. We hope that the

17 issues that have been discussed in this panel in

18 a general manner will fire up more specific

19 discussions during the afternoon panels. I think

20 we got pretty good insight and direction from

21 these panel members, and I would like to ask you

22 to join me in expressing our appreciation in the

23 usual manner.

24 (Applause.)

25 MR. FILIPPATOS: Thank you very much,

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1 Dan. An extremely compelling and excellent panel

2 for us to kick off this conference. We\'re going

3 to head to lunch now which is just across the

4 hall here out these doors. And the FAA and

5 conference staff will be able to guide you. I

6 think we should also, in addition to thanking the

7 excellent panelists, thank Dan in the same way

8 for moderating that great panel \--

9 (Applause.)

10 (Whereupon, off the record at 11:19

11 a.m. and back on the record at 12:15 p.m.)

12 MR. STURGELL: Good afternoon,

13 everybody. It\'s going to be a real treat for all

14 of us. You know, let\'s face it, as a group,

15 generally pilots are known for always trying to

16 one up each other. Well, after sitting at the

17 table here, that\'s not a place to go with Captain

18 Gene Cernan. Naturally, though, he is a Naval

19 Aviator, thousand and thousands of flight hours,

20 but the ace up this guy\'s sleeve is those 73

21 hours on the moon. That makes for a tough round

22 of been there, done that. You know? So instead

23 of going on, I\'m going to let the following video

24 speak for itself.

25 (Whereupon, begin viewing of video at

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1 12:16 p.m. and end video at 12:21 p.m.)

2 (Applause.)

3 MR. STURGELL: Ladies and gentlemen,

4 please join me in welcoming Captain Gene Cernan.

5 CAPTAIN CERNAN: Thank you, Tom. What

6 an honor and pleasure and privilege it is to be

7 here with all of you and have a chance to take up

8 some of your time and share a couple experiences

9 that I\'ve had. I\'ve got a couple of slides I\'d

10 like to go into, show you a little bit on the

11 lunar surface a little bit better. And Tom, I

12 appreciate your acknowledging the Naval \-- you

13 know, the Navy has aviators, the Air Force has

14 pilots and that\'s something we\'re very proud of.

15 (Laughter.)

16 CAPTAIN CERNAN: I\'m glad to see a

17 Naval Aviator at the helm of the FAA, and I\'m

18 here at the invitation of Nick Sabatini and

19 become a good friend. We share some of the same

20 values and outlooks for the future safety of

21 aviation around the world. It\'s his job to solve

22 the problems. It\'s not mine but I want to be as

23 much help as I can.

24 You know, we all \-- the aviation

25 community around the world doesn\'t make any

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1 difference what language we speak, what country

2 we come from, we all share something special, the

3 excitement, the adventure, the challenge, the

4 love of aviation whether you\'re in the cockpit,

5 on the ground or in an executive office building

6 somewhere, you\'re all here, I believe, because

7 you want to be here, because this is your life.

8 This is a future.

9 And space has made the world a lot

10 smaller than it was 30 and 40 and 50 years ago,

11 and aviation itself continues to keep it smaller.

12 We can go from one continent to the other in 8 or

13 10 or 12 hours, around the world quicker than,

14 you know, than we can sail a boat across Lake

15 Michigan, we are really an a very challenging and

16 exciting profession.

17 But I think the thing we all share

18 perhaps even more than the excitement and

19 adventure \-- you saw the work here \-- it\'s a word

20 that\'s very near and dear to my heart \-- is

21 passion. We all have a passion for what we do.

22 We all have a passion for aviation. I had a

23 chance to talk to about 500-plus corporate pilots

24 here in October, and I told them the same thing.

25 I said if you don\'t have the passion for what

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1 you\'re doing in a cockpit, then get out and do

2 something else, because you don\'t belong there.

3 And I think it\'s that passion that is

4 significantly important to all of us.

5 But what we\'ve got to do with that

6 passion is direct it towards committing ourselves

7 \-- and it\'s another word I use quite a bit,

8 because I believe in it very strongly \-- we\'ve

9 got to direct the passion that we and others have

10 in this industry and this business and this

11 profession, we have to direct that passion to

12 commit to being professionals. We have to commit

13 to being the best that we can be, whether at the

14 controls of an aircraft, the controls of a

15 console, making some long-term or immediate

16 decision in the boardroom, it really doesn\'t make

17 a difference. We\'ve got to take that energy and

18 that excitement, that love for flying and

19 aviation to be the best that we can be so that

20 the industry can be the best that it can be and

21 solve some of the problems that we have.

22 We were talking a minute ago about

23 professionalism and the challenge of aviation.

24 You know, down here on earth, we live in a two-

25 dimensional world \-- well, three if you count

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1 time. Time is important to us down here. We

2 don\'t pay much attention to it. The sun comes up

3 in the morning. We eat breakfast. The sun goes

4 down. We have dinner and go to bed. You got a

5 problem you want to solve, you\'ll write some

6 notes and you\'ll say let\'s meet tomorrow morning

7 at 9:00 o\'clock, see if we can solve this

8 problem.

