[Senate Hearing 111-605]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-605
 
                       AVIATION SAFETY: ONE YEAR 
                     AFTER THE CRASH OF FLIGHT 3407

=======================================================================

                                HEARING

                               before the

       SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY

                                 of the

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 25, 2010

                               __________

    Printed for the use of the Committee on Commerce, Science, and 
                             Transportation




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       0SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman
DANIEL K. INOUYE, Hawaii             KAY BAILEY HUTCHISON, Texas, 
JOHN F. KERRY, Massachusetts             Ranking
BYRON L. DORGAN, North Dakota        OLYMPIA J. SNOWE, Maine
BARBARA BOXER, California            JOHN ENSIGN, Nevada
BILL NELSON, Florida                 JIM DeMINT, South Carolina
MARIA CANTWELL, Washington           JOHN THUNE, South Dakota
FRANK R. LAUTENBERG, New Jersey      ROGER F. WICKER, Mississippi
MARK PRYOR, Arkansas                 GEORGE S. LeMIEUX, Florida
CLAIRE McCASKILL, Missouri           JOHNNY ISAKSON, Georgia
AMY KLOBUCHAR, Minnesota             DAVID VITTER, Louisiana
TOM UDALL, New Mexico                SAM BROWNBACK, Kansas
MARK WARNER, Virginia                MIKE JOHANNS, Nebraska
MARK BEGICH, Alaska
                    Ellen L. Doneski, Staff Director
                   James Reid, Deputy Staff Director
                   Bruce H. Andrews, General Counsel
             Ann Begeman, Acting Republican Staff Director
                  Nick Rossi, Republican Chief Counsel
             Brian M. Hendricks, Republican General Counsel
                                 ------                                

       SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY

BYRON L. DORGAN, North Dakota,       JIM DeMINT, South Carolina, 
    Chairman                             Ranking Member
DANIEL K. INOUYE, Hawaii             OLYMPIA J. SNOWE, Maine
JOHN F. KERRY, Massachusetts         JOHN ENSIGN, Nevada
BARBARA BOXER, California            JOHN THUNE, South Dakota
BILL NELSON, Florida                 ROGER F. WICKER, Mississippi
MARIA CANTWELL, Washington           GEORGE S. LeMIEUX, Florida
FRANK R. LAUTENBERG, New Jersey      JOHNNY ISAKSON, Georgia
MARK PRYOR, Arkansas                 DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           SAM BROWNBACK, Kansas
AMY KLOBUCHAR, Minnesota             MIKE JOHANNS, Nebraska
MARK WARNER, Virginia
MARK BEGICH, Alaska


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on February 25, 2010................................     1
Statement of Senator Dorgan......................................     1
Statement of Senator DeMint......................................    20
Statement of Senator Thune.......................................    30

                               Witnesses

Hon. Deborah A.P. Hersman, Chairman, National Transportation 
  Safety Board...................................................     2
    Prepared statement...........................................     4
Margaret Gilligan, Associate Administrator for Aviation Safety, 
  Federal Aviation Administration................................    10
    Prepared statement...........................................    11

                                Appendix

Hon. Frank R. Lautenberg, U.S. Senator from New Jersey, prepared 
  statement......................................................    41
Letter, dated April 6, 2010, to Hon. Byron L. Dorgan and Hon. Jim 
  DeMint from Deborah A.P. Hersman, Chairman, National 
  Transportation Safety Board....................................    41
Response to written questions submitted by Hon. Frank R. 
  Lautenberg to Hon. Deborah A.P. Hersman........................    42
Response to written questions submitted to Margaret Gilligan by:
    Hon. John D. Rockefeller IV..................................    43
    Hon. Byron Dorgan............................................    44
    Hon. Frank R. Lautenberg.....................................    45


                       AVIATION SAFETY: ONE YEAR 
                     AFTER THE CRASH OF FLIGHT 3407

                              ----------                              


                      THURSDAY, FEBRUARY 25, 2010

                               U.S. Senate,
  Subcommittee on Aviation Operations, Safety, and 
                                          Security,
        Committee on Commerce, Science, and Transportation,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 9:32 a.m. in 
room SR-253, Russell Senate Office Building, Hon. Byron L. 
Dorgan, Chairman of the Subcommittee, presiding.

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Dorgan. I'm going to call the hearing to order. My 
colleagues will be joining me shortly, but in the interest of 
starting on time, I want to begin the hearing.
    This is a hearing on aviation safety of the Aviation 
Subcommittee of the Commerce Committee, one year after the 
crash of Flight 3407 of Colgan Air at Buffalo, New York.
    I welcome our witnesses this morning. The witnesses will be 
Deborah Hersman, the Chairman of the National Transportation 
Safety Board; and Ms. Peggy Gilligan, the Associate 
Administrator for Aviation Safety at the FAA. We appreciate 
both of you coming.
    I note that, this week, the National Transportation Safety 
Board released a 300---I believe, 300-plus-page report on the 
Colgan crash. We've just observed the 1-year anniversary, as 
I've indicated. That terrible tragic accident has crystallized, 
I think, a number of issues that are in front of us to try to 
deal with the issue of aviation safety. The issue of pilot 
training, rest, experience, a wide range of issues dealing 
with, in this case, regional carriers, but a number of these 
issues relate to all of the carriers.
    It has become clear to me that Congress and the industry 
needs to take major steps to ensure that there is indeed one 
level of safety throughout the entire commercial aviation 
industry. We are told that that is the standard, and yet the 
evidence suggests that that is not the practice. I note that 
the newspaper reports of the National Transportation Safety 
Board investigation cites, quote, ``pilot error,'' unquote. And 
yet, I know, from the reading that I have done and the 
evaluation I have done of information that's come across my 
desk, that there is much, much more to the rest of the story.
    Pilot error. That would suggest that something happened in 
a moment in that cockpit that caused that accident. Well, we do 
know that something happened in that cockpit. A number of 
things happened in that cockpit that were inappropriate 
responses to the conditions in which that airplane was flying. 
But, we also know that there were many other conditions leading 
up to that moment that cause us great concern and cause us to 
believe--some of us to believe that they were contributing 
factors to that accident.
    And the question, for me, is, As we look at all these 
issues, what is being done to address them? Not only what is 
being done, but when is it being done? When can we expect the 
achievement of the goals that we establish to make certain this 
cannot and will not happen again? And the discussion that's 
been held between the FAA, the NTSB, the Congress, the families 
of the victims of Colgan Air, all of that, I think, has led to 
some real impatience about trying to make certain that this 
morning, at 10:36, there's not some airplane flying in weather, 
someplace around this country, in which the similar conditions 
would have led to similar mistakes that will cause us to lose 
the lives of other people who are on commercial airlines.
    I have said, at every hearing, that we have a remarkably 
safe system in aviation. I mean, if you just take--and you 
measure that by how many airline crashes, how many crashes have 
we had in commercial aviation in recent years. It is a 
remarkably safe way to travel, and we don't want these hearings 
to suggest otherwise. But, these hearings are necessary, and 
the investigation of the Colgan accident, or crash, in Buffalo, 
New York, describes to me that this level of safety travels on 
a very thin edge.
    What I have learned from this crash, and what we need to 
apply to other standards across the industry here, is that a 
number of things are occurring that can be causal to some 
future accident if we don't take action. I'm talking about 
fatigue, I'm talking about traveling all night across the 
country. I'm talking about training. I'm talking about the 
question of how the regional carriers carry the colors and the 
brand of the majors, and yet there's--the majors, in many 
cases, have no responsibility for much of anything of that 
regional carrier. All of these things are issues. The full and 
complete background of a pilot, that airlines don't have access 
to now, in most cases, when they hire a pilot. All of these 
things, in my judgment, are important, and we are required to 
address them all. Because, most surely, they will come together 
once again at some point and take the lives of others if we 
don't address these issues.
    So, let me thank the witnesses for being here. I'm going to 
have a lot of questions today. I appreciate very much your 
willingness to appear this week at a time when the NTSB has 
issued its report.
    Ms. Hersman, you have been with us before. And as I 
indicated, I wanted to start on time. We will have some 
colleagues join us, but I'm going to call on you for an opening 
statement, and then I will call on Ms. Gilligan, and then we 
will proceed from there.

  STATEMENT OF HON. DEBORAH A.P. HERSMAN, CHAIRMAN, NATIONAL 
                  TRANSPORTATION SAFETY BOARD

    Ms. Hersman. Good morning, Chairman Dorgan.
    On February 12, 2009, Colgan Air Bombardier Q-400, 
operating as Continental Connection Flight 3407, crashed while 
on approach to Buffalo, New York. All 49 people on board, and 
one person on the ground, were killed.
    I'd like to start by showing an animation of the last 
minutes of the accident flight. As you will see, the top half 
of the screen shows the 3-dimensional model of the airplane and 
its motion. Superimposed over the model is the cockpit voice 
recorder text. The time is shown in the middle of the screen, 
on the right side. The bottom half of the screen depicts a set 
of instruments and indicators.
    Moving from left to right, the airspeed indicator is boxed 
in red during low speed with the low-speed cue in red next to 
the airspeed tape; altitude; stall protection system; stick 
pusher and stick shaker; an icon depicting the control wheel 
rotating right or left; and control column moving up and down. 
We will now play the animation of the accident sequence. The 
animation does not depict the weather or visibility conditions 
at the time of the accident.
    [Pause.]
    Ms. Hersman. You can see the low-speed cue is visible at 
this time, and the landing gear is up. The airspeed is about 
170 knots. Flaps are at zero degrees. And the autopilot is 
engaged, with the altitude hold mode selected, at about 2,300 
feet.
    [Pause.]
    Ms. Hersman. See the flap handles move from 0 to 5 degrees. 
The airplane is in level flight, and the control column is in 
neutral position. You can see the shadowing when it's not in 
neutral.
    [Pause.]
    Ms. Hersman. The engine power levers are moved to near 
flight-idle, and during the next 10 seconds the engine 
condition levers move, the airspeed starts to slow down, and 
the gear comes down.
    Now the upset begins. You see the stick shaker's on. The 
airplane stalls. The pusher's activating. The gear comes up.
    In May, the Safety Board held a 3-day public hearing to 
collect testimony on issues related to the accident, including 
aircraft performance, flight crew training and procedures, and 
fatigue management. On February 2, 2010, we met to consider the 
final report. Holding a hearing and completing this 
investigation in less than a year was quite a challenge and 
reflects the dedication of our staff.
    One of our 46 findings indicated that, although the 
aircraft had some ice accumulation, it did not affect the 
crew's ability to control the airplane. We determined that the 
probable cause of the accident was the captain's inappropriate 
response to the activation of the stick shaker. Contributing 
factors included the flight crew's failure to monitor airspeed 
and adhere to sterile cockpit procedures, the captain's failure 
to effectively manage the flight, and Colgan's inadequate 
procedures for airspeed selection in icing conditions. We 
issued 25 recommendations addressing training, fatigue, 
previous flight test failures, records retention, expanding 
FOQA programs, and the use of portable electronic devices.
    Before closing, I would like to highlight two related 
events that the Safety Board has planned for later this year. 
In May, we will be holding a public forum on pilot and air 
traffic controller professionalism; and in the fall, we will 
hold a symposium on code sharing and its role in aviation 
safety.
    Thank you, and I'm pleased to answer your questions.
    [The prepared statement of Ms. Hersman follows:]

      Prepared Statement of Hon. Deborah A.P. Hersman, Chairman, 
                  National Transportation Safety Board

    Good morning. On February 12, 2009, about 22:17 eastern standard 
time, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as 
Continental Connection Flight 3407, was on an instrument approach to 
Buffalo-Niagara International Airport in Buffalo, New York, when it 
crashed into a residence in Clarence Center, New York, about 5 miles 
northeast of the airport. The 2 pilots, 2 flight attendants, and 45 
passengers on board the airplane were killed, one person on the ground 
was killed, and the airplane was destroyed by impact forces and a post-
crash fire.
    Within minutes of the accident, the NTSB was notified, and a go-
team was launched to the accident site early the next morning. The NTSB 
named 6 parties to the investigation, including:

   Federal Aviation Administration (FAA)

   Air Line Pilots Association

   National Air Traffic Controllers Association

   United Steelworkers Union (representing the flight 
        attendants)

   Transportation Safety Board of Canada

   Air Accidents Investigation Branch of the United Kingdom

    In addition to the parties, other organizations participated in the 
investigation--more than 60 in total--including Transport Canada, 
Bombardier, Pratt & Whitney Canada, Dowty Propellers, as well as 
representatives from state agencies, area-wide county and city offices, 
emergency responders, police departments, service organizations, and 
many others.
    As part of its investigation, the NTSB held a 3-day public hearing 
in Washington, D.C., May 12 through 14, 2009. Witnesses included 
representatives of FAA, Colgan Air, the Air Line Pilots Association, 
and Bombardier. The issues presented and explored during the hearing 
were the effect of icing on airplane performance, cold weather 
operations, sterile cockpit rules, flight crew experience, fatigue 
management, and stall recovery training.
    This tragic accident significantly changed countless lives. Many 
family members and friends of the victims of Flight 3407 have come 
together to tirelessly advocate for improved aviation safety. The NTSB 
made a commitment to the families some months ago that we would 
aggressively pursue the issues uncovered in the accident and endeavor 
to complete the investigation before the one-year anniversary. Holding 
a public hearing and then finalizing this investigation in less than a 
year was a challenge for the agency; the last time we accomplished both 
a hearing and completion of a major investigation in less than a year 
was more than 15 years ago. This effort required a significant amount 
of staff overtime and reprioritizing other investigative activities. 
Nevertheless, our dedicated staff presented a draft final accident 
report late last month, and in a public Board meeting on February 2, 
the Board voted unanimously to adopt the report, thus concluding this 
significant accident investigation.
    The final report includes 46 separate findings and a determination 
that the probable cause of the accident was the captain's inappropriate 
response to the activation of the stick shaker, which led to an 
aerodynamic stall from which the airplane did not recover. Contributing 
to the accident were the: (1) flight crew's failure to monitor airspeed 
in relation to the rising position of the low-speed cue, (2) the flight 
crew's failure to adhere to sterile cockpit procedures, (3) the 
captain's failure to effectively manage the flight, and (4) Colgan 
Air's inadequate procedures for airspeed selection and management 
during approaches in icing conditions. The final report also makes 25 
new recommendations to the FAA and reiterates 3 previously issued 
recommendations. The recommendations cover a wide range of safety 
issues that were factors in this accident, including pilot training and 
fatigue.

Pilot Training
    Although the NTSB's investigation was broad-reaching, the 
performance of the pilots in this accident was the primary focus of the 
investigation. Not only was the captain's inappropriate response to the 
stick shaker identified as the primary cause of the accident, but 
several performance lapses on the part of the crew were cited as 
contributing factors to the accident. Therefore, the NTSB staff spent 
considerable time reviewing the pilots' performance on the night of the 
accident, documenting their activities in the days leading up to the 
crash, and scrutinizing their previous performance including detailed 
reviews of their past proficiency checks and the training they received 
while employed by Colgan Air.