9 But when you\'re in the skies, when

10 you\'re up there and the decision you folks, as I

11 say, whether you\'re in the executive office

12 building or on the ground or in the cockpit, the

13 guys up there and the gals up there, the people

14 up there are flying in a four-dimensional world.

15 The three-dimensional world of space plus the

16 fourth dimension of time. And you don\'t have the

17 luxury, as we did in the simulator, of pressing

18 the freeze button and saying, well, let\'s go and

19 have a cup of coffee and talk about the problem

20 that we\'ve just encountered.

21 You have to be prepared to make the

22 right decision at the right time to solve the

23 problem that you\'ve just encountered. Everybody

24 in the sky, or they wouldn\'t be there, can handle

25 a stick and rudder. They wouldn\'t get by that

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1 first solo if they didn\'t. Everybody can push

2 pedals and move yolks and sticks around. But

3 when I speak of professionalism, I speak of,

4 well, the preparedness and the knowledge that you

5 have to \-- that it\'s up here that controls what

6 you do with those stick and rudders and controls

7 what you do at that console on the ground. And

8 it controls some of the decisions that you\'re

9 going to be making in your own companies and in

10 your own countries that are going to affect other

11 people.

12 And so as I say, your challenge, as

13 far as I\'m concerned, is taking the excitement of

14 this industry, and aviation has been my life all

15 my life. And it\'s going to be my life, I expect,

16 for the rest of my life. But we have to take all

17 that. We have to bundle it up and commit to each

18 other individually, collectively to be the best,

19 to be professionals.

20 And, you know, I\'m getting a little

21 bit ahead of myself. But we\'re going to go back

22 to the moon. And we\'re going to go back to Mars

23 and that\'s part of the aviation and aerospace

24 industry I\'m talking about. But the world has

25 become uniquely smaller, and we\'re going to do it

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1 collectively. We got to be able to work

2 together. We got to be able to talk together.

3 And the problems you have in China and the

4 problems you have in the UK are the same

5 problems, I\'m sure, maybe dressed up differently,

6 that we have here in the U.S. That\'s why it\'s so

7 significant. That\'s why Nick and Tom, this kind

8 of \-- I\'ve heard more people tell me before we

9 started lunch, this is the place to be. This is

10 the best meeting of its kind on the issues of

11 safety and procedures and whatever that is held

12 anywhere at any time anywhere in the world. And

13 I congratulate you on that.

14 That\'s just my little spiel. I said,

15 Nick, what am I going to tell people who know

16 more about flying airplanes than I\'ll ever know

17 in a million years? Just tell them about going

18 to the moon. He said, I don\'t think anyone in

19 this audience has done that.

20 Let me \-- and I\'ve got a young man

21 over there, he\'s got a 10, he\'s got a 5, and he\'s

22 got a cut which \-- because I know you\'re busy.

23 You\'ve had a busy schedule. You\'re going to have

24 a busy schedule. I don\'t want to take more time

25 than I need. I\'ve got a few slides. I\'d like to

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1 take you to the moon very quickly and bring you

2 back. Well, let me back up a minute about

3 bringing you back.

4 Because we can be better than we are,

5 I\'m more familiar with the corporate world of

6 aviation. And 80 percent of the accidents in the

7 corporate world emanate from the cockpit. I\'m a

8 pilot. I\'m a Naval Aviator. I\'m still flying.

9 I\'m still flying Lears and Globals and my own

10 little 421. Don\'t talk to me about pilot error.

11 I\'m too good for that. The fact is I\'ve still

12 got a lot to learn. And we can do better than

13 that. We can do better than 80 percent.

14 And I\'ll give you an example of how

15 and why we can do better than that. In the space

16 program, we\'ve lost some people. We\'ve lost some

17 people in spacecraft and we\'ve lost some people

18 in airplanes. Astronauts, supposed to be the

19 best at what they do, we all make mistakes. We

20 all are subject to doing a dumb thing. And in

21 some cases, it\'ll kill us or hurt somebody.

22 We\'ve lost people in spacecraft.

23 We\'ve lost people in airplanes. But everybody \--

24 this is why I say we can do better \-- we\'re

25 capable of doing better if we commit ourselves to

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1 doing better as we have in the past during

2 Apollo. Everybody we sent to the moon came home

3 to talk to about it including the crew of Apollo

4 13.

5 Now ladies and gentlemen, I think

6 that\'s a testimonial to professionalism, to

7 taking the passion of going to the moon and

8 committing, committing \-- as the President said

9 on that film a minute \-- to send a man to the

10 moon and return him safely to earth \-- that is a

11 testimonial of the fact that we can, in the

12 aviation industry do better. We can take that 80

13 percent, Nick, and chop it down significantly.

14 We can take whatever percent it is in the

15 commercial world and chop it down,

16 notwithstanding that this is the safest

17 transportation industry in the world. Corporate

18 and general and commercial aviation is safer

19 today than it\'s ever been, and I\'m sure it\'s

20 primarily because of the commitment you people

21 have made.

22 Now, let me take you on a quick trip to the

23 moon which is sort of a passionate trip, but it

24 does show you the results of a commitment, and it

25 shows you what I would like to think is a little

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1 bit of professionalism along the way. Now

2 there\'s a lot of stories, I\'m told \-- and I\'m

3 talking as fast as I can because I\'d really like

4 to give you a chance to ask some questions if we

5 can \-- now if there\'s not a green button and a

6 red button, I\'m in trouble. Okay. Let me back

7 up.

8 This was our flag. Everyone wants to

9 be part of something. Apollo 17 was the last

10 flight, 35 years ago December 7th, next week.

11 Thirty-five years ago, we made the final steps on

12 the surface of the moon. I know there are people

13 in this audience who weren\'t born when Neil

14 Armstrong made the first steps and probably, at

15 best, were in diapers and knee pants when I made

16 the final steps on the surface of the moon \-- 35

17 years ago. We have a whole generation of 30-some

18 year olds who are now mothers and fathers who

19 weren\'t even born when we walked on the moon.

20 It\'s hard to believe it\'s happened,

21 but we wanted \-- at that point in time, I used to

22 say Apollo 17 is not the end, it\'s just the

23 beginning of a whole new era in the history of

24 mankind. We\'re not only going to go back to the

25 moon, we\'re going to go on to Mars. And I said

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1 that in 1973 and I said we\'ll be on our way to

2 Mars by the turn of the century, and my glass has

3 been half empty for 3-1/2 decades.

4 Ladies and gentlemen, we are going

5 back and my glass is now half full. And what we

6 wanted to depict with mankind, all of mankind,

7 with the bust of Apollo \-- looking into the

8 future, future depicted by the stars and the

9 planets. Parochial thought. It\'s a modern

10 American Eagle, three stars representing the crew

11 whose wing just touches the moon saying we\'re not

12 \-- we\'re going to learn from what \-- we\'re going

13 to learn from having gone to the moon, and we\'re

14 going to lead mankind into the future, And

15 that\'s still, I think, a very reputable goal.

16 Here\'s our crew. Another Naval

17 Aviator and a lunar geologist, the first and only

18 scientist that ever went to the moon, did an

19 outstanding job. We\'re all a little bit younger

20 there. There\'s a Lunar Rover we drove on the

21 room. You\'ll see a picture of it. I\'m going to

22 go through these things pretty fast. Saturn V,

23 36 stories high, unbelievable vehicle. I had a

24 chance to ride it twice. I went to the moon on

25 Apollo 10. It was a daytime launch. It was

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1 unbelievable to get on top of that thing. Flew

2 it again on Apollo 17.

3 And this is what it looked like in the

4 still picture. Someone said to me it was like

5 the universe lit up from without. I know you got

6 questions. What\'s it feel like, you know? What

7 happened? We talked about when you get to 10 or

8 15 seconds, does it feel like you\'re really going

9 to go? Let me tell u, at this point in time,

10 you\'re in control of your own destiny. Nobody in

11 the blockhouse. Nobody in Houston can say, oh,

12 we don\'t like what we see; you\'ve got to hold;

13 try tomorrow.

14 You\'re on your way. You\'re going. I

15 had an abort switch right in front of me, and

16 Apollo 17, as Commander of the crew, I could have

17 shut this thing down. I also, if I\'d lost my

18 guidance from the booster itself, could have \--

19 with spacecraft guidance, the computer

20 technology, I get more \-- I got more computing

21 power, well, in my telephone anyway than I \-- in

22 the palm in my hand than I had to go to the moon.

23 And yet if you watch these kids today, you know,

24 you drive an automobile. I wish I had that stuff

25 when I landed on the moon. I mean it\'s

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1 incredible the technology where we are today.

2 Anyway, we\'re on our way. This is

3 what we saw from Orlando. From Orlando, someone

4 took a time lapsed picture. We circled the Earth

5 one time, made sure everything was in good shape.

6 I don\'t know if you can see there. Everything

7 was in good shape, so we fired that engine. We

8 were going 18,000 miles an hour, fired that

9 engine and accelerated to 25,000 miles an hour

10 and headed out, and in a few short hours, this is

11 what we saw. And this is a part of the world

12 that I am sure is familiar to everybody, Saudi

13 Arabia, tip of Africa, India, the Indian Ocean.

14 Up on top was the Mediterranean. Wasn\'t too many

15 hours later that the Earth began to look like

16 this, all of Africa, Antarctica in December.

17 The world got small very, very, very

18 quick until \-- it, you know, continues to get

19 smaller. It continues to do something else. It

20 rotates on an axis mysteriously yet majestically

21 you can\'t see, because every 12 hours \-- boy I\'d

22 like to tell you a lot about what this feels like

23 \-- we don\'t have time \-- but every 12 hours, you

24 see the other side of the world, and you have to

25 pinch yourself, and you\'re saying, you know, I

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1 guess I\'m really on a space mission, I\'m really

2 going somewhere.