Remedial Training
    The captain of Flight 3407 had multiple certificate and rating 
failures which were a matter of record with the FAA. His training 
records at Gulfstream International Airlines showed that his flying 
skills needed improvement, although he met the minimum standards 
required for completion of the training. His continued demonstrated 
weaknesses in basic aircraft control and attitude instrument flying 
during annual checks at Colgan Air should have made the captain a 
candidate for remedial training. However, at the time of the accident, 
Colgan Air did not have a formal program for pilots who demonstrated 
ongoing weaknesses. Furthermore, Colgan Air's electronic pilot training 
records did not contain sufficient detail for the company or the FAA 
Principal Operations Inspector (POI) to properly analyze the captain's 
trend of unsatisfactory performance.
    In 2005, the NTSB recommended that the FAA require all Part 121 air 
carrier operators to establish oversight and training programs for 
pilots who have demonstrated performance deficiencies or have 
experienced failures in the training environment (A-05-14). In 
response, the FAA issued SAFO 06015, ``Remedial Training for Part 121 
Pilots,'' the purpose of which was to promote voluntary implementation 
of remedial training for pilots with persistent performance 
deficiencies. While the FAA had recently conducted surveys to determine 
if carriers have remedial training programs consistent with the SAFO, 
the POI for Colgan Air stated during the NTSB's public hearing that he 
was not aware of the existence of this SAFO.
    Remedial training and additional oversight for pilots with training 
deficiencies and failures would help ensure that the pilots have 
mastered the necessary skills for safe flight. In 2003, during our 
investigation of a landing accident involving a Fed Ex MD-10 in 
Memphis, the NTSB's review of FedEx's pilot training procedures and 
oversight revealed that, consistent with other operators in the 
aviation industry, it focused on a pilot's performance on the day of 
the checkride with little or no review of that pilot's performance on 
checkrides months or years earlier. The NTSB was concerned that this 
single-event focus does not allow a carrier to monitor changes or 
patterns in a pilot's performance history that could provide 
significant information about the competency of a pilot. For example, 
in the FedEx case, the first officer's repeated substandard 
performances on checkrides were addressed as singular events that did 
not require further evaluation or monitoring after the checkride was 
satisfactorily completed. Yet, post-accident review of the first 
officer's training history and post-accident interviews suggested a 
pattern of below-standard performance. In our report on Flight 3407, we 
reiterated our 2005 recommendation to the FAA (A-05-14) and issued 
several additional recommendations focused on pilot training.
    The NTSB also reiterated our concern about reviewing all available 
pilot records for new hires. Following the 2003 Air Sunshine ditching 
accident near the Bahamas, which involved a pilot who had failed 9 FAA 
flight checks, the NTSB issued recommendations to address the 
importance of obtaining all pilot records prior to hiring. In addition 
to reiterating our 2005 recommendations (A-05-01), we issued 3 
additional recommendations addressing the maintenance and sharing of 
pilot training records (A-10-17, A-10-19, and A-10-20).

Stall Training
    As pilots transition to larger transport-category airplanes, they 
do not have an opportunity to experience stalls in flight or in a 
simulator, because air carrier training does not require pilots to 
practice recoveries from fully developed stalls. The FAA's practical 
test standards for pilot certification currently require pilots to 
recover from an ``approach to stall'' with minimal altitude loss. This 
recovery procedure can be effective as long as an airplane is not fully 
stalled. However, altitude loss standards are not appropriate for 
responding to a fully developed stall. Once a stall has occurred, an 
airplane cannot be recovered until the wing's angle of attack (AOA) is 
reduced, which will usually necessitate a loss of altitude.
    The current air carrier approach-to-stall training did not fully 
prepare the crew for an unexpected stall in the Q400 and did not 
address the actions that are needed to recover from a fully developed 
stall. The stick shaker, which is a component of the stall warning 
system in the Q400, produces an audible vibration of the control yoke 
when it activates to alert the pilot to take immediate action. However, 
the existing industry practice of training to approach-to-stall does 
not prepare pilots for unexpected situations where the stick shaker 
activates and simultaneously disconnects the autopilot. The stick 
pusher response is another feature designed to prevent and/or recover 
from a stall by pushing the control yoke forward and achieving a nose 
down attitude. Stick pusher training was not consistently provided to 
pilots of Q400s, nor was it required by the FAA.
    The NTSB has investigated other accidents in which the pilots 
applied inappropriate nose-up pitch control inputs during an attempted 
stall recovery, including West Caribbean Airways Flight 708 in 2005, 
Pinnacle Airlines Flight 3701 in 2004, and an Airborne Express DC-8 in 
1996. We remain concerned that classroom training of this important 
system is incomplete because the training does not familiarize pilots 
with the forces associated with stick pusher activation or provide them 
with experience in learning the magnitude of the airplane's pitch 
response.
    The NTSB believes that more realistic stall and upset training is 
possible due to advances in simulator technology. Flight crew training 
on full stalls and recoveries has not previously been included in 
simulator training partly because of industry concerns about the lack 
of simulator aerodynamic model fidelity in the post-stall flight 
regime. However, research demonstrates that simulator fidelity can be 
significantly improved and the useful data envelope for upset training 
can be expanded. Pilots could have a better understanding of an 
airplane's flight characteristics during the post-stall flight regime 
if realistic, fully developed stall models are incorporated into 
simulators that are approved for such training.
    Colgan Air pilots were trained to address tailplane stalls through 
a NASA-produced video intended to enhance a pilot's ability to assess 
hazardous icing conditions. The tailplane stall recovery procedure 
discussed in the video required pilots to pull back on the control 
column, reduce flap setting, and for some aircraft, reduce power. 
However, the tailplane stall recovery procedure presented in the video 
was the opposite of the recovery procedure for a conventional wing 
stall, which requires lowering the nose and adding power. Many Colgan 
pilots believed the Q400 was susceptible to tailplane stalls, but 
according to Bombardier, the manufacturer, it was not. Training in 
tailplane stalls, when it is not appropriate for the aircraft for which 
the pilot is being trained, may add confusion to a pilot's reaction in 
addressing conventional wing stalls.
    To address stall recovery and stick pusher training in simulators, 
NTSB recommended that the FAA:

   Require Parts 121, 135, and 91K operators and Part 141 pilot 
        schools to develop and conduct training that incorporates 
        stalls that are fully developed, are unexpected, involve 
        autopilot disengagement, and include airplane-specific 
        features, such as a ref speeds switch (A-10-22);

   Require Parts 121, 135, and 91K operators with stick pusher-
        equipped aircraft to provide their pilots with pusher 
        familiarization simulator training (A-10-23);

   Define and codify minimum simulator model fidelity 
        requirements to support expanded stall recovery training (A-10-
        24);

   Identify which airplanes operated under Parts 121, 135, and 
        91K are susceptible to tailplane stalls and then require 
        operators of those airplanes to provide appropriate stall 
        recovery training, and direct operators of airplanes that are 
        not susceptible to tailplane stalls to ensure that their 
        training does not include tailplane stall recovery.

Training for Active Monitoring
    The flight crew of Flight 3407 failed to monitor the airplane's 
pitch attitude, power, and especially its airspeed, and they failed to 
notice, as part of their monitoring responsibilities, the rising low-
speed cue on the indicated airspeed (IAS) display. There are multiple 
strategies to use to protect against catastrophic outcomes resulting 
from monitoring failures like this one, not the least of which is pilot 
training.
    Current pilot training programs often do not address monitoring 
skills in a systematic manner. Some of Colgan Air's guidance to its 
pilots referenced the importance of monitoring, and the subject was 
discussed and evaluated during simulator training and initial operating 
experience. However, the company did not provide specific pilot 
training that emphasized the monitoring function. Further, the 
company's crew resource management (CRM) training did not explicitly 
address monitoring or provide pilots with techniques and training for 
improving their monitoring skills.
    As a result of this accident investigation, the NTSB reiterated a 
recommendation that was issued in 2007. That recommendation called for 
the FAA to require that all pilot training programs be modified to 
contain modules that teach and emphasize monitoring skills and workload 
management and include opportunities to practice and demonstrate 
proficiency in these areas (A-07-13).
    The crash of Flight 3407 and a subsequent event near Burlington, 
Vermont, revealed that Colgan Air's standard operating procedures did 
not promote effective monitoring behavior. The NTSB is concerned that 
other air carriers' standard operating procedures may also be deficient 
in this area. We therefore recommended that the FAA require Part 121, 
135, and 91K operators to review their standard operating procedures to 
verify that they are consistent with the flight crew monitoring 
techniques described in the FAA's advisory circular, AC 120-71A, and to 
revise the procedures if they are not (A-10-10).

Training Captains for Leadership
    The captain of a flight is responsible for setting the appropriate 
tone in the cockpit and managing communications and workload in a 
manner that promotes adherence to standard operating procedures. The 
captain of Flight 3407 did not establish a professional environment in 
the cockpit when he performed checklists and callouts late, initiated 
and encouraged non-pertinent conversation in flight, and failed to 
effectively manage the workload in the cockpit or communicate with the 
first officer during an emergency situation.
    Industry changes have resulted in opportunities for pilots to 
upgrade to captain without having accumulated significant experience as 
a first officer in a Part 121 operation. Furthermore, Part 121 
operators are not required to provide upgrading captains with specific 
training on leadership skills. When the captain of Flight 3407 upgraded 
in October 2007, Colgan Air provided an 8-hour training course on 
duties and responsibilities, the content of which focused on the 
administrative duties associated with becoming a captain. It did not 
contain significant information about developing in-cockpit leadership 
skills, management oversight, and command authority.
    The NTSB recommended that the FAA issue an advisory circular with 
guidance on leadership training for upgrading captains at Parts 121, 
135, and 91K operators (A-10-13). The guidance should include:

   methods and techniques for effective leadership;

   professional standards of conduct;

   strategies for briefing and debriefing;

   reinforcement and correction skills;

   other knowledge, skills, and abilities that are critical for 
        air carrier operations.

Training Pilots for Adherence to Sterile Cockpit and SOPs
    Both pilots of Flight 3407 engaged in non-pertinent conversation 
during the flight, and neither pilot addressed the other pilot's 
deviation from sterile cockpit procedures. Their ease in engaging in 
non-pertinent conversation suggested that the practice is not unusual 
among company pilots during critical phases of flight.
    The sterile cockpit rule (14 CFR 121.542) is intended to ensure 
that a pilot's attention is directed to operational concerns during 
critical phases of flight rather than nonessential activities or 
conversation. In 2006, the NTSB recommended that the FAA direct POIs of 
all Parts 121 and 135 operators to reemphasize the importance of strict 
compliance with the sterile cockpit rule (A06-7). In response to this 
recommendation, the FAA issued SAFO 06004 on April 28, 2006, to 
emphasize the importance of sterile cockpit discipline. Four months 
after the SAFO was issued, the crew of Comair Flight 5191 attempted to 
take off on the wrong runway in Lexington, Kentucky. There were 49 
fatalities in that accident, and the NTSB determined that the crew 
missed important cues during their taxi because they were engaged in 
non-essential conversation. Since the SAFO was issued, the NTSB has 
continued to investigate other accidents where the sterile cockpit rule 
was violated.
    Even though the responsibility for sterile cockpit adherence is 
ultimately a matter of a pilot's own professional integrity, pilots 
work within the context of professionalism created through the mutual 
efforts of the FAA, operators, and pilot groups. The continuing number 
of accidents involving a breakdown in sterile cockpit discipline 
warrants innovative action by the FAA and the aviation industry to 
promptly address this issue. In the accident report for Flight 3407, 
the NTSB recommended that the FAA develop and distribute to all pilots 
multimedia guidance materials on professionalism in aircraft operations 
(A-10-15). The guidance should contain:

   standards of performance for professionalism;

   best practices for sterile cockpit adherence;

   techniques for assessing and correcting pilot deviations;

   examples and scenarios;

   detailed review of accidents involving breakdowns in sterile 
        cockpit and other procedures, including this accident.

Fatigue
    The crash of Flight 3407 gave the NTSB an opportunity to reexamine 
fatigue in aviation, an issue that has been on our Most Wanted List of 
Transportation Safety Improvements since 1990. Numerous accident 
investigations, research data, and safety studies show that flight 
crews who are on duty but have not obtained adequate rest present an 
unnecessary risk to the traveling public. Fatigue results from 
continuous activity, inadequate rest, sleep loss or nonstandard work 
schedules. The effects of fatigue include slowed reaction time, 
diminished vigilance and attention to detail, errors of omission, 
compromised problem solving, reduced motivation, decreased vigor for 
successful completion of required tasks, and poor communication.
    Although the schedules of both pilots of Flight 3407 were within 
flight and duty time requirements, the flight crew was likely fatigued 
according to factual information gathered by NTSB investigators. The 
night before the accident, the captain likely did not obtain quality 
sleep because he slept in the company crew room, and his sleep time was 
interrupted, as evidenced by multiple log-ins to the company scheduling 
system at 21:51, then at 03:10, and again at 07:26. At the time of the 
accident, the captain had been awake at least 15 hours. A 1994 NTSB 
study identified performance degradation in accident flight crews when 
they have been awake for 12 hours.\1\
---------------------------------------------------------------------------
    \1\ National Transportation Safety Board (1994). A Review of 
Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 Through 
1990. Safety Study NTSB/SS-94-01. Washington, D.C.
---------------------------------------------------------------------------
    Similarly, the first officer likely was not properly rested when 
she reported for duty. The night before the accident, she commuted from 
Seattle to Newark, changing planes shortly after midnight in Memphis, 
and arriving in Newark at 06:30, which was 03:00 Seattle time. In the 
preceding 34 hours, she had obtained a maximum of 8.5 total hours of 
sleep. Approximately 3.5 of those hours were obtained as she traveled 
cross-country in an airplane jumpseat, and those hours were interrupted 
by her stop in Memphis. She obtained the remaining 5 hours resting in 
the company crew room. Although the crew room had couches and 
recliners, it was not isolated and was subject to interruptions, 
uncontrolled noise and activity, lights, and other factors that prevent 
quality rest.
    Scientific research and accident investigations have demonstrated 
the negative effects of fatigue on human performance, including reduced 
alertness and degraded mental and physical performance. Evidence 
suggests that both pilots were likely experiencing some degree of 
fatigue at the time of the accident. However, because the errors and 
decision made by the pilots cannot be solely attributed to fatigue, the 
NTSB stopped short of making fatigue a causal factor in the accident.

Commuting
    The NTSB continues to look at the many factors that affect a flight 
crew's ability to achieve adequate rest. Long-distance commuting by 
pilots is often a necessity because of base transfers that change a 
pilot's home base to a location that is far from family or is in a 
high-cost area. About 70 percent of the Colgan Air pilots based in 
Newark were commuters, and approximately 20 percent of the pilots, like 
the pilots of Flight 3407,\2\ commuted from over 1,000 miles away. Some 
commuting pilots rent ``crash pads'' (shared rooms or apartments) at 
their base, and some operators provide crew rest facilities so that 
crews can obtain uninterrupted sleep. Colgan Air did not have a crew 
rest facility, and neither of the pilots of Flight 3407 had a crash 
pad. Colgan Air's commuting policy addressed their pilots' 
responsibility to arrive at their base and report for duty on time, but 
the policy did not reference ways to mitigate fatigue resulting from 
commuting.
---------------------------------------------------------------------------
    \2\ The captain commuted from Florida, and the first officer 
commuted from Seattle.
---------------------------------------------------------------------------
    As a result of this accident investigation, the NTSB recommended 
that the FAA require all Parts 121, 135, and 91K operators to address 
fatigue risks associated with commuting, including identifying the 
number of pilots who commute, establishing policy and guidance to 
mitigate fatigue risks for commuting pilots, using scheduling practices 
to minimize opportunities for fatigue in commuting pilots, and 
developing or identifying rest facilities for commuting pilots (A-10-
16). Unfortunately, in the aviation industry, fatigue-related decisions 
by operators and pilots--such as minimum crew hires, flight crew 
schedules and commuting--are decisions that too often reflect the 
economics of the industry, rather than the data and science of fatigue 
and human performance.