3 You know, the controllers in Houston

4 who are plotting our trajectory said, you know,

5 you\'re right on; we\'re moving out at 25,000 miles

6 trying to outrun the Earth\'s gravitational pull

7 and get captured by another planet, if you will -

8 - going to call the moon a planet for now \-- and

9 he says, you\'re right on; you\'re going to miss

10 the moon by 50 miles. I kept thinking that\'s a

11 hell of a lead shot. You know? Two hundred and

12 forty thousand, we\'re going to miss it \-- and my

13 answer to that on a transcript was, \"I hope so.\"

14 You cannot \-- I\'d like to, if I could,

15 spend a little time telling you what it feels

16 like to look back at the moon, or maybe I will

17 here in a minute \-- the moon, we can\'t see it

18 until we\'re there. This was actually a picture

19 we took, I think, on the way back. Some people

20 call it a hostile place. You know, you\'ve heard

21 the word magnificent desolation. I don\'t call it

22 hostile at all. It was \-- where we landed, and

23 I\'ll show you in a minute, it became my own

24 little Camelot for three days of my life.

25 The Lunar Module, upside we\'re still -

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1 - we\'re going around the moon now in zero

2 gravity. Doesn\'t make any difference what\'s up -

3 - up and down is based upon what you see. So

4 literally, we\'re upside down. The Lunar Module -

5 - I keep thinking in a hundred years, people are

6 going to say how in the devil did that thing go

7 to the moon. I guarantee you we were like the

8 Beverly Hillbillies pickup truck. We didn\'t have

9 the piano, but we had a Lunar Rover strapped to

10 it. We had small nuclear power plants. We had

11 experiments. We had geology equipment. It was

12 just if someone down there could have been taking

13 a picture while we landed, that\'s the picture I\'d

14 like to show you. But unfortunately, I can\'t do

15 it.

16 There\'s our landing site. There\'s

17 Camelot. We landed in a valley that was

18 surrounded by mountains on three sides that are

19 higher than the Grand Canyon is deep, surrounded

20 at 7,000 feet. When I pitched the spacecraft

21 over \-- and contrary to some popular belief, I

22 flew the spacecraft. Everyone who landed on the

23 moon flew the spacecraft.

24 There\'s a lot of aviators in here and,

25 as I say, a lot of people who are passionate

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1 about aviation. We had a switch in there that

2 said manual and auto. Now do you think anybody

3 is going to go all the way to the moon and put

4 that switch in auto? Okay? There\'s no way that

5 that\'s going to happen. And I flew it all the

6 way down and I just, you know, the blood, sweat

7 and tears. But that was our first pass looking

8 at our landing site. We landed right in the

9 middle of that valley.

10 This is one of the first things we did

11 when we got there \-- I\'m skipping through some of

12 these \-- we didn\'t plant the flag to conquer the

13 \-- a portion of the moon for any one country or

14 for the U.S. We put it there, and I said that as

15 I stepped on the moon \-- I said, this was a

16 symbol to thank the people in this country of

17 mine, in this nation of ours \-- and I hope you

18 understand why I speak parochially abut it,

19 because I\'m proud of it \-- who made it possible,

20 a lot of people.

21 You know, we\'re the tip of the arrow,

22 but I tell you one thing there. A lot of \-- you

23 know, it took the vision of a President, the

24 effort, the courage, the self-sacrifice and the

25 unbelievable dedication of a lot of people to do

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1 something that back in 1961 when President

2 Kennedy said we\'re going to go the moon thought

3 was impossible. You know, most people thought it

4 couldn\'t be done. And all of a sudden, we all

5 got involved. That\'s \-- those are the people who

6 should be at this podium today. Those are the

7 people who made it possible for these things to

8 happen.

9 That\'s a Lunar Rover. We don\'t have

10 all our equipment on it. An electric car.

11 That\'s possible, too. We drove it on the moon.

12 We drove an electric car on the moon. I used a

13 cordless drill on the moon \-- cord would have to

14 be pretty long if it weren\'t cordless. I mean

15 seriously, one of the first developments of the

16 cordless, we used it on the moon. I knocked a

17 fender off of this. I don\'t know if I got a

18 picture of it or not.

19 Oh, this is a picture of the landing

20 area. The soil is like \-- the lunar dust is like

21 graphite, real fine sand, grain color, shades of

22 gray, only graphite is a lubricant. This is just

23 the opposite. It gets in your suit. It gets

24 everywhere. Going through these fast. This

25 gives you another idea of the texture of the

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1 soil. That was our home.

2 And I was up in Long Island yesterday

3 and met with a lot of people from Bethpage, from

4 old Grumman, and that\'s who built this machine.

5 And it was sort of nostalgic to talk to some of

6 those people. And they had one of the first

7 lunar test articles in a museum up there that I

8 remember seeing way, way back when we were trying

9 to figure out how we could build something that

10 would do what this machine did.

11 And every one of those Lunar Modules,

12 including the last one, performed flawlessly.

13 And I say the last one, which is the one I \-- I

14 flew two of them \-- but the last one I flew \--

15 those people got their pink slips the day we

16 lifted off. They were gone and they still did

17 the best \-- what I\'m saying is we can do it. We,

18 collectively, around the world can do it if we

19 want to do it badly enough.

20 That rock is about three stories high.

21 Our Lunar Module, you can\'t see it, but if you

22 look at the tip of the rock just to the left,

23 you\'ll see a little white \-- that\'s home away

24 from home, can barely see it. We went over the

25 hill and around the corner. We\'re a long way

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1 from home.

2 That rock was painted by Alan Bean, a

3 colleague of mine, who flew to the moon on Apollo

4 12. He\'s become a great, great painter, paints

5 things that he saw and pictures we took on the

6 moon. He asked me \-- he said, Gene, what were

7 you thinking about when we took that picture?

8 And I said, well, Alan, if I knew you were going

9 to paint it and make it so famous, I would have

10 put Tracy\'s initials, my daughter. He said, how

11 would you have done it? I said, TDC. So he went

12 back, painted it.

13 That\'s my hand print. I reached up

14 and got a sample. He put TDC in there and said,

15 I painted Gene\'s daughter\'s initials in the rock

16 because I wanted to save him a trip back and the

17 taxpayers a lot of money. And the fact of life

18 is I did put her initials in the lunar surface.

19 Someone said, how long will they be there? And I

20 said, forever, however long forever is.

21 This, I love this picture. That gives

22 you the enormity, the magnificent desolation,

23 that\'s our Lunar Module. That little speck out

24 there is where we lived. We were on the lunar

25 surface oh, I guess, somewhere close to 75 hours.

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1 I think you said 73. I don\'t know, 73, 75. We

2 were out on the surface 8 \-- you know, 7 to 8

3 ours at a time. And then we had to get in this

4 little thing which is about \-- I\'m sure \--

5 literally, there\'s not any more room than a front

6 seat of one of those old Volkswagen bugs. We had

7 to take our suits off to dry them out, and we

8 would, quote, rest and get ready for the next

9 day. And when we took the suits off, it was like

10 four people in there instead of two people,

11 because the suits were almost like mannequins.

12 But I love this picture.

13 This is just a picture around the

14 Lunar Rover. We had a television camera. That

15 was the only thing that was controlled from the

16 ground remotely, because we didn\'t want to mess

17 with it, and it probably was the best way they

18 could follow what we were doing.

19 I don\'t know if I got the fender

20 picture \-- there. I\'m the only car within

21 240,000 miles away and guess who knocked the

22 fender off. Okay?

23 (Laughter.)

24 CAPTAIN CERNAN: Now this was built

25 between Boeing, General Motors and NASA. All

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1 conspired to design and build this Lunar Rover.

2 The President of General Motors, I had met and

3 was a pretty good friend of mind at that time \--

4 when I got back, I gave him this picture and I

5 signed it and I said, I thought you might enjoy

6 this but where in the heck was that 24-hour

7 roadside assistance when I really needed.

8 Anyway, this is from the cockpit, some of our

9 footprints, some of our trails.

10 This is a picture I really like. I

11 took this picture of Jack Schmitt. It caught the

12 American flag. It caught Earth. It caught home.

13 You can see the reflection \-- it caught mankind.

14 See the reflection in it? You can see the

15 reflection of the moon itself. That\'s one of my

16 favorite pictures. This is \-- I wish this were

17 brighter, because I look \-- this is on the third

18 day. My suit is filthy. I look like a West

19 Virginia coal miner in here.

20 But, you know, did we sleep well? Not

21 really. Did we rest? We had to. Three

22 fascinating days which went faster than I could

23 imagine. A pretty happy camper at that point in

24 time.

25 This is probably after our third EVA

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1 and we slept there that night and came home the

2 next day. This is when we\'re ready to come home.

3 The Lunar Module was built in two sections, the

4 descent stage which we used as a launching

5 platform, and the ascent stage. We had to blow

6 explosive bolts, blow the two apart and light the

7 engine, and a couple seconds later, we were on

8 our way. Who took the picture? The television

9 camera that we had left on the move remotely

10 controlled from the ground. Someone \-- some

11 young school kid said, well, who else was on the

12 moon with you? Who\'d you leave there? You know?

13 And when you going back to get him.

14 And we got back into orbit and, of

15 course, the Earth had changed phases just like

16 the moon. This was three days gone. This was

17 six, seven, eight days later. And that\'s the

18 lunar surface ,50 miles above the surface, and

19 that was our Mother Ship, our Command Module who,

20 Ron Evans, another Naval Aviator stayed in orbit,

21 did lot of experiments while we were on the

22 surface for those three days, and he was a

23 welcome sight when we rendezvoused and docked

24 with him. This is what\'s left of the Lunar

25 Module, our little engine that fired it off the

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1 surface.