Most Wanted List of Transportation Safety Improvements
    The issues of pilot proficiency and human fatigue are among the 
NTSB's most critical areas of concern in the safety of aviation. Last 
week, the NTSB updated its 2010 Most Wanted List to better emphasize 
these two safety concerns.

Improve the Oversight of Pilot Proficiency
    The investigation of Flight 3407 demonstrated once again that there 
are troubling loopholes in the system under which airlines check 
records of prospective flight crew employees. When Colgan Air conducted 
a background check of the captain prior to his employment, the airline 
checked records from other airlines in accordance with the Pilot 
Records Improvement Act of 1996 (PRIA). However, these records do not 
include a review of FAA certificates of disapprovals. The captain of 
Flight 3407 had reported on his employment application that he had 
failed 1 FAA checkride, when in fact he had failed 3. Neither PRIA nor 
FAA's guidance under PRIA requires operators to obtain notices of 
disapproval for flight checks for certificates and ratings.
    Our testimony has already discussed the captain's demonstrated 
weaknesses in basic aircraft control and attitude instrument flying 
during annual checks at Colgan Air, which should have made the captain 
a candidate for remedial training. The NTSB has long recommended 
remedial training. On October 30, 2009, the FAA indicated that about 
one-third of carriers had implemented remedial training programs, 
including 6 of 27 regional carriers; less than 3 months later, on 
December 10, 2009, the FAA Administrator stated during his testimony 
before this committee that two-thirds of the air carriers without 
advanced qualification programs had systems in place to identify and 
manage low-time pilots and pilots with persistent performance problems. 
In their ``Call to Action'' report published in January 2010, the FAA 
stated that only 15 carriers had some part of a remedial training 
program and 8 carriers did not have any component of a remedial 
training program in place. While the NTSB asked for the complete survey 
results, this information has not been provided, and the NTSB has not 
determined the extent that air carrier remedial training programs 
address pilot performance deficiencies and failures during training.
    Therefore, we added 2 recommendations to the 2010 Most Wanted List 
under a new issue area, ``Improve the Oversight of Pilot Proficiency:''

   Require all Parts 121 and 135 air carriers to obtain any 
        notices of disapproval for flight checks for certificates and 
        ratings for all pilot applicants and evaluate this information 
        before making a hiring decision. (A-05-01);

   Require all 14 Code of Federal Regulations Part 121 air 
        carrier operators to establish programs for flight crewmembers 
        who have demonstrated performance deficiencies or experienced 
        failures in the training environment that would require a 
        review of their whole performance history at the company and 
        administer additional oversight and training to ensure that 
        performance deficiencies are addressed and corrected. (A-05-
        14).

Fatigue Management Systems
    In June, 2008, the NTSB issued recommendations to the FAA to 
develop guidance for fatigue management systems (A-08-44) and to 
develop and use a methodology to continually assess the effectiveness 
of fatigue management systems used by operators (A-08-45). A fatigue 
management system incorporates various components and strategies to 
mitigate the hazards of fatigue in aviation operations, including 
scheduling policies and practices, attendance policies, education, 
medical screening and treatment, personal responsibility during non-
work periods, task and workload issues, rest environments, commuting 
policies and napping policies. The FAA has neither guidance nor 
regulations addressing fatigue management systems.
    In response to the FAA's lack of action in this area, the NTSB 
updated the Most Wanted List issue area ``reduce Accidents and 
Incidents Caused by Human Fatigue in the Aviation Industry'' to include 
these recommendations on fatigue management systems.

Conclusion
    Our investigation of Flight 3407 revealed 2 other aviation safety 
issues which we will explore in greater depth in events planned for the 
coming months. On May 17-19, 2010, we will hold a Public Forum on 
Ensuring and Supporting High Standards in Flight Crew and Air Traffic 
Controller Performance. At this forum we plan to bring industry leaders 
together to discuss the selection of pilots and controllers, training 
methods, and the development of techniques that support safe practices, 
such as peer mentoring and support, voluntary reporting programs, and 
the use of technology in oversight.
    Later this fall, we will hold a Public Symposium on Airline Code-
Sharing Arrangements and Their Role in Aviation Safety. The symposium 
will provide background information on domestic and international code-
sharing arrangements and their oversight, and provide insight into the 
best practices regarding the role of major airlines in ensuring the 
safety of regional code-sharing partners.
    In conclusion, the tragic crash of Flight 3407 brought the world's 
attention to the seriousness and complexity of maintaining safety in a 
transportation industry that continually evolves. If we are serious 
about aviation safety, we must establish a system that minimizes pilot 
fatigue and ensures that flight crews report to work rested and fit for 
duty. We must also have a system in which we are steadfastly confident 
that all of our commercial pilots are proficient and well-trained.

    Senator Dorgan. Ms. Hersman, thank you very much.
    Ms. Gilligan?

                STATEMENT OF MARGARET GILLIGAN,

          ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY,

                FEDERAL AVIATION ADMINISTRATION

    Ms. Gilligan. Thank you very much. I'm pleased to be here 
today to update you on the FAA's Call to Action on airline 
safety and pilot training--to strengthen our safety program.
    We released the final report on Call to Action at the end 
of January. We have given copies to your staff. The report 
details the results of our efforts, including the new and 
renewed commitments we received from industry and labor, the 
results of our Focused Inspection Initiative, and an update on 
our rulemaking activities.
    But, efforts have not stopped, nor even slowed down, just 
because we completed the final report. For example, since the 
final report was issued, we've published an Advance Notice of 
Proposed Rulemaking seeking recommendations from the public to 
improve pilot performance and qualifications. Just last week, 
we completed a survey to follow up on the results of our 
Focused Inspection Initiatives. The survey revealed even more 
improvement in the number of carriers who have implemented 
remedial training programs. When we first did the inspection 
initiative, 15 carriers had only partially implemented remedial 
training programs, and 8 carriers had no program at all. As of 
last week, 93 of the 95 active certificates have completed--
completely implemented remedial training programs, and the 
remaining 2 have implemented parts of those programs. Safety is 
at the core of FAA's mission, and we will always strive to make 
the safe system even safer.
    Our efforts in the Call to Action reflect the same approach 
we've taken to establish the unprecedent level of safety we 
enjoy today: identify voluntary actions, monitor 
implementation, propose new standards, and oversee the 
compliance of the industry. Unfortunately, FAA safety programs 
are too often measured by how precisely, or how rapidly, we 
comply with NTSB recommendations for rulemaking. This measure 
creates a misimpression about the safety of the aviation safety 
system and the efficacy of the FAA.
    For example, since the Board added fatigue recommendations 
in aviation to its most wanted list in 1995, we have reduced 
the passenger fatality rate by 85 percent, even while 
operations increased and approximately 11 billion passengers 
traveled by air. Few industries in the world can claim that 
kind of success. Using the same multipronged approach we've 
used in the Call to Action, we took action to address pilot 
fatigue while longer-term solutions were being developed. The 
FAA supported--and, in fact, in most cases, financed--the 
research that has been done to advance the scientific study of 
fatigue as it affects aviation. While we were doing that 
research, in order to mitigate the remaining risk, we clarified 
the requirements of our existing regulations, and we focused 
our oversight to ensure that those rules were followed.
    During that same 15 years, FAA issued nearly 400 final 
rules, more than 20 final rules every year. These rules 
introduced new technology, improved training, and enhanced 
procedures. More importantly, these actions virtually 
eliminated accidents such as controlled flight into terrain, 
wind shear, and even icing, just as an example, from scheduled 
commercial aviation. Acknowledging that we can never remove all 
the risk in the system, we've improved the design standards for 
aircraft to ensure passengers have every possibility to 
evacuate a damaged aircraft. And we have seen the success of 
those efforts in recent years.
    While we are proud of the aviation safety record we've 
established, safety professionals at FAA have not been resting 
on our laurels while the Board has issued recommendations. 
We've been acting, we have been implementing, and ultimately 
we've been improving the safety of the system.
    Much of our work in those years has addressed Board 
recommendations. We appreciate the direction that the Board 
helped set, and we appreciate the fact they have found our work 
acceptable in 82 percent of those recommendations.
    But, it's important to note, we don't wait for 
recommendations. In fact, when the Board issued the 25 new 
Colgan-related recommendations this week, we already had work 
underway to address many of them.
    Since aircraft accidents are so rare, the tragic Colgan 
accident has served, as you've noted, to refocus our ongoing 
efforts to improve aviation safety. The FAA's work over the 
last 50 years of commercial aviation has yielded measurable and 
meaningful safety improvements, and I assure you, under the 
leadership of Administrator Randy Babbitt, that will continue.
    That concludes my opening remarks, Mr. Chairman. We'll be 
glad to take any questions.
    [The prepared statement of Ms. Gilligan follows:]

 Prepared Statement of Margaret Gilligan, Associate Administrator for 
            Aviation Safety, Federal Aviation Administration

    Chairman Dorgan, Senator DeMint, members of the Subcommittee:
    Thank you for inviting me here today to provide you with an update 
on the Federal Aviation Administration's (FAA's) Call to Action on 
airline safety and pilot training. There is no question that the FAA's 
job is to ensure that we have the safest aviation system in the world. 
The aviation safety record in the United States reflects the dedication 
of safety-minded aviation professionals in all parts of our industry, 
including the FAA's inspector workforce. In an agency dedicated to 
aviation safety, any failure in the system, especially one that causes 
loss of life, is keenly felt. When accidents do happen, they reveal 
risks, including the tragic Colgan Air accident. Consequently, it is 
incumbent on all parties in the system to identify the risks in order 
to eliminate or mitigate them. As Administrator Babbitt noted when he 
appeared before you in December, history has shown that we are able to 
implement safety improvements far more quickly and effectively when the 
FAA, industry, and labor work together on agreed upon solutions. The 
fastest way to implement a solution is for it to be done voluntarily, 
and that is what the Call to Action was intended to facilitate. On 
January 27, the FAA issued a report that describes the progress made 
toward fulfilling commitments made in the Call to Action and offers 
recommendations for additional steps to enhance aviation safety. I 
would like to use this opportunity to review the issues the 
Administrator identified in December and let you know where we stand on 
them.
    Pilot Flight Time, Rest and Fatigue: When Administrator Babbitt was 
last here he told you that the aviation rulemaking committee (ARC) he 
convened for the purpose of making recommendations on flight time, rest 
and fatigue, consisting of representatives from the FAA, industry and 
labor organizations, provided him with recommendations for a science-
based approach to fatigue management in early September. While we were 
extremely pleased with the product provided, the ARC did not reach a 
consensus agreement on all areas and was not charged with doing any 
type of economic analysis. Consequently, in spite of the 
Administrator's direction for a very aggressive timeline in which to 
develop a Notice of Proposed Rulemaking (NPRM), his hope that a 
rulemaking proposal could be issued by the end of last year was not 
realized. The complexities involved with these issues are part of the 
reason why the FAA has struggled to finalize proposed regulations on 
fatigue and duty time that were issued in the mid-1990s. However, with 
the Administrator's continued emphasis on this topic, we hope to issue 
an NPRM this spring. Although this is slightly later that we originally 
hoped, it is still an extremely expedited schedule, and I can assure 
you the FAA team working on this is committed to meeting the target.
    One of the issues contributing to fatigue, that I know is of 
interest to many of you, is that of pilots who commute by air to their 
job. I would like to describe some of the e-mails and letters the 
Administrator has been receiving on the issue of commuting, from pilots 
who choose to commute by air to their job. As you can imagine, those 
pilots who commute responsibly are understandably concerned that they 
could be forced to relocate because of the irresponsible actions of a 
few. Should some sort of hard and fast commuting rule be imposed, it 
could result in families being separated, people being forced to sell 
homes at a loss, or even people being forced to violate child custody 
agreements. It is important to keep in mind these personal accounts, 
because, to people not familiar with the airline industry, the issue of 
living in one city and working hundreds of miles away in another does 
not make sense. But in the airline industry, this is not only a common 
practice, it is one airline employees have come to rely on. So we want 
to emphasize these issues are complex and, depending on how they are 
addressed, could have significant impacts on people's lives.
    Focused Inspection Initiative: From June 24, 2009 to September 30, 
2009, FAA inspectors conducted a two-part, focused review of air 
carrier flight crewmember training, qualification, and management 
practices. The FAA inspected 85 air carriers to determine if they had 
systems to provide remedial training for pilots. The FAA did not 
inspect the 14 carriers that have FAA-approved Advanced Qualification 
Programs (AQP) because AQP includes such a system. Seventy-six air 
carriers, including AQP carriers, have remedial training programs. An 
additional 15 air carriers had some part of a remedial training 
program. There were eight air carriers that lacked any component of a 
remedial training program that received additional scrutiny and have 
since instituted some component of a remedial training system. Since we 
started, all carriers have implemented some component of a remedial 
training program. The FAA inspectors also observed 2,419 training and 
checking events during the evaluation. In the few instances we observed 
regulatory non-compliance, we took corrective action.
    Training Program Review Guidance: Based on the information from 
last summer's inspections, the FAA is drafting a Safety Alert for 
Operators (SAFO) with guidance material on how to conduct a 
comprehensive training program review in the context of a safety 
management system (SMS). A complementary Notice to FAA inspectors will 
provide guidance on how to conduct surveillance. SMS aims to integrate 
modern safety risk management and safety assurance concepts into 
repeatable, proactive systems. SMS programs emphasize safety management 
as a fundamental business process in the same manner as other aspects 
of business management. Now that we have completed our data evaluation 
and drafting, both guidance documents are in internal coordination.
    Obtain Air Carriers' Commitment to Most Effective Practices: To 
solidify oral commitments made at the Call to Action, Administrator 
Babbitt sent a letter to all part 121 operators and their unions and 
requested written commitments to adhere to the highest professional 
standards. Many airlines are now taking steps to promote the larger 
airline's most effective safety practices at their smaller partner 
airlines. The Air Transport Association's Safety Council is now 
including safety directors from the National Air Carrier Association 
and the Regional Airline Association in their quarterly meetings. 
Several large air carriers are conducting periodic meetings with those 
with whom they have contract agreements to review safety information 
and we are encouraged by these efforts.
    In addition, I am pleased to say that since July 2009, after the 
Call to Action, the FAA approved 12 new Flight Operations Quality 
Assurance (FOQA) programs. Three air carriers that had no Aviation 
Safety Action Programs (ASAP) have now established them. Four more air 
carriers have established new ASAP programs for additional employee 
groups. All of this supports the contention that the Call to Action did 
make a difference.
    Professionalism and Mentoring: Last week, the FAA met with labor 
organizations to discuss further developing and improving 
professionalism and transfer of pilot experience. In the interim, these 
organizations have answered the Call to Action and support the 
establishment or professional standards and ethics committees, a code 
of ethics, and safety risk management meetings between the FAA and 
major and regional air carriers. We also believe that labor 
organizations can explore some of the ideas raised in the Call to 
Action road shows, such as establishing joint strategic councils within 
a ``family of carriers,'' use of professional standards committee 
safety conferences, and mentoring possibilities between air carriers 
and university aviation programs, with the goal of coming up with 
concrete ideas on mentoring. These ideas merit further discussion and 
the FAA looks forward to continuing to work with these organizations on 
these concepts.
    Crew Training Requirements: As the Administrator explained during 
his last appearance before this committee, the FAA issued a rulemaking 
proposal in January 2009 to enhance training programs by requiring the 
use of simulation devices for pilots. More than 3,000 pages of comments 
were received. The FAA is now developing a supplemental proposal that 
will be issued in the coming months to allow the public to comment on 
the revisions that were made based on the comments that were submitted.
    One of the things that the Call to Action has shone a light on is 
the issue of varying pilot experience. The FAA is attempting to address 
this issue with an Advanced Notice of Proposed Rulemaking (ANPRM) in 
which we can consider possible alternative requirements, such as an 
endorsement on a commercial license to indicate specific 
qualifications. We know some people believe that simply increasing the 
minimum number of hours required for a pilot to fly in commercial 
aviation is appropriate. As Administrator Babbitt has stated 
repeatedly, he does not believe that simply raising quantity--the total 
number of hours of flying time or experience--without regard to the 
quality and nature of that time and experience--is an appropriate 
method by which to improve a pilot's proficiency in commercial 
operations.
    The ANPRM requests recommendations from the public to improve pilot 
performance and professionalism; specifically on whether existing 
flight crew eligibility, training and qualification requirements should 
be increased for commercial pilots engaged in part 121 operations. The 
FAA is requesting comments and recommendations on four concepts for the 
purpose of reviewing current pilot certification regulations. The four 
concepts are: (1) requirement for all pilots employed in part 121 air 
carrier operations to hold an Airline Transport Pilot (ATP) certificate 
with the appropriate aircraft category, class and type rating, or meet 
the aeronautical experience requirements of an ATP certificate; (2) 
academic training as a substitute for flight hours experience; (3) 
endorsement for air carrier operations; and, (4) new additional 
authorization on an existing pilot certificate. The FAA has also asked 
for recommendations from industry and the public on any other concepts 
they may wish to offer. The ANPRM was published in the Federal Register 
on February 8.
    Pilot Records: While Congress is working to amend the Pilot Records 
Improvement Act of 1996 and the FAA amends its guidance to airlines, 
Administrator Babbitt asked that air carriers immediately implement a 
policy of asking pilot applicants to voluntarily disclose FAA records, 
including notices of disapproval for evaluation events. The airlines 
agreed to use this best practice for pilot record checks to allow for a 
more expansive review of records created over the course of a pilot's 
career. The expanded review would include all the records the FAA 
maintains on pilots in addition to the records airlines already receive 
from past employers. Of the 80 air carriers that responded to the FAA 
on this issue, 53 air carriers, or 66 percent, reported that they 
already require full disclosure of a pilot applicant's FAA records. 
Another 15 percent reported that they plan to implement the same 
policy.
    As the Administrator stated when he appeared before you in 
December, the core of many of the issues facing the air carrier 
industry today is professionalism. It is the duty of the flight crew to 
arrive for work rested and ready to perform their jobs, regardless of 
whether they live down the street from the airport or a thousand miles 
away. Professionalism is not something we can regulate, but it is 
something to which we must encourage and urge pilots and flight crews 
to aspire. The conversations we have been having, in part because of 
the Call to Action, help emphasize the importance of professionalism in 
aviation safety.
    In conclusion, our efforts will not stop or even slow down just 
because the final report on the Call to Action was issued. We have been 
gratified with the response to this effort. We believe that the 
collective efforts of FAA, the airlines, labor unions and, of course, 
Congress, will continue to result in implementing best practices, 
transferring pilot experience, and achieving an overall improvement in 
safety. Safety is at the core of the FAA's mission, and we will always 
strive to make a safe system safer.
    Mr. Chairman, Senator DeMint, members of the Subcommittee, this 
concludes my prepared remarks. I would be happy to answer any questions 
that you might have.