2 I know you\'re saying well, what would

3 have you done if the engine didn\'t fire, and I\'m

4 going to tell you, I don\'t know. And thank God I

5 don\'t have to answer that question. No, we

6 didn\'t have any poison pills or anything else.

7 We only had one engine, redundant

8 systems. We had the computer fire the engine.

9 Remember I said green buttons and red buttons? I

10 had a green button over and a red button. The

11 green button was a manual bypass to everything to

12 fire the engine just to get us off. The key to

13 that is the engine, in our particular case, had

14 to fire 7 minutes and 14 seconds to get us into

15 exactly the correct orbit to rendezvous with the

16 Mother Ship. If it fired 7 minutes and 7 seconds

17 or less, we came back down. Yes, we thought

18 about that before we left. We thought about a

19 lot of things before we left. But we figured

20 that what we were doing was worth the effort,

21 worth the risk.

22 When President Kennedy said we\'re

23 going to go to the moon, that was a bold

24 statement. When we went to the moon, it was a

25 bold move. And to get where we want to go as a

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1 humanity in this world today, we got to take some

2 bold moves. We got to do some things and we\'ve

3 got to take some risks, and that\'s a culture that

4 I think we have to remind our kids and grandkids

5 of is manage your risks, but you\'ve got to be willing

6 to be bold and you got to be willing to take it.

7 That was in the parachutes when we

8 came down. John Young, who I flew with on Apollo

9 10, he commanded 16. We said what\'s the most

10 beautiful sight in all space flight? Well, you

11 know, I think to most of us, it was the earth.

12 John said the parachutes. He had a point. And

13 that was the old U.S.S. Ticonderoga. We came \--

14 he was a little bit off of the target, so I

15 logged that as a carrier landing, Tom. Matter of

16 fact, all three of my flights I logged as carrier

17 landings, because we were close from \-- listen,

18 from a quarter million miles away, that\'s as

19 close as I\'m going to get anyway.

20 Let me just answer one more question,

21 because I want to share this with you, and it\'s a

22 question I get asked. People say, how did you

23 feel? You know, I went to the moon first time and

24 we came close, didn\'t land \-- 47,000 feet, a long

25 way to go without landing. How did it feel to

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1 make that first step on the surface of the moon

2 on Apollo 17? You know, let your imagine \--

3 unbelievable \-- it\'s something unique and

4 special. But for me, it was special, I\'ll tell

5 you why \-- because I finally was \--it was that

6 you can walk \-- you can climb the highest

7 mountain on this planet to walk the depths of the

8 deepest ocean and you\'re still on Earth anywhere

9 in the world. I\'m stepping on something hard,

10 firm.

11 Oh, yes, it was a Lesser G. It didn\'t

12 make any difference, but this is not Earth. When

13 I stepped down on the surface of the moon, I real

14 \-- I\'m now stepping on another body in this

15 universe which is not Earth. That struck me.

16 And now I\'ve made it. You know? I was fulfilled

17 in a sense.

18 But the other thing is all these

19 people when you come back and say, oh, we didn\'t

20 go to the moon; they did it in Arizona; they did

21 it in Hollywood, let me tell you, my answer to

22 that is the truth, needs no defense. The truth

23 needs no defense and my footstep, that\'s final

24 foot \-- first and last footstep both on the moon.

25 And nobody but nobody in this world can take

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1 those footsteps away from me. So I don\'t really

2 care what they think or what they believe. Feel

3 sorry for them because they missed one of the

4 greatest adventures in the history of mankind.

5 Let me just finish by saying even more

6 important to me than the first step, my first

7 step \-- Neil had already taken the first real

8 step \-- my first step lest is less important to

9 me than my final step, because as I left the

10 surface of the moon and climbed up that ladder

11 and I looked down at that step, I knew I wasn\'t

12 coming this way again. You know, it\'s not like

13 going to grandma and grandpa\'s farm for the

14 summer knowing you\'re going to go back next year.

15 I wasn\'t going to come this way again.

16 I started up that ladder and I looked

17 over my shoulder, and there\'s the Earth in all

18 its splendor and in all its beauty. And I wanted

19 that freeze button like we had in the simulator -

20 - freeze, stop time. I just want to take time to

21 enjoy this particular moment in my life. But I

22 couldn\'t stop the clock and we had to leave and

23 we were going.

24 And I kept thinking, you know, I\'ve

25 been on some plateau out here somewhere in the

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1 universe a long way from home, and it\'s a plateau

2 that science and technology, which is extremely

3 important to our industry, the industry of

4 aviation, aerospace \-- science and technology got

5 me to the moon. They put me on that plateau.

6 And then when I stood there and I

7 looked back home at the Earth, which is really

8 your only identity with reality, because you\'re

9 living on the moon literally in a different

10 world. Looking back at the Earth, you\'re only

11 identity with reality \-- all of a sudden, I had

12 the same questions I think anyone and everyone

13 would have. What does it feel like? What does

14 it look like? Science and technology didn\'t have

15 the answers for me.

16 You know, the Earth didn\'t tumble

17 through space. It moved with purpose. It moved

18 with beauty. It was surrounded by the blackest

19 black you can conceive in your mind. The

20 infinity of space, the infinity of time, the

21 endlessness of it all \-- and I can tell you that

22 exists because I saw it with my own eyes. and

23 three-dimensionally, the Earth sits out there.

24 If your arm were long enough, you could just grab

25 it and bring it back into your heart. And all

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1 those questions I had because of the logic and

2 purpose, I just came up with one simple

3 conclusion. And call it what you want. It\'s not

4 a religious statement. It\'s spiritual perhaps,

5 because I\'ve always felt you can call your God by

6 whatever name you want, dress him or her in any

7 way you want, but I can stand here and tell you

8 that this Earth, the small part of the universe

9 that I was privileged to see some 35 years ago

10 did not come about by accident. There is

11 something we don\'t yet understand about how we

12 got here and where we\'re going and what we\'re

13 going to do with what we\'ve got.

14 Science and technology got me there

15 but it didn\'t have the answers. The world is

16 just too beautiful to have happened by accident.

17 I just wanted to share that with you, because we

18 didn\'t send robots. We didn\'t send computers.

19 We didn\'t send machines to the moon. We sent

20 human beings who maybe we all came back with a

21 different feeling. We probably did for the most

22 part, because we\'re all different. That\'s just

23 my \-- I just wanted to relate that to you, and if

24 I could take every human being on the world today

25 regardless of the culture, regardless of the

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1 politics, regardless of the religion, and stand

2 them next to me on the surface of the moon and

3 let them look back home for two or three or four

4 or five minutes, I truly do believe that the

5 world would be a different place today.

6 So we do have a challenge. We are

7 making the world smaller. We are going to go

8 back to the moon. The legacy of the Wright

9 Brothers is not all of technology. The legacy of

10 the Wright Brothers is the inspiration that they

11 provided into the hearts and minds of all of us

12 dreamers who followed in their footsteps. And

13 that\'s what your industry is all about. It\'s

14 about dreamers. It\'s about once again doing what

15 has never been done before, dream the impossible

16 and make it happen, because it can. It has. I

17 went to the moon. That\'s impossible. If I would

18 have thought about that when I was learning to

19 fly, they would have put me in a straightjacket.

20 But it can happen and it will happen.

21 You folks truly are professionals or

22 you wouldn\'t be here. That\'s the first

23 indication. But don\'t sell yourselves short. We

24 can do it. We will do it collectively, not just

25 individually as nations, but collectively because

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1 we have a unique problem that we have to continue

2 to attack in the world, and it\'s make aviation

3 and flying safer for each and every one of us,

4 each and every human being who flies. Aviation

5 is going to get bigger and stronger. It is the

6 transportation system of the world. It\'s brought

7 us together, will continue to do it, and God

8 bless you for your work. I don\'t \-- did I hit

9 the zero button, or do I have a question. I cut

10 \-- no questions. Unless Nick \--

11 (Applause.)

12 MR. SABATINI: Why don\'t we give them

13 \-- CAPTAIN CERNAN: Okay. Two questions.

14 I\'m taking your time. You know, it\'s not my

15 time. My airplane doesn\'t go to Houston until

16 5:00 o\'clock. Yes, sir?

17 UNIDENTIFIED SPEAKER: (Off mic

18 question.)

19 CAPTAIN CERNAN: What?

20 UNIDENTIFIED SPEAKER: The back part

21 of the moon, the back side?

22 CAPTAIN CERNAN: I\'m not going to \--

23 that\'s a secret. I\'m not going to tell what \--

24 (Laughter.)

25 MR. COHEN: But question was what does

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1 the back side of the moon look like. The back

2 side of the moon is much more rugged. On the

3 front side, you see those light areas and dark

4 areas. Full moon, the light areas are the

5 mountains, the reflection of the mountains. The

6 dark areas are the mare, the deserts. Not that

7 the deserts don\'t have potholes and crates and

8 boulders in them as Neil found out, because he

9 landed in a desert. We landed in the mountains.

10 The back side almost entirely

11 mountainous, no deserts. Why is that? I don\'t

12 know. You know? Why does the moon only show us

13 one face as it goes around? It goes around the

14 Earth once every 28 days. It rotates on its axis

15 every 28 days. I\'m one of those dumb Purdue

16 engineers who thinks it\'s got something to do

17 with the gravity, because the front side of the

18 moon has got a lot more mass concentrations, and

19 maybe it\'s like a pair and it\'s just, you know,

20 two magnets. They just \-- it turns \-- I don\'t

21 know. But what do I know? Has anyone anywhere

22 got a question? Yes, sir?

23 MS. PARISH: The video started with

24 the most magnificent vision statement most of us

25 can recall. Do you think we have a clear vision

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1 for human space flight now in this country? And

2 if not, what do you think that vision should be?

3 CAPTAIN CERNAN: Do we have a clear

4 vision for human space flight in this country?