    Senator Dorgan. Thank you very much.
    It is true that accidents--commercial aviation accidents 
have become rare. There's no question about that. And yet, as I 
look at this particular accident and all of the evaluation of 
issues that relate to it, it seems to me that we are very 
fortunate that accidents have been rare.
    I was on the phone this morning, on some airline service 
issues for a community, and like most communities, that 
community's service has changed substantially over the years. 
Used to be served by a carrier that would fly 727s originally, 
and then 319s, and so on, larger carriers--or, larger planes 
with pilots from the trunk carrier. Now most of the service in 
that particular city is by regional carriers. Eighty percent--I 
think 75 percent of the service is RJ--50-seat regional jets. 
And so, the companies that fly them are, in many cases, very 
different than the companies that were flying into that city 
previously, despite the fact that most passengers wouldn't know 
that, because the planes look the same, same company name on 
the planes, and so on.
    So, service has changed very substantially. With 50 percent 
of the flights--as I understand it, 50 percent of the flights 
in this country are now regional carrier flights. And the 
question is, Do we have one level of safety? And so, I want to 
ask a series of questions.
    First of all, I think, Ms. Gilligan, you mentioned, in the 
Focused Inspection Initiative, which started June 24, 2009, you 
wanted to go to these carriers and inspect the carriers to 
determine, Do they have remedial training for pilots? And you 
indicated that eight carriers lacked any component of any 
remedial training program. These are carriers, I assume, that 
are picking up passengers at various airports around the 
country?
    Ms. Gilligan. Yes.
    Senator Dorgan. All regional carriers, would they have 
been?
    Ms. Gilligan. I don't know that, off the top of my head 
right now.
    Senator Dorgan. What would you----
    Ms. Gilligan. We do have the names of the carriers, and we 
can certainly check that.
    Senator Dorgan. What would you think?
    Ms. Gilligan. They were not the eight or nine mainline 
carriers that most people are familiar with, but they--I don't 
know that they were providing service that is--regional 
service----
    Senator Dorgan. Right.
    Ms. Gilligan.--or were independent operators.
    Senator Dorgan. But I was stunned that----
    Ms. Gilligan. But, we can provide that.
    [The information referred to follows:]

    Prior to the Call to Action, these eight carriers (three of which 
were predominately cargo carriers) lacked procedures for identifying 
pilots who needed remedial training as a result of substandard 
performance during a check ride. In one case, however, the carrier had 
in place an Advanced Qualification Program (AQP), a voluntary 
alternative to the traditional regulatory requirements for pilot 
training and checking under which the FAA may approve significant 
departures from traditional requirements, subject to justification of 
an equivalent or better level of safety. At the time of the focused 
inspection, however, the carrier had just acquired a new aircraft type 
that was not yet covered by its AQP. Therefore, we listed the carrier 
as not meeting the focused inspection criteria.

    Senator Dorgan. I was stunned that you have eight 
commercial air carriers that are--that were, last summer, 
picking up passengers and flying passengers around the country, 
that would have had no remedial training program for pilots, of 
any type. Does that stun you?
    Ms. Gilligan. It surprises me. But, if I may put that in a 
little context?
    Senator Dorgan. Sure.
    Ms. Gilligan. By regulation, anytime a pilot fails a check 
ride or an event in that training, they are required by 
regulation to receive additional training and to be signed off 
by an instructor pilot before they can take that check again. 
So, by regulation, any pilot who does fail a particular event 
must get additional training, have that signed off, and then is 
tested by a different independent check pilot. All of the 
carriers meet that regulation.
    Several years ago, we put out guidance that recommended the 
creation of a remedial training program, which not only assured 
that regulatory requirement, but recommended that the carriers 
track, over the career of the pilot, those failures. Because 
you may have one, and it may be 5 years before you may have 
another one. It may be 5 months. It was important, we believed, 
that they be able to track that, for two reasons: to evaluate 
the effectiveness of their own training programs, and to 
continue to identify if there are particular pilots who 
demonstrate the failure of check items more often than others. 
It is that tracking program that those eight carriers had not 
then implemented. As of today, I believe six of those have 
implemented fully, and I believe the two that still only have 
partial programs were part of that original eight, and we can 
give you all of that data, if you'd like.
    [The information referred to follows:]

    Through a Safety Alert for Operators (SAFO), the FAA strongly 
encourages part 121 air carriers to establish remedial training 
programs for pilots with persistent performance deficiencies. Remedial 
training programs are specific to each carrier's operations and to its 
FAA-approved training program. Although these programs are voluntary, 
we are happy to report that of the 95 carriers active today, 93 meet 
the intent of the FAA's SAFO regarding remedial training. The remaining 
two carriers offer remedial training programs, but they do not meet the 
full intent of the SAFO because they do not currently have procedures 
in place to follow up and ensure the effectiveness of the remedial 
training.

    Senator Dorgan. But, it just seems to me--I understand that 
most carriers complied, and moved, as a result of the request 
of the FAA, and some did not.
    Ms. Gilligan. Yes.
    Senator Dorgan. And it seems to me to be pretty persuasive 
evidence that you've got to make things happen. I mean, the FAA 
has to make sure that carriers are doing what the FAA wants 
them to do. And I----
    Anyway, let me go on to the range of issues that are 
raised. Ms. Hersman, you said 25 recommendations, is that 
correct, in your report?
    Ms. Hersman. Yes.
    Senator Dorgan. Can we begin to go through some of those in 
the major categories? What have you recommended, or what is in 
your report with respect to fatigue or crew rest?
    Ms. Hersman. In our report, the Safety Board issued a 
recommendation specifically to address commuting. One of the 
things that we thought was important in this accident, was that 
this crew were both commuting pilots, and they both commuted 
from some distance away. But we did identify that this wasn't 
unusual. In Colgan's base in Newark, 70 percent of the pilots 
at that base were commuter pilots, and over 20 percent of those 
commuting pilots commuted from over 1,000 miles away. What we 
found in this investigation was that neither of the crew 
members had a residence or a crash pad in the Newark area, and 
so we did identify some concerns about the choices that they 
made, either commuting across country on an overnight flight, 
with a stop in Memphis, or sleeping in the crew room. The 
captain had slept in the crew room two of the three previous 
nights before the accident. And we know that not just the 
quantity of sleep is important, but the quality of sleep is 
important. Trying to get sleep on a redeye, coming across 
country, is not going to produce quality sleep. So, we did make 
a recommendation----
    Senator Dorgan. Can I stop you at that point?
    Ms. Hersman. Sure.
    Senator Dorgan. The captain of this flight, you say, spent 
two of the previous three nights in the crew room, all night 
long. Is that correct? I mean, during the night and morning 
hours? Are there beds in the crew room?
    Ms. Hersman. No. They do have some sofas and some reclining 
chairs in the crew room, but it is not set up for recuperative 
rest. And the company actually prohibited overnighting in the 
crew room.
    Senator Dorgan. All right. So, the--this issue of--which 
is, I think, somewhat different than how the FAA classifies 
fatigue--I mean, that's--I think that relates more to a workday 
period. But, this issue of commuting, and then whether they 
have a crash pad or someplace to sleep, or whether, in this 
case, a pilot of an airplane spends two nights in a crew room 
with no bed, prior to a flight, in the winter, with icing, and 
so on--that just begs the question of, Is that a very unusual 
occurrence? Or have you done anything to determine whether this 
is just, sort of, an aberration? This is one captain who wasn't 
thinking very clearly about not sleeping in a bed someplace. 
Have you done any surveys to find out, at LaGuardia, is this 
the only captain that did that, or has done that, or is doing 
that? What's your sense of that?
    Ms. Hersman. In this accident investigation, we could find 
specific information about this crew and we know that this was 
a commuting concern, because many of the pilots recently had 
been moved to Newark. When we asked Colgan to look at how many 
of their pilots were commuting--we actually have a chart that 
shows where they're commuting from around the country. What was 
of most concern to us was that 70 percent of the pilots were 
commuting pilots, and 20 percent were commuting from over 1,000 
miles away.
    [Additional information from Ms. Hersman follows:]

    These data were provided by Colgan during the Flight 3407 
investigation. They apply to pilots assigned to the Newark base, and 
are described in section 1.17.4.1 on page 47 of the NTSB accident 
report (AAR1001). The chart is contained on page 26 of the Human 
Performance Group Chairman's Factual Report (http://www.ntsb.gov/
Dockets/Aviation/DCA09MA027/418082.pdf).



    The NTSB has heard anecdotally that as many as 50 percent of pilots 
commute to work. Pilots sometime choose to commute to work from distant 
cities as a matter of personal choice and sometimes out of necessity. 
Air carriers occasionally close bases, forcing many of their pilots to 
relocate or begin commuting.

    One of the other issues that we identified was that the 
first officer's pay was fairly low. Many pilots--some who 
contacted us with anecdotal information, during the public 
hearing and after--described circumstances where their bases 
were changed, and they could not afford to live in the new 
area. We noted that Colgan's management did have a cost-of-
living adjustment for living in the Newark area, but the pilots 
did not.
    Senator Dorgan. But, let me put up--these are the Colgan 
air pilots commuting to the Newark base. You will see--and this 
is probably the chart you're referring to, it's the one we are 
working with--and it shows the locations across the country 
from which pilots are traveling to Newark.
    But, my question is more specific. Do any of us in this 
room have any knowledge of whether this is a--just a complete 
aberration with one captain, who spends two nights in a crew 
room with no bed prior to this flight that ended in tragedy? Do 
we have any knowledge, have we done any surveys, have we asked 
anybody about that? And I would ask both of you--Ms. Hersman, 
any surveys done? And, Ms. Gilligan, is it your sense that this 
is a practice that's prevalent, or highly unusual?
    Because it seems to me, on this issue of fatigue and crew 
rest and commuting--all of which kind of go into one bundle, 
for me--it seems to me that, clearly, if any one of us in this 
room were about to board an airplane, and someone told us, 
``That captain that's getting in the cockpit hasn't slept in a 
bed for two nights,'' would any of us have second thoughts 
about that? You'd better believe we would.
    So, tell me, what do we know about this? Do we know, is--we 
know about this crew. Do we know anything else? Or are we just 
blind on everything else, at the moment?
    Ms. Hersman. The Safety Board doesn't have any further 
information, beyond our survey of the commuting pilots in 
Newark. We don't know how many of them had crash pads. We do 
know the information about the two pilots involved in this----
    Senator Dorgan. How----
    Ms. Hersman.--accident.
    Senator Dorgan.--about the carrier itself even asking for 
self-reporting? Have they, in the aftermath of this accident, 
said, ``You know what? We had a captain here that hadn't been 
in a bed for two nights. We'd better ask the others?'' How 
prevalent is it to find people spending all night in a crew 
room, without a bed, before a flight? Do they know whether 
Colgan has asked other pilots, at least on a self-reporting 
basis, to know what is happening there?
    Ms. Gilligan. I don't know, sir, but we can certainly ask 
the carrier and find out if they have done any kind of review 
to that extent. We do know commuting is a fairly common 
practice within the industry, both for the major and for the 
regional carriers, and it has been for a very long time. As the 
Chairman indicates, the movement of bases, the pilots bid on 
different equipment out of different locations, for career 
reasons. It is a--there are lots of reasons why where a pilot 
works changes over the course of his or her career. And their 
decision to remain living where their family is located is a 
decision that is not uncommon.
    We do know it sounds--to most of us who drive a few miles, 
perhaps, or take the metro into work like an odd decision to 
make. But, many pilots have commuted for their whole careers, 
and do so very responsibly. And we agree, we need to address 
this as we look at the issues of fatigue.
    Senator Dorgan. But let me ask you whether you think that 
this is a reasonable concern.
    If--Ms. Gilligan, if you have a flight at 12 o'clock from 
National this afternoon, and you're about to drive out and get 
on that Dash-8, and you know the captain hasn't slept in a bed 
for two nights--does that give you pause about whether you want 
to take that flight?
    Ms. Gilligan. Certainly, sir. We expect pilots to react 
professionally and to be responsible and arrive at work rested 
and ready to take their responsibilities. I absolutely agree.
    Senator Dorgan. The thing that kind of troubles me about 
this is, when--and we'll get to all of these things--stick 
shaker training and sterile cockpit and commuting and--the 
thing that troubles me is, we now have done an unbelievable 
inspection of what happened in that cockpit of one airplane 
taking one flight, and it appears to me to have about six or 
eight very serious problems. And the question is, Is this just 
serendipitous, that it all is created in that one cockpit and 
doesn't exist elsewhere, or are we seeing the evidence of 
problems that we really need to get on and address and fix?
    And in this area of commuting, and the question of, ``At 
the end of your commute, where are you getting some rest in 
order to be prepared for that next flight, as a professional 
pilot?''--that's a very important question. And the thing is, 
we apparently--the three of us in--well, four of us--know 
nothing about the practice, beyond the description of these two 
people. My understanding is that the copilot herself--the 
copilot did not have--in your investigation, the copilot was 
not seen to have had a rest period in a bed, either. Is that 
correct?
    Ms. Hersman. No, the first officer flew from Seattle. She 
boarded a flight in Seattle the evening before the accident, 
flew in the jumpseat of a cargo operator, to Memphis, got off 
in Memphis, and then flew from Memphis to Newark. There's a 3-
hour time difference that she experienced as she traveled 
across country, as well. They estimated that she received a 
couple of hours of sleep when she was flying across country. 
She tried to nap, also, in the crew rest area that morning, 
before she went on duty.
    So, both individuals did not have recuperative-quality 
sleep the night before the accident. That's why we made our 
recommendation to the FAA to address fatigue risks associated 
with commuting: identifying pilots who commute, establishing 
policy and guidance to mitigate fatigue risks for commuting 
pilots, using scheduling practices to minimize opportunities 
for fatigue, and developing or identifying rest facilities for 
commuting pilots.
    We don't think that Colgan is unique. We know that this 
goes on in the industry. I think our problem is that we can't 
identify what the issues are until an accident occurs, and we 
investigate what happened in that situation.
    After the accident, Colgan did take some action. One of the 
things that the company did was to put out a policy that 
required the lights to stay on in the crew room at all times, 
24 hours-a-day. That wasn't mitigating the challenge for people 
who were commuting; it was just ensuring that any sleep 
obtained in the crew room was going to be with the lights on.
    Senator Dorgan. Yes. The difficulty is, this also relates 
to the question of compensation, because someone who is living 
in Seattle, flying to the duty station in LaGuardia, and is 
paid--I don't know what--I think it was $20- or $23,000 a 
year--is not very likely going to have the resources to go get 
a hotel room somewhere. So, there's a relationship there, as 
well.
    Well, I--what do you--just on--leaving this point, what do 
you think we need to do to understand whether this is a common 
practice or a very unusual practice, that we've got people 
boarding commuter airlines with no sleep, or very little sleep? 
You're making recommendations. What do we do at the FAA to 
implement those recommendations?
    Ms. Gilligan. Well, I think, as you know, we already have 
our flight and rest rule under executive review within the 
Administration. As the Administrator committed, we're moving as 
quickly as possible to put forward that new proposal, which 
will enhance the requirements for flight and rest, and how work 
is assigned.
    In that, we were also asking for additional insight into 
this particular issue, because, again, commuting has been a 
part of the industry for quite a long time, and can be done 
responsibly. We want to understand how we can set a framework 
for that and how the airlines can hold their crew members 
responsible for that. And I think we'll see real progress in 
that way.
    The recommendation is for additional guidance materials. I 
think that will be a part of how we will implement our new 
rulemaking. We will provide guidance on how the airlines can 
best address these kinds of risks.
    Senator Dorgan. But, the issue is, there's already a rule. 
I mean, the rule would have told both of those pilots, ``You 
can't show up at LaGuardia and spend your time in the crew 
room. You've got to get rest somewhere.'' Right? I mean----
    Ms. Gilligan. Yes, sir.
    Senator Dorgan.--doesn't that rule exist?
    Ms. Gilligan. Yes, sir.
    Senator Dorgan. So, then the question is--then the question 
is, not just a new rule, although a new rule is probably 
reasonable, but, How do we enforce rules?
    Ms. Gilligan. That's right.
    Senator Dorgan. And what do we know about whether these 
current rules are enforced, generally, or not enforced much at 
all?
    Ms. Gilligan. And that's why the Administrator is calling 
for a renewed emphasis on pilot professionalism, because, at 
the end of the day, oftentimes it is up to the pilot himself or 
herself to evaluate that they have met their personal 
responsibility. In the meantime, you're right, we can enhance 
the framework within the regulations, we can give both the 
airline and the individual crew member better opportunities to 
be properly prepared for the flights. But, the pilot must come 
to work prepared to work----
    Senator Dorgan. All right.
    Ms. Gilligan.--and rested and mentally fit and physically 
capable. And we are putting a huge push on pilot 
professionalism as part of the Administrator's agenda.
    Senator Dorgan. All right. I'm going to ask about a series 
of things that--the credentials of a pilot, that are necessary 
to fly an airplane, the responsibility of trunk carriers for 
the regionals that bear their name, and specifically about 
training issues. But, before I do that, I want to call on the 
Ranking Member of the Subcommittee, Senator DeMint.

                 STATEMENT OF HON. JIM DeMINT, 
                U.S. SENATOR FROM SOUTH CAROLINA

    Senator DeMint. Thank you, Mr. Chairman. And I really 
appreciate your line of questioning.
    The Chairman has mentioned, several times, the idea of a 
survey. I did a lot of that in my previous life, and I think he 
has made an excellent point. We know what happened in this 
particular situation, a year ago. The rules weren't followed, 
so making new rules is not necessarily going to help the 
situation.
    But, it does seem that an anonymous-type survey of pilots 
could, not only help determine what is really happening now, 
but also get some ideas from them on what they see as a way to 
assist in this lifestyle, that has apparently been created over 
many years of sometimes very long commutes. We don't have a 
real handle on whether this is a problem of 5 percent of pilots 
or 80 percent of pilots. Hopefully, some of their ideas on what 
could assist them during their commutes, whether it's per diems 
or just other facilities available would be useful. It seems 
like we're flying in the dark here, really. And after a year of 
knowing we had serious, and multiple problems in this one 
cockpit, it doesn't seem as we know much more today about how 
widespread that is than we did a year ago.
    And so, I'm concerned about the approach here of 
encouraging accountability and professionalism and things like 
that without trying to find out more about how widespread it is 
or even how they--the carriers--could assist pilots in making 
sure that they have every resource available to be 
professional, and to show up rested. I'm just curious why there 
hasn't been more pursuit to find out, industrywide, the degree 
of this problem.
    Ms. Gilligan. Well, I think, sir, there are two things. One 
is that we do know that the vast majority of pilots come to 
work prepared to work. The data shows that.
    Senator DeMint. Now, how do you know that?
    Ms. Gilligan. Because the safety data indicates that. We 
are not seeing accidents and incidents in----
    Senator DeMint. OK, so----
    Ms. Gilligan.--any vast number, and----
    Senator DeMint. But, you don't know that they're rested, 
you just know that we don't have a lot of accidents, right?
    Ms. Gilligan. We know they are performing and meeting their 
responsibilities----
    Senator DeMint. OK.
    Ms. Gilligan.--and that is a measure of whether or not 
they're properly rested. You're right, we can't know exactly, 
but I think it's a reasonable measure that most pilots are 
professional. We can't implicate the whole community based on 
this accident.
    So, you're right. We need to find exactly what the sweet 
spot for this issue is.
    There is the ability for pilots to self-report, right now. 
All the airlines have programs for pilot reporting, anonymous 
reporting. They can then look at the results from that 
reporting and begin to address those safety trends. I haven't 
asked the airlines whether they're seeing a trend in reports 
related to either commuting or fatigue, but we certainly can do 
that. I think that's a wise thing to do.
    The industry comes together twice a year to review their 
general results on those safety reports, and we will ask them 
at the next meeting to come in and report on what they are 
seeing on the issues of commuting, and whether there's a trend 
there. That would certainly be helpful.
    Senator DeMint. OK, go ahead.
    Senator Dorgan. Let me just--on that point--because the 
entire system has changed so dramatically, with half the 
flights now being regional carriers, isn't it just something 
that we should assume, that when you've got somebody making 
$20- or $22,000 a year flying across the country to get to 
their duty station, that they're not going to have the money to 
go out and get a hotel room? So, shouldn't we just assume that 
there is probably a larger problem here, that is a growing 
problem as you have more and more flights that are commuter 
airline flights with lower-paid pilots?
    Ms. Gilligan. Well----
    Senator Dorgan. Shouldn't we assume that's a problem?
    Ms. Gilligan. I think we certainly agree that it is a risk 
area that we have to understand better. I completely agree with 
that. I don't know how far most pilots commute. I don't know--
and perhaps we need to know that data. I agree with you, sir, 
that that's something that we should be pursuing, certainly as 
we're looking at our fatigue rule, to see whether and how we 
can give better guidance on how both the pilots and the 
operators can try to address this issue. I agree.
    Senator DeMint. Mr. Chairman, I know you've got a line of 
questioning. But, I would encourage you, just that--the power 
of finding out the extent of the problem. I know the carriers, 
they say the pilots can report. But, I think we should consider 
the idea of asking all the carriers to get all of their pilots 
to fill out some anonymous survey that helps us to create a 
pattern of what's going on now, to seek pilots' advice on how 
we could help.
    The carriers have a different role to play than we do here. 
Our job is strictly safety, and they have to run an airline, 
they have to make a profit, they have to do a lot of things. 
And I know safety's at the center of that for them, as well. 
But, this is more than a carrier-to-carrier issue, and I would 
just ask you to consider ways that we might collect information 
and develop a clear assessment of the situation today to see 
if--from the pilots and the carriers perspective, that there 
may be a role that we play that can either limit this commuting 
system or make it work in a way that's safer. Because, just 
because the safety record is good does not mean the pilots are 
rested. All of us have driven cars on long trips and wondered 
how we ever got there, we were so tired. We made it, so we had 
a safe outcome. But I think we need to take it a step further 
here. And I really do think the Chairman's right, that we don't 
know how widespread this is, I'm not sure we can fix the 
problem, or--and neither can the carriers.
    Senator Dorgan. Senator DeMint, thank you.
    I think we're going to ask to have some kind of survey 
done. We'll work together on that. Because I think we need to 
understand, What is the dimension of the issue out there, and 
the problem? It just seems logical to me that if we--if we've 
got more low-paid people out there commuting across the 
country--in this case, both people in the cockpit going through 
the evening without having proper bed rest--I just--it's 
unlikely, to me, that--it seems unlikely to me that this is the 
only circumstance.
    Maybe this has become a practice; that's the way you do 
things. If it is, it has to stop. And----
    Let me ask some questions about training, if I might. Ms. 
Hersman, my understanding is that, in that cockpit that 
evening, the stick shaker and the stick pusher both were 
engaged at some point, right? And the--tell me your conclusion 
about the pilots' acquaintance with, and response to, the stick 
pusher.
    Ms. Hersman. The stick pusher and the stick shaker are two 
different things. Once the upset started, the stick shaker was 
pretty much firing continuously, telling the pilot that they 
needed to get some additional airspeed and get the nose of the 
airplane down. The stick pusher actually takes action and 
attempts to push the yoke forward to try to get the airplane's 
nose down. It's the airplane almost trying to help itself. The 
captain never pushed forward. Once the onset of the shaker 
occurred, he continued to pull back, which is exactly the 
opposite of what he had been trained to do in response to a 
stick shaker. The stick shaker was giving him an approach-to-
stall indication. Pilots are trained on approach-to-stall, so 
they should know how to respond when they get a shaker. This 
pilot did not respond according to his training or give any 
response that our investigators would have expected of him. The 
first officer didn't recognize what was going on and intervene 
or take any corrective action, such as calling ``stall,'' and 
helping to push the yoke forward.
    Senator Dorgan. But, I'm talking--did this pilot have 
adequate training on--you know, look, in the first 10 hours of 
instruction, when you want to get a pilot's license, you learn 
what a stall is and how to recover from it. That's--I mean, 
that's one of the most----
    Ms. Hersman. Right.
    Senator Dorgan.--basic things you learn when you learn to 
fly an airplane. So, it's not--it's surprising to me--not 
surprising to me, I guess, that in that airplane, when 
something happened with the airspeed and that plane began to 
stall, they got the stick shaker that was sounding warnings to 
them, and so on. But, I--what I don't understand is, Did the 
pilot have adequate training in both the mechanics of the 
shaker and the pusher? And what's your conclusion of his 
actions?
    Ms. Hersman. We----
    Senator Dorgan. And the training.
    Ms. Hersman. We've made recommendations about upset 
training in the past. We've reiterated some of those 
recommendations.
    There are two issues here that I want to make clear. The 
pilot did get the required training. One of the things that we 
found was that this pilot had multiple practical test failures, 
some in scenarios similar to the accident scenario, in which he 
did not respond appropriately. So, we made recommendations 
about multiple test failures and remedial training. His 
performance in the cockpit was somewhat consistent with his 
previous performance on past tests.
    However, we've also made recommendations about improving 
training. We think that there's a lot of room for improvement 
for training in upset situations. Pilots get trained on 
approach-to-stall; they don't get trained in a full stall. 
We've made recommendations that pilots need training in that 
area. Simulator fidelity is improving. And we have recommended, 
also, in the past, based on other accident investigations, that 
pilots be exposed and trained to stick pusher. They are not 
generally exposed to that. We asked Colgan's training pilots, 
``When pilots were exposed to pusher, if they exposed them to 
it, what did they do?'' And they said 75 percent of the pilots 
in training who might have been exposed to pusher tried to 
override it, as this pilot did, which was the wrong response. 
We've made recommendations, in the past, to train pilots to 
pusher. They're not trained that way now.
    Senator Dorgan. Well, your recommendations say, ``Stick-
pusher training was not consistently provided to pilots of the 
Q-400s, nor was it required by the FAA.''
    Ms. Hersman. That's true. We've made recommendations that 
they need to have that training; we found that they weren't 
trained in this situation. They were trained to shaker, not to 
pusher.
    Senator Dorgan. Let me ask about the icing issue, if I 
might, because you have some comments and some recommendations 
on icing in your report. Can you describe them?
    Ms. Hersman. Yes. In our investigation, we found that this 
aircraft did go through icing conditions, it had accumulated 
some ice, but it was well within its performance capabilities. 
The ice, the pilots were aware of, and they had addressed it, 
to some extent. They did make some mistakes. They didn't 
correlate a switch and the landing speed that they needed to 
do, which we found was a contributing factor. But, the aircraft 
was certainly capable of performance in that ice and to fly out 
of the stall that it was in. We did make some recommendations, 
however, about information about icing, to make sure that 
pilots are trained.
    We also found that the dispatch materials that were 
provided to the crew did not contain required information to 
tell the crew what weather conditions they were facing. This 
has been a concern in the past. We've made recommendations, in 
this accident, to make sure the crew has full information. We 
know that they were aware of the ice, so this wasn't a causal 
issue in the accident, but it was an area that we identified as 
a concern.
    Senator Dorgan. When you talk about the dispatcher, is that 
a dispatcher from this company?
    Ms. Hersman. Yes. The dispatcher is a company dispatcher, 
but they contracted for that weather information. They weren't 
properly overseeing their contract to ensure that they had the 
right materials in the information that they provided to their 
pilots.
    Senator Dorgan. And have you evaluated whether that is a 
unique condition, again, to this particular carrier in this 
circumstance, or is this something that may be a problem across 
commuter carriers?
    Ms. Hersman. It's something that could be a wider problem, 
and that's why we made the recommendation to the FAA to look at 
this issue and address it.
    I will say that the Safety Board has had concerns in the 
past. We've looked at other accidents where the materials that 
the pilots were provided were not always helpful. They get 
large packets. The information isn't always sorted for 
priority. You don't want to have the icing alert on the 40th 
page of the materials that you're being handed. We have looked 
at this issue of information and how it's presented to the 
pilots, in other accidents, including the Comair accident.
    Senator Dorgan. So, this issue was contracted out by Colgan 
to a contractor, and Colgan did not oversee the contractor 
properly, you're saying?
    Ms. Hersman. Yes.
    Senator Dorgan. Has that been remedied?
    Ms. Hersman. I would hope so, since it was brought to 
Colgan's attention. But, what we found in the accident was that 
it was not handled properly for this flight.
    Senator Dorgan. Ms. Gilligan, when I ask, ``Has that been 
remedied,'' the question is always, not ``What are the rules?'' 
but ``How are they enforced?'' So, do we know whether Colgan 
has responded to that?
    Ms. Gilligan. I don't know, sir. I'll certainly look into 
whether they specifically have done so.
    [The information referred to follows:]