5 Yes and no. I said my glass is now half full

6 rather than half empty. I don\'t know. Politics

7 play such a great part in it. The rest of the

8 world, you know \-- space station, which I think

9 is one day going to be a great asset, is truly

10 becoming an international event, because we\'re

11 going to put the European module on it. They\'re

12 going to put the Japanese module on it. It will

13 be completed. It will be a very useful tool. I

14 don\'t think anyone can predict what will come

15 from science, but it is going to be a great

16 scientific asset. That\'s space exploitation.

17 I\'m one of those guys who said we

18 can\'t afford not to participate in space

19 exploration. And we know China\'s doing it. We

20 know European is doing it. We know Japan. We

21 know countries around the world. And I think

22 that\'s good. I think we all ought to do our own

23 thing to a point.

24 But when it comes to going to Mars,

25 which is going to be a major \-- going back to the

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1 moon is not going to be an easy thing, either \--

2 looking back at how and why we did it, I said we

3 had to be bold \-- I\'m not sure we\'re that bold in

4 today\'s world, but we\'ll get there \-- but going

5 to Mars is going to be a significant event in

6 human history, and it\'s going to be \-- I think

7 it\'s going to be necessary to rally the technical

8 resources, the intellectual resources, the

9 financial resources and every other kind of

10 resource we can find from the great minds and

11 brains and from the economies of people around

12 the world to make that Mars trip a reality. But

13 it will happen. It will happen.

14 I have and will continue to look at

15 fourth and fifth graders and look them straight

16 in the eye and tell them if they have the same

17 opportunity that someone gave me a long time ago,

18 that they\'re the ones that are going to take us

19 to Mars. And I do believe that in my heart. I

20 know, I know that there\'s a young boy or girl or

21 many of them or several of them somewhere in the

22 world, maybe your children, maybe your

23 grandchildren, maybe your nieces and nephews,

24 somewhere in the world with the indomitable will

25 and courage, with the desire to learn \-- you

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1 know, curiosity is the essence of human existence

2 \-- who are we, where are we, where are we going -

3 - the indomitable will and courage to one day

4 take us back out there where I think we belong.

5 We\'ve left the cradle of civilization.

6 We are now \-- you know, we have been there, so

7 why can\'t we \-- you know, this is just a hiatus.

8 We don\'t even know what the significance of

9 Apollo is. What is the significance of mankind

10 leaving this planet and going and living on

11 another body in this universe? I don\'t know what

12 that means yet. I\'m not sure we will know for

13 another hundred years. How long did it take us

14 as a civilization to realize the significance of

15 Columbus\' journey across the Atlantic? We didn\'t

16 \-- I can\'t conceive that we didn\'t appreciate

17 that until after 100, 150 years passed. And then

18 we realized what it really meant.

19 And I think it\'s going to be \-- Apollo

20 is going to be looked back as the incubator at

21 the beginning of a major, major change in human

22 nature in terms \-- it\'s, you know, Apollo itself

23 \-- and that\'s just something \-- I said it wasn\'t

24 the end. It was the beginning of a whole new era

25 in the history of mankind. I truly do believe

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1 that. And I truly \-- that\'s why it\'s so great

2 that this is an international group, because you

3 are going to maybe be writing the rules. You are

4 going to be part of it. This is aviation

5 aerospace. You can\'t separate the two. Thank

6 you and God bless.

7 (Applause.)

8 MR. SABATINI: Thank you, Gene. That

9 was absolutely incredible. I will tell you that

10 each and every time that I hear you, it\'s like

11 hearing you for the first time. God bless you,

12 my friend. And it\'s an absolute honor to be

13 counted as your friend. And thank you for coming

14 here and sharing your experiences. Let\'s give

15 him another round of applause.

16 (Applause.)

17 MR. SABATINI: So coming up this

18 afternoon, our selection of Breakout Panel

19 sessions. You will see that we structured them

20 around them around the four pillars of safety

21 management. And starting at 1:10, you have the

22 choice of a panel session on safety policy, which

23 addresses the global approach to safety

24 management and international alignment. The

25 other 1:10 panel is on safety risk management.

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1 The panel frames the discussion on safety risk

2 management and the need for a consistent and

3 standard approach.

4 After the afternoon break, you have

5 two more choices for Breakout Panels. The first

6 panel is on safety assurance and this panel looks

7 at one of my favorite topics, data gathering,

8 sharing, and interpreting that data. The second

9 3:15 panel is on the important topic of safety

10 promotion and supporting a safety culture. Now

11 each and every year, we have made you a promise.

12 You will not be subjected to death by PowerPoint.

13 So this evening, please join us for a

14 taste of the Americas. We will have a sampler of

15 great food and great music. I am told the music

16 will make you want to dance. That means casual

17 dress and gentlemen, no ties. See you at 1:10.

18 (Applause.)

19 (Whereupon, at 1:05 p.m., the Plenary

20 Panel portion of the Fourth Annual International

21 Aviation Safety Forum was concluded.)

22

23

24

25

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