    To address concerns about provision of weather information to 
flight crews, Colgan Air has updated its computer system and 
streamlined its requirements for weather data packages. These packages, 
which are part of the flight release given to the captain, include 
departure, en route, and arrival weather.
    As part of its overall surveillance of Colgan Air, the FAA is 
monitoring the carrier's provision of weather data to flight crews.

    Ms. Gilligan. But, it is common for airlines to acquire the 
weather information that they need from official weather 
providers. The airlines themselves don't collect their own 
weather. And so, there's fairly common use of information 
related to weather. We will look closely at the Board's 
recommendation, to make sure that--either in the Colgan case, 
in particular, or, as you suggest, that more broadly through 
the system--that we don't have a risk here that has not been 
addressed.
    Senator Dorgan. Let me ask you some questions about the 
issue of the major carriers and their relationship to, and 
responsibility for, the regional carriers.
    Ms. Hersman, as I understand it, the movement in the 
industry toward regional carriers with smaller planes, in most 
cases, and having the regional carrier carry the brand of the 
major carrier, is a circumstance where they have a contractual 
relationship. But, the major carrier, in most cases, does not 
have responsibility for, or liability for, the regional 
carrier. Is that correct? Do you know the circumstances of 
that?
    Ms. Hersman. I'm sorry, Mr. Chairman, can you----
    Senator Dorgan. Well----
    Ms. Hersman.--please restate your question?
    Senator Dorgan. Yes, perhaps it was--as we've gone to 
regional carriers--and the major trunk carriers have employed 
the regional carriers to service part of their territory--is 
that relationship between the major and the regional carrier 
one in which the major carrier has liability for the actions of 
the regional carrier? Or is it a--kind of an arm's-length 
transaction, where the regional carrier is autonomous, although 
it has the colors and the brand on the fuselage of the 
airplane, it is not, in fact, part of, or is not the 
responsibility of, or the--of the major carrier, for training 
and many other things?
    Ms. Hersman. I think that's a very complicated question, 
because there is a business arrangement, clearly, that's an 
arm's-length arrangement. But, then there are other 
relationships. That is one of the reasons why the Safety Board 
is holding a symposium later this year to really try to 
understand the structure of those relationships, the 
performance requirements that exist, and the support that might 
be provided for those carriers.
    They are separate entities. Colgan was a party 
representative in the accident investigation, not Continental. 
So, they are----
    Senator Dorgan. Why is that----
    Ms. Hersman.--clearly separate entities----
    Senator Dorgan. Why is that the case? It was a 
Continental--it was called a ``Continental'' flight, right? The 
flight number----
    Ms. Hersman. Yes.
    Senator Dorgan.--was a Continental flight number.
    Ms. Hersman. Because they are separate entities, and Colgan 
is responsible, and they have control of the day-to-day 
operations. We recognize that this is a very complex 
relationship, and we want to understand it better, not just for 
the oversight purposes, but for the aftermath of the accident. 
Following an accident, generally the smaller carriers, such as 
Colgan, don't have the resources to provide the support to the 
families, and so the care teams usually come from the codeshare 
partner, the larger partner. We've seen this in other 
accidents. That's one of the reasons why we want to have our 
symposium to identify these practices, the procedures, the best 
practices, these relationships. For example, if there's a 
requirement for the regional carrier to have an audit, would--
is that some--is that information that the mainline carrier 
ought to have information about?
    We found, in this accident investigation, that there were 
two audits. There was an IATA-IOSA audit, where there were some 
findings, and then there was a separate Department of Defense 
audit of Colgan. Continental did not have that information.
    Senator Dorgan. That also is stunning to me, because those 
airplanes are flying with Continental's name on it. And it 
seems to me that Continental--in this case, Continental; we 
could be talking about any of the major carriers--will want to 
understand everything about a carrier--a regional carrier that 
is carrying the brand name of the major carrier.
    My understanding is, both the FAA and NTSB are looking at 
code sharing arrangements between the regionals and the majors. 
So, what do you hope to determine from that effort? And what 
is--what's the status at this point?
    Ms. Hersman. We would be looking at the structures, the 
present practices, and oversight of both domestic and 
international codeshares. Certainly the FAA would be a part of 
the work that we would do. This symposium is designed to give 
us a better understanding of these relationships and to 
identify best practices. If there's room for improvement, 
that's what we want to focus on.
    Ms. Gilligan. I believe you're aware that, as a part of the 
Call to Action, the Administrator asked the airlines to commit 
to work more closely with their regional partners, and that 
effort has already begun. All of the majors who have codeshare 
partners--and not all of them do--have begun having regular 
meetings, generally quarterly meetings, to share the kinds of 
audits that the Chairman refers to, to identify shared safety 
risks, to share best practices.
    It gets a little complicated, because there are several 
regional carriers who provide support to more than one of the 
mainlines. And what we don't want is to have different 
mainlines creating different requirements for the same 
operator. So, the next step now will be to make sure that we--
with FAA's participation--are refining what those expectations 
are, so that the regional carrier has one set of shared 
information.
    But, this is very important. The Administrator saw that as 
one of the first positive steps that he could initiate, and 
that's already underway.
    Senator Dorgan. Are there cases in which the regional 
carrier is wholly owned by the major carrier and, therefore, 
subject to identical requirements--training, and all the other 
requirements--of the major carrier?
    Ms. Gilligan. All the carriers are held to the same 
standards, because as the Chairman points out, Colgan holds its 
own certificate, issued by the FAA. We provide oversight--first 
we determine that they meet the standard, we issue the 
certificate, we provide oversight to Colgan with a team from 
the FAA that is only assigned to Colgan. So, in that regard, 
they're held to the same set of safety standards. There are 
some regional carriers that are a part of the same corporate 
structure as a mainline carrier. But, from an FAA safety 
perspective, each certificateholder has its own responsibility 
to demonstrate compliance with these standards and our 
inspectors oversee each certificateholder.
    Senator Dorgan. I understand that. I think I'm----
    Ms. Gilligan. Oh.
    Senator Dorgan. I'm asking about a slightly different 
approach.
    Ms. Gilligan. I'm sorry.
    Senator Dorgan. The carriers--the major carriers themselves 
have their own routine and their own procedures for training 
and a range of other employee practices. And my question was, 
Are there regional carriers that are wholly owned by the majors 
and, therefore, subject to identical practices and procedures 
of the major that it--that owns it?
    Ms. Gilligan. I don't know, offhand. I can certainly find 
out.
    [The information referred to follows:]

    Several ``regional'' air carriers are owned by holding companies 
that also own ``major'' air carriers. Examples include American Eagle/
American Airlines (AMR Corporation) and Horizon Air/Alaska Airlines 
(Alaska Air Group). Although these airlines are owned by a common 
holding company, they are separate entities as certified by the FAA. 
The FAA oversees each airline separately, with a separate certificate 
management team for each one. These airlines may share common 
practices, but they are not required to do so. In some cases, the 
procedures developed for one airline may not be appropriate for the 
other.

    Ms. Gilligan. There is----
    Senator Dorgan. American Eagle, for example.
    Ms. Gilligan. Yes.
    Senator Dorgan. Is that--would that not be a case?
    Ms. Gilligan. Well, American Eagle has its own training 
programs and its own set of simulators, and has demonstrated 
that it meets all of our regulations on its own. But, I'll be 
glad to look at, just, whether there is a sharing of some of 
those training and other facilities. I'm just personally not 
aware.
    [The information referred to follows:]

    Both American Airlines and American Eagle have independent training 
programs, individually developed by the air carriers and individually 
approved by separate FAA certificate management teams. Although the 
simulators for American Airlines and American Eagle are co-located at 
the same training facility, the air carriers do not use the same 
training program, because the training programs are designed to meet an 
individual carrier's specific operational needs and requirements.

    Senator Dorgan. The larger question is--I have a list of 
some of the regional carriers here--Shuttle America, Pinnacle, 
Freedom, Chautauqua, Atlantic, Southeast, Colgan, ExpressJet 
Chautauqua, Trans States, GoJet, Great Lakes, Mesa, SkyWest, 
and the list goes on. Trans States. And the larger question 
from all of this is, Is there now one level of safety in this 
country, with the names of the carriers I have just read, as 
compared to the trunk carriers--or the--I should--I don't know 
that the--the word ``trunk carrier'' is a term of art these 
days--but, the major carriers--and I think that describes a 
group of carriers that are the larger carriers--is there one 
level of safety? I think there's supposed to be, right, dating 
back to the 1990s?
    Ms. Hersman, do you think there is one level of safety?
    And, Ms. Gilligan, do you?
    Ms. Hersman. I think that all Part 121 carriers are 
required to meet the same minimum standards.
    Senator Dorgan. All right, I'll respond to that and ask 
another question.
    Ms. Gilligan, you?
    Ms. Gilligan. It is accurate, as the Chairman has just 
responded. There is one set of standards for anyone who 
provides commercial transportation under Part 121 of our 
regulations. Those standards must be demonstrated by anyone who 
holds a certificate. FAA inspectors make the determination, 
that carriers meet those standards, and oversee continued 
compliance.
    I think, Mr. Chairman, you are asking whether there are 
different ways to demonstrate compliance with those standards? 
And yes, there are. And some of those may well be more mature 
than in other cases. There are some carriers that are quite 
small. They meet the standards by demonstrating compliance 
through logbooks and paper records. There are some that are 
quite large and complex, and they have automated systems and 
very mature safety risk analysis processes. That's accurate. 
Within the system, there are some differences.
    Senator Dorgan. Do you think the confluence of mistakes 
that occurred in the cockpit, and even prior to entering the 
cockpit of the Colgan flight that evening, would that 
confluence of mistakes be able to be found in a major carrier's 
cockpit, do you think? I mean----
    Ms. Gilligan. I think----
    Senator Dorgan.--we all know, now----
    Ms. Gilligan.--to the extent----
    Senator Dorgan.--that six or eight----
    Ms. Gilligan. I'm sorry.
    Senator Dorgan. Go ahead.
    Ms. Gilligan. I think, to the extent that pilot performance 
is implicated, the human in the loop in this case is a part of 
our risk. People make mistakes. People demonstrate bad 
judgment. And in this case, as the Board found, the primary 
cause of this accident was personal and human failure. And so, 
yes, I think those can occur on--because humans can make those 
kinds of mistakes.
    I think that we have provided the level of safety that we 
have, by having a huge number of redundancies within the system 
that allow us to trap those errors, most of the time, when they 
occur.
    I believe people are making mistakes as they operate 
airplanes, but the airplane itself, or the second pilot, or the 
training that comes to bear at the right moment, help trap 
those errors and continue to maintain the level of safety that 
we expect in the system.
    Senator Dorgan. But, I--I'm thinking that it is almost 
expected, given the way the system has developed, that we would 
begin to see these mistakes. I mean, it just will not 
surprise--it shouldn't surprise any of the three of us--that 
two of the people who got in a cockpit that day to fly to 
Buffalo, one hadn't slept in a bed for two nights, and the 
other hadn't been in a bed the night before. Pretty weary, 
pretty difficult time for them, I assume. And so, they make 
mistakes in the cockpit. That's not surprising. You make 
mistakes when you are either ill trained or when you are tired. 
You make mistakes.
    And I'm wondering if we--if you don't agree that we're 
setting up a system here that is guaranteed to provide more and 
more mistakes. Because, as I--it is not rocket science to 
believe that a young woman who wants a career in aviation and 
has--and is living out in--I think--perhaps living with her 
parents out in Seattle, flying across the country at night to 
get to the duty station, and not having a full night's rest, 
is--I mean, it's not rocket science to believe that that 
particular pilot is more prone to mistake. And if you don't get 
a night's rest in a motel because you're being paid $20,000 a 
year, again, it is not surprising that we see someone sitting 
in a crew lounge all night. It's wrong, but not surprising.
    And it's not surprising to me, I guess, that we don't know 
anything about that subject. We just think, OK, we've got this 
little telescope focused on one little spot. We know what we 
know about that spot, and that's it. But, that is not it. This 
goes way beyond that. And that's what I'm trying to--I'm trying 
to understand how we get our arms around this.
    I just think--I think this whole system has morphed into a 
different kind of commercial airline service, and we're kidding 
ourselves if we don't think some of the things that we've seen 
with respect to this Colgan crash aren't happening today and 
tonight.
    Last night I was at an airport--late last night--and I saw 
a young pilot walk off an airplane. And I thought--and I was 
thinking about this hearing, because--- it was a young pilot--
I'm sure, somebody, you know, cares a lot about their career, 
God bless them; I'm sure they feel, ``I'm glad I've got a 
job.'' But, this person looked bone tired, dragging that bag 
behind her. And I was just thinking about how little they are 
paid, in many cases, sitting in the second seat in a regional 
jet. And then we expect all the same things to exist, with 
respect to the rules, as exist with somebody that's flying in a 
757 Dulles-to-Los Angeles nonstop, being paid, you know, 
$90,000 or whatever. And the fact is, those same circumstances 
will not exist for that young pilot. And it's not unusual 
that--it's shocking to me, but, again, probably not unusual 
that we have found these confluence of mistakes that led to 
this crash.
    ``Pilot error'' is a term that relates to so many other 
issues leading up to those two people getting in that cockpit, 
and then flying in ice, and then making very bad judgments 
about how to control that airplane.
    Well, I--again, I have some additional questions. I 
appreciate your indulgence.
    We're joined by Senator Thune.
    Senator Thune?

                 STATEMENT OF HON. JOHN THUNE, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Thune. Thank you, Mr. Chairman, for your focus on 
this subject.
    On the 1-year anniversary of this very tragic crash, we 
continue to try and get answers, and continue to try and come 
up with policies that we think make sense and that will prevent 
anything like this from ever happening in the future. So, I 
appreciate the focus and attention that you've placed on this, 
and welcome our panel today to the Committee.
    I want to follow up on an issue that I've been focused on 
throughout the course of the hearings that we've had on this 
subject, and it deals with the whole issue of pilot fatigue. 
And I know that, in the report, it wasn't necessarily the 
factor that was pointed to in this particular incident, but it 
does seem to me that it's a broader issue with regard to the 
whole debate about safety.
    I'd be interested in hearing, from both of you, on how you 
reconcile the industry and the FAA claim that pilot fatigue and 
commuting need to be solely the responsibility of individual 
pilots. It seems, to me at least, that the safety of the 
passengers, both for regional carriers and large carriers, 
should be the overriding factor, versus self-reporting. I think 
it's somewhat alarming that roughly 70 percent of the Colgan 
pilots based in Newark commute, and 20 percent of those pilots 
commute from over 1,000 miles away. And so, it kind of comes 
back to what Senator Dorgan was alluding to.
    But, give me your perspective on that, because it seems 
that the argument, that this ought to be solely the 
responsibility of individual pilots, runs clearly in the face 
of the testimony that I think we've had in hearings, and in 
listening to different comments and observations about this 
throughout the course of this debate.
    Ms. Gilligan. Senator, we believe, as I think everyone 
does, that this issue of commuting is quite complex, and 
clearly one that we need to work within the industry to 
understand and address. The dilemma is that there's no easy 
solution. Someone can drive to National Airport from 
Fredericksburg, and I don't think any of us would think that 
was an unreasonable commute. But, it can run into several 
hours. On the other hand, someone can fly from St. Louis to 
National Airport and be there in an hour after having slept the 
night at home, in their own bed, not in a motel. So, it's 
complicated. If we could do it easily, we would have.
    I do think you'll see, in the new rulemaking that we're 
putting forward, that we are asking these kinds of hard 
questions. What is the role of government in this kind of a 
question? And beyond that, what can the airline and the 
individual pilot be expected to do, and be held accountable to 
do, to perform professionally? But, it is a very difficult 
issue for the government, I believe, to take on, and we're 
looking at how we could do that.
    Ms. Hersman. Senator, I think the issue of fatigue is very 
complicated. It's not just about commuting. It's about flight 
and duty time; it's about a medical condition, such as sleep 
apnea; it's about having good policies at a company, so that if 
a pilot is fatigued, for whatever reason, they can call in and 
be taken off duty, without punishment.
    We've investigated accidents in the past where pilots have 
gotten very little sleep the night before, because they had 
insomnia or something else was going on, not because of their 
schedule. They were nervous about calling in ``fatigued,'' 
because they were afraid they would lose their job. So, they 
flew, they made bad decisions and they had an overrun on an icy 
runway, they had gotten 1 hour of sleep in the past 30 for 
example.
    Commuting is only one part of this issue. That's why the 
Safety Board issued our recommendation to the FAA following the 
Colgan accident to address this commuting issue and to look at 
scheduling practices. I think the challenge is to identify 
whether a commute is appropriate or inappropriate. I've seen a 
case where a pilot based in Hawaii, who lived in Florida. At 
some point, there are things that go beyond what makes sense 
for anyone to do.
    I looked at that first officer in the Colgan accident, 
flying on a red-eye flight from Seattle to Newark with a stop 
in Memphis the night before the accident. I feel very 
uncomfortable having to perform my job after I've taken a red-
eye flight, and I don't hold peoples' lives in my hand.
    I think that probably all of us reasonably can say that 
commuting is a challenge and it needs to be addressed. It's 
going to take the cooperation of the FAA, the industry, and the 
pilot's unions to try to address it.
    Senator Thune. To the extent that you can, please comment 
on your rulemaking. How does it address that?
    Ms. Gilligan. I believe the Administrator previously shared 
with this committee that, at this point, the rulemaking 
advisory committee we put together, made up of pilots and the 
airlines, did not make a recommendation in the area of 
commuting. They believe that it is a pilot responsibility, and 
that is the recommendation that they made to the Administrator.
    We will seek additional input into that rulemaking, asking 
for ideas, because, as the Chairman points out, we don't have a 
ready solution to this. So, we are asking for comment, we are 
asking for the insights from the industry, both the pilots and 
the airlines, to see how we might go about addressing this in a 
reasonable and professional way.
    Senator Dorgan. Would the Senator yield on that, please?
    Senator Thune. Yes.
    Senator Dorgan. I believe there are some cargo companies 
that have a ready solution for it, right? I mean, there are 
cargo companies that have commuting pilots that pay for their 
pilot's motel room when they show up for their duty station the 
night before the flight. Is that not correct?
    Ms. Gilligan. There is, I believe, one that does that. 
There is also a cargo carrier that provides rest facilities, at 
some of their locations, that are temperature controlled and 
lighting controlled, and those kinds of things. So, there are 
some options that have been implemented by some in the 
industry. We want to understand those, and we want to see how 
those might be able to be applied more broadly throughout the 
industry.
    Senator Thune. Well, it just seems like the example of a 
pilot who lives in Hawaii and operates out of Florida--it--just 
as a practical matter. Hopefully that's an outlier, but at some 
point, it seems like practical considerations would come into 
play here.
    I understand there's a balance you have to strike, and 
you've got to try and find what makes the most sense. Clearly, 
common sense too, would seem to be a consideration here, but, I 
think people push themselves, and they do things that they 
probably shouldn't do and put themselves in situations where 
they are fatigued. That's an issue that, I think, needs to be 
addressed. I hope that the process that you're undertaking 
right now can get at that, and perhaps use some of the ways in 
which the cargo carriers are dealing with this issue as an 
example of how to best address it.
    But it seems to me, at least right now, that we've got a 
problem, and it needs to be addressed.
    Ms. Gilligan. We agree, sir. And I think, to the Chairman's 
point, there is a role for everyone in this--the airline, the 
pilot, and the government. And we're trying to understand those 
roles and responsibilities--how to best describe those--so that 
everyone holds each other accountable. The airline should be 
determining that their crew is competent and ready to fly. The 
individual pilot should be able to report if he or she is not. 
The copilot or others on the crew should be ready to report if 
they are concerned that there is a member of the crew who is 
not ready to take that flight. So, there are roles and 
responsibilities here for all of the parties.
    Senator Thune. OK.
    Thank you, Mr. Chairman.
    Senator Dorgan. Let me--I'm going to ask about pilots' 
qualifications and hours. But, first I want to ask about the 
issue of pilot experience in icing.
    You are aware that the second officer says that she had, 
really, no experience with icing. Senator Thune and I--I've not 
talked to Senator Thune about this, but I assume that he--as 
have I, been in a lot of small planes, where we shine 
flashlights on the wings to find out how much rime ice has 
developed. In our part of the country, it is not unusual to fly 
and have some icing as you go up or come down in a charter 
flight.
    But, this is a copilot who speaks about icing. She says, 
``I have 1,600 hours,'' she says, ``I have 1,600 hours, all of 
that in Phoenix. How much time do you think, actual, I had, or 
any, in ice? I had more actual time on my first day of IOE than 
I did in my 1,600 hours when I came here.'' And then she says, 
``I've never seen icing conditions. I've never deiced. I've 
never seen any--I've never experienced any of that. I don't 
want to have to experience that and make those kind of calls. 
You know, I freaked out. I'd have, like, seen this much ice and 
thought, oh my gosh, we're going to crash.''
    So, I want, Ms. Hersman, for you--the NTSB, I assume, has 
analyzed this. What kind of icing experience did this copilot 
have? And this is a plane--this is a dash-8 with, I assume, hot 
props and boots on the wings--flying in the winter, in icing 
conditions, in the Northeast. That's where this pilot was 
assigned. And at least on the voice cockpit recorder, this 
copilot is saying, ``I've never seen any of this, and have no 
experience with it.''
    Your investigation of that?
    Ms. Hersman. Chairman Dorgan, when the first officer is 
talking about that on the cockpit voice recorder, she's 
reflecting back to when she first started at Colgan. She came 
from Phoenix, and she had not had a lot of time in winter 
weather conditions. She's talking to the captain, telling him, 
``I got more time in my Initial Operating Experience in my 
first days on the job at Colgan in ice than I'd had in my 
entire career.'' And then she goes on to talk about captain 
upgrades, that in the first year when she was with the company, 
that a lot of people were upgrading to captain early, and that 
she was glad that she didn't have to upgrade to captain early, 
because she had not had a lot of experience in icing conditions 
and she would not have wanted to make those decisions that you 
reference. She's reflecting back, saying, ``If I had had to 
operate in conditions like this in my first year, and upgrade 
to captain, I would have been very uncomfortable.''
    Since she was employed with Colgan, she did operate in 
winter weather conditions, and she had accumulated over 2,200 
hours. She did have exposure to winter weather conditions and 
the kind of environment she was flying in the night of the 
accident while she accumulated those additional hours at 
Colgan.
    But, I think your point is, is that----
    Senator Dorgan. That may be the right----
    Ms. Hersman.--when she first came----
    Senator Dorgan. Yes, that----
    Ms. Hersman.--that when she first came, she didn't have a 
lot of experience. That's----
    Ms. Gilligan. Right.
    Senator Dorgan. That may be the right interpretation of her 
second comment, I don't know.
    Ms. Hersman. Yes.
    Senator Dorgan. But, her first comment suggests that she 
saw more ice in her first day than in her--flying in that 
area--than her entire previous 1600 hours.
    Ms. Hersman. Yes.
    Senator Dorgan. So, you put someone with 1600 hours in a 
cockpit and say, ``Go fly,'' and fly into ice--what she seems 
to have been saying to the captain is, ``I was put out here 
with almost no experience in icing.'' Is that what you hear?
    Ms. Hersman. Yes. That's something that the Safety Board 
has been concerned about. In the past, we have made 
recommendations about training, certainly in the aircraft type 
and in the conditions that a pilot is going to be exposed to. 
In our investigation of the Montrose, Colorado, accident that 
involved Dick Ebersol's family, we found, that the pilot and 
the captain had a high number of hours but when we looked back 
at his experience and found that in the previous 4 years even 
though he'd flown about 18 times in the northern half of the 
U.S.--he hadn't been in icing conditions.
    There are definitely challenges about making sure that 
people are prepared for the conditions that they're flying in, 
and that's why it's important for the carrier, depending on 
what environment they're operating in--it may be a challenging 
airport, it may be challenging weather conditions--they need to 
make sure that their crew is appropriately trained for those 
conditions.
    Ms. Gilligan. And sir, if I might just clarify. She did 
receive training from Colgan in icing and what the 
characteristics of the aircraft are, and how to respond to it. 
In addition, the Initial Operating Experience is a regulatory 
requirement. She must be paired with an experienced pilot or a 
check airman for her Initial Operating Experience, for this 
very purpose, to make sure the transfer of knowledge has 
occurred. So, in those early flights she was accompanied by or 
assigned to an experienced pilot who would have been evaluating 
whether, in fact, she had had the proper transfer of knowledge 
to be able----
    Senator Dorgan. Could that happen with passengers in the 
back of the plane?
    Ms. Gilligan. It is with passengers, sir.
    Senator Dorgan. See, I'm not----
    Ms. Gilligan. It is her Initial Operating Experience.
    Senator Dorgan. See, I'm not sure--I don't agree that the 
first flight--the first experience you might have with icing 
should be in a cockpit where you're carrying passengers.
    Ms. Gilligan. Well, her training would have occurred in 
simulator.
    Senator Dorgan. I understand that, but I'm talking about 
experience in the air. There's no--I've been in the simulator--
there's no ice in the simulator. I understand the value of a 
simulator, and so on----
    Ms. Gilligan. Right.
    Senator Dorgan.--but actual experience flying through 
icing, if--what you're saying is, they are trained, then put in 
a cockpit in the second seat, and--but always the person in the 
first seat has good experience. You know, this is their first 
experience with icing--under the supervision of someone who has 
been there, but what if something happens to the captain? The 
purpose of the copilot is to take over, and this is their first 
flight with--first experience in icing, and they've got 
passengers in the back. I mean, I think that's--I don't know. 
I----
    Let me also ask a question, before I talk about pilot 
qualifications. I'm looking at the transcript here, and--22, 
13, 58--the last sound in this cockpit--minutes later, there is 
still discussion about the career. And it relates to this 
question of a sterile cockpit. What are the requirements with 
respect to a sterile cockpit?
    Ms. Gilligan?
    Ms. Gilligan. The regulatory requirement is that they 
should maintain sterile cockpit below 10,000 feet. And that 
means that the exchange of information should be related only 
to the operation of the aircraft so as to complete the approach 
into the arriving airport.
    Senator Dorgan. Let me ask about ATP license. Is it an ATP 
``license''?
    Ms. Gilligan. An Airline Transport Pilot certificate, yes, 
sir.
    Senator Dorgan. Certificate. ATP certificate.
    Tell me about the ATP certificate, and what the requirement 
is for its use. How does one achieve one?
    Ms. Gilligan. The Airline Transport Pilot certificate is 
the highest rating that FAA issues. It is accomplished after 
someone goes through the steps of private pilot certificate, 
instrument rating, and commercial pilot certificate. They often 
get instructor certificates, as well. And at each level, from 
private to commercial to airline transport pilot, we have 
increasing requirements for both the number of hours of 
experience as well as training and other kinds of experiential 
learning, and those kinds of things.
    Senator Dorgan. And what gross hour--are there any gross 
number of hours----
    Ms. Gilligan. Yes.
    Senator Dorgan.--that are required to get an ATP?
    Ms. Gilligan. Yes. It's a minimum 1500 hours.
    Senator Dorgan. So, a minimum of 1500 hours. All right.
    What is the requirement for a--the hiring of a captain or 
someone in the right seat, a copilot, on the major carriers or 
the commuter carriers?
    Ms. Gilligan. The rules permit----
    Senator Dorgan. Regional carriers.
    Ms. Gilligan. The rules permit anyone with a commercial 
pilot certificate to be able to be compensated for flying. So, 
anyone with a commercial pilot certificate is eligible to be 
hired into commercial service. For a commercial pilot 
certificate, a minimum of 250 hours is required.
    Senator Dorgan. And what is the common purpose of, and the 
requirement for, an ATP license, then? In other words, if you--
you can fly a charter flight or get hired by a regional airline 
or a major carrier with, let's say, 300 hours.
    Ms. Gilligan. Right.
    Senator Dorgan. What is the function of, and the purpose 
of, an ATP?
    Ms. Gilligan. To serve as pilot in command in that 
operation, you must have an Airline Transport Pilot 
certificate. The purpose of that was to assure that there would 
be pilot-in-command responsibilities assigned to someone who 
has demonstrated the ability to take on that additional 
responsibility.
    Senator Dorgan. Is that true for all of commercial 
airline--is that true for all of the flights that exist on a 
commercial airline? The pilot in command must have the 1500 
hours and the ATP license?
    Ms. Gilligan. For all scheduled----
    Senator Dorgan. Or certificate, rather?
    Ms. Gilligan. For all scheduled passenger carriage, yes, 
that's correct.
    Senator Dorgan. So, everyone in a left seat for all 
scheduled--Senator Thune, did you have any other questions? I 
wanted to make sure you--all right.
    So, it is true, for all scheduled commercial flights, that 
the person sitting in the left seat will have an ATP?
    Ms. Gilligan. Yes, sir.
    Senator Dorgan. And have a minimum of 1500 hours.
    Ms. Gilligan. Yes, sir.
    Senator Dorgan. All right. And what is the requirement, 
generally speaking, for the person in the right seat?
    Ms. Gilligan. Again, that pilot may have a commercial pilot 
certificate. Airlines can set different requirements. But, by 
regulation, in order to be paid, you must have at least a 
commercial pilot certificate.
    Senator Dorgan. And that's the 250 hours.
    Ms. Gilligan. 250 hours minimum.
    Senator Dorgan. And you say different airlines set 
different requirements. Can you tell me about some of those 
carriers and requirements? Are there some carriers that say 
that everyone who steps in a cockpit of ours should have an 
ATP?
    Ms. Gilligan. I'm not familiar with any that have that 
requirement, but carriers set their requirements based on what 
their hiring pool permits. And so, many of the carriers require 
more experience than what the regulation permits. And pilot----
    Senator Dorgan. Ms. Hersman----
    Ms. Gilligan. I'm sorry?
    Senator Dorgan. Go ahead.
    Ms. Gilligan. No, I'm just saying, pilots build that 
experience through flight instruction or other commercial kind 
of operation, whether it's spraying crops or doing some charter 
work, as you suggest. They build additional time, beyond the 
250 hours, for the purposes of being hired into those 
commercial positions.
    Senator Dorgan. Ms. Hersman, do you want to comment on the 
issue of ATP license and the practice of requiring only a 
commercial license for the right seat? Has that played a role, 
in your judgment, in anything that you have investigated?
    Ms. Hersman. The Safety Board investigated events in which 
things went wrong, and so, we don't always have a control group 
about what went right. We've investigated accidents where we've 
seen very high-time pilots, and we've also investigated 
accidents where we've seen low-time pilots.
    We don't have any recommendations about the appropriate 
number of hours for different categories. We see that they do 
have different standards. As Ms. Gilligan referenced, some 
might use 250, some may have higher standards, require 600 
hours, 800, 1,000.
    We do know that there is a correlation, from our accident 
investigations and some studies we've done, between individuals 
who fail practical flight tests, and their potential likelihood 
to be involved in an accident later, but we don't have any data 
supporting the number of hours for a certificate, or its 
correlation with being involved in an accident.
    Senator Dorgan. Would that data be useful? You don't have 
it just because you don't have it, or you don't have it because 
you've never felt the need to go look for it, or--I mean, I 
guess I'm asking the question, Is there something here we 
should know? And I don't know the answer to it.
    But, it does seem to me that someone with 250 hours is--has 
dramatically less experience than someone with 4,000 hours. And 
someone with 250 hours has substantially less experience than 
someone with 1,500 hours. And the question, I suppose, is--and 
I don't know the answer--is, If there is a regional carrier out 
there that is hiring someone, for the right seat, who has a 280 
hours, received a commercial license, has the capability to be 
hired, because--meets the minimum requirement--is--what does 
that airline do, then, to further prepare that pilot? Or is 
that pilot put in the right seat and able to fly around with 
passengers in the back, and gain experience by sitting next to 
a skilled captain?
    So, Ms. Gilligan----
    Ms. Gilligan. Right.
    Senator Dorgan.--can you tell us your impression of what's 
happening----
    Ms. Gilligan. Our----
    Senator Dorgan.--in the real world?
    Ms. Gilligan. Yes, sir. Our impression is quite clear, that 
we are concerned as to whether or not those are sufficient 
criteria. That's why the Administrator had us already issue an 
Advance Notice of Proposed Rulemaking, asking those----
    Senator Dorgan. Right.
    Ms. Gilligan.--particular questions. Should there be a 
difference in hours? Should there be a different kind of 
certification for a commercial pilot who is operating in Part 
121 passenger-carrying service. It may well be a gap. We'll see 
what the response is to our rulemaking, and we will take 
appropriate action, because it is an area of concern to all of 
us.
    Senator Dorgan. And that rulemaking is welcomed by the 
Congress. But, you know, as we all understand, the rulemaking 
process takes too long, it's difficult, it's--you know, we've--
Administrator Babbitt was here--has been here twice--and I know 
they had set, originally, a--on--I think it was on the fatigue 
issue--the December timeline, and that is now, I believe, 
March.
    Can you tell us what the new timeline is on the work you're 
doing in that area?
    Ms. Gilligan. That rule is in executive review with the 
Department of Transportation. After that, we will also consult 
with the Office of Management and Budget. But, we have a 
package that is, we believe, complete, and as soon as that is 
through executive review, we'll publish that for comment.
    Senator Dorgan. And--but, that includes--it has--you'll 
publish for comment----
    Ms. Gilligan. Yes, sir.
    Senator Dorgan.--after OMB passes on it?
    Ms. Gilligan. Yes, sir. It'll go out for public comment in 
the standard process.
    Senator Dorgan. Yes. Well, that's a--I mean, OMB is--as you 
know, is a major problem, because things go into OMB that no 
human being ever sees again.
    Ms. Gilligan. The Administrator is quite dedicated to this 
project. I'm certain that----
    Senator Dorgan. Right.
    Ms. Gilligan.--we'll see this project.
    Senator Dorgan. All right. I mean, I think there's an 
urgency here that needs to be reflected in the actions of the 
FAA. I appreciate that--new administrator. I think he is taking 
some action that has not previously been taken. But I--I do 
think there's an urgency on the fatigue issue, there's an 
urgency on the issue of qualifications. We need to get at this.
    And my own view of this tragedy is, I think it's very 
unlikely that we are seeing a series of about eight--eight 
significant problems that existed on this flight, that is 
unique only to this flight. I think that's very unlikely. I 
think we would be very unwise if we didn't understand the 
consequences of these actions, the consequences of pilots that 
are flying without enough rest. It's very serious. That's what 
relates to pilot error. The consequences of the lack of 
adequate training or the consequences of the lack of adequate 
credentials and, you know, the consequences of not having 
liability existing between those who have rented their name out 
to a regional carrier. You know, all of these things together--
and there are more, but it--there are just so many of them that 
have come to the front here on this issue that it just 
literally demands that we say, ``You know what? Things have 
changed dramatically in the commercial aviation sector, and we 
have to make changes to respond to it.''
    If you go back three decades, there were not many regional 
carriers at all. Just--I mean, we--you know, and my State's a 
good example. We basically had the major carriers coming in and 
picking people up in a hub-and-spoke system, taking them to a 
hub, and moving out of the hub. That's just the way it all 
worked. That has morphed into something that is completely 
different.
    We now have the same major carriers' brands and colors and 
logos on different airplanes run by different companies--
smaller companies and younger companies, newer companies. And I 
think this--the question of whether there is one level of 
safety is a question that is fairly easily answered these days. 
The answer is no. We're not quite measuring up with the same 
level of safety with this new area of regional carriers.
    I'm not saying they are unsafe as a group, but I am saying 
I think that people that get into airplanes, where, in the 
cockpit, there is dramatically less experience than they are--
they would have, getting onto an airplane on a 757 flying 
Dulles to Los Angeles--it just makes sense for us to 
understand, if you're getting into an airplane where someone in 
the cockpit's being paid $18- or $20,000 a year, they are going 
to be somebody with substantially less experience, as well, as 
opposed to the kind of pilots you would expect in other 
circumstances.
    So, I think all of these things together tell us that we'd 
better get moving here and understand that things have changed 
in this industry, and we need to understand the implications of 
those changes, and respond to those implications.
    And I'm not--again, you know, I don't want to scare people. 
I think we have a circumstance of safety that is admirable. 
This is an industry that has a pretty remarkable safety record. 
But, that record is of no consolation to those who lose loved 
ones in a tragic accident that should not have happened, and 
could have and should have been prevented.
    So, let me say, Ms. Hersman, I've really appreciated and--
more than ever--the work of the NTSB. I've watched NTSB folks 
come on television and explain things in the news cycle and--
haven't paid as much attention as I should have to the way the 
NTSB works, and the work that is done there. I appreciate your 
work. These 300 pages, I hope, is now a clarion call to 
substantial change, and is the roadmap to making those changes.
    And, Ms. Gilligan, again, I'm going to be appreciative of 
Administrator Babbitt, but, in the weeks and months ahead, 
unbelievably nettlesome about wanting to make sure we get 
things done on time. You've--and let me help you with OMB, if I 
can. They're very fond of me.
    [Laughter.]
    Senator Dorgan. And I do know that it's difficult to get 
things through OMB, but it's even been more difficult in the 
past to get something out of the FAA, so with a new 
administrator and a new approach, I want the FAA to work, I 
want our government to work, and I want Ms. Hersman's most-
wanted list not to be ignored. I want them to be implemented, 
and implemented post haste.
    Let me thank both of you for spending part of your morning 
with us. And this discussion will continue throughout this year 
as we try to see if we can implement some changes that will 
provide an added margin of safety in our commercial airline 
sector.
    This hearing's adjourned.
    [Whereupon, at 11:06 a.m., the hearing was adjourned.]

                            A P P E N D I X

            Prepared Statement of Hon. Frank R. Lautenberg, 
                      U.S. Senator from New Jersey

    One year ago, after taking off from Newark Liberty International 
Airport, Colgan Flight 3407 crashed outside Buffalo, taking the lives 
of 50 people.
    The crash was a horrible and deadly reminder that we have more work 
to do to make sure that when passengers board a commercial aircraft, 
they have pilots that are well rested, well trained, and ready for any 
task that is put before them.
    Whether passengers are flying a regional carrier from state to 
state or a major carrier from continent to continent, planes must be 
equally safe and the crews should be performing at an equally high 
standard.
    That means we need to have--and enforce--consistent safety and 
training standards across the board. Tragically, that was not the case 
with Colgan Flight 3407.
    The National Transportation Safety Board has concluded its 
investigation of the Colgan Flight 3407 crash. In its findings, the 
NTSB revealed that the aircraft's pilots were ill-trained and 
unprepared to meet the demands of their mission, as well as possibly 
too fatigued to fly.
    Pilot fatigue is not a new issue. The NTSB first called on the FAA 
to update the flight and duty time rules for pilots in 1990 and has 
renewed that call in the wake of this deadly crash. The current FAA 
flight and duty rules have not been updated for over fifty years. I 
urge FAA Administrator Babbitt to put in place a rule that is 
scientifically-based and takes into consideration the demands facing 
today's pilots.
    Furthermore, all airlines--regional and mainline carriers alike--
have a responsibility to ensure that all of their pilots are trained 
and ready to take the controls before they step on-board any aircraft. 
And all airlines must guarantee that every pilot is not only trained to 
complete their mission, but also getting enough pay and rest. There are 
far too many examples of pilots stretched beyond their capabilities 
because of inadequate rest and compensation.
    The millions of passengers that fly everyday deserve an efficient, 
comprehensive transportation network where safety comes first.
    Our aviation system is safe, but the tragedy of Colgan Air Flight 
3407 serves as a stark reminder that we cannot be complacent when it 
comes to our aviation safety.
    You can be sure that I, and this committee, will continue to work 
to keep our aviation system the safest in the world.
    Thank you.
                                 ______
                                 
       National Transportation Safety Board--Office of the 
                                                   Chairman
                                      Washington, DC, April 6, 2010
Hon. Byron L. Dorgan, Chairman,
Hon. Jim DeMint, Ranking Member,
Subcommittee on Aviation Operations, Safety, and Security,
Committee on Commerce, Science, and Transportation,
U.S. Senate
Washington, DC.

Dear Chairman Dorgan and Ranking Member DeMint:

    Thank you for providing the transcript of the hearing of the 
Subcommittee of February 25, 2010, on the crash of Colgan Air Flight 
3407 for review and correction. Although most of the corrections are 
minor, I would like to take this opportunity to draw your attention to 
a substantial correction of the record.
    During the question and answer portion of the hearing, I stated 
that Colgan Air did not share the findings and recommendations of the 
International Air Transport Association (IATA) and the Department of 
Defense (DOD) safety audits with its code-share partner, Continental 
Airlines. Following the hearing, it was brought to my attention that I 
misspoke on this particular point.
    In fact, Colgan Air did share the IATA and DOD audits with 
Continental Airlines. However, the audit information was not shared 
with the Federal Aviation Administration. In his statement provided to 
our investigators, the principal operations inspector for Colgan Air 
stated that the FAA did not get copies of these audits. We noted this 
directly in our report where we stated that ``the Colgan POI stated 
that he was aware of these audits but did not get a copy of the 
reports, which prevented him from having a comprehensive understanding 
of the reports' findings.'' \1\
---------------------------------------------------------------------------
    \1\ ``Loss of Control on Approach, Colgan Air, Inc, Operating as 
Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, 
Clarence Center, New York, February 12, 2009,'' Accident Report of the 
National Transportation Safety Board, NTSB/AAR-10/01, at page 137.
---------------------------------------------------------------------------
    I regret my error regarding who received copies of the audits and 
appreciate the opportunity to correct the record.
            Sincerely,
                                      Deborah A.P. Hersman,
                                                          Chairman.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to 
                       Hon. Deborah A.P. Hersman

    Question 1. The First Officer of Colgan Flight 3407 earned a base 
salary of around $20,000. The salary of Captain Sullenberger, the 
veteran pilot of U.S. Airways Flight 1549, also known as the ``Miracle 
on the Hudson,'' was cut 40 percent in recent years, forcing him to 
take a second job. Given all of the responsibilities that commercial 
pilots shoulder, do you consider low pilot pay a safety issue?
    Answer. The NTSB has not systematically studied whether pilot pay 
is a safety issue. Historically, accidents and incidents have not been 
limited to pilots new to the industry earning entry level wages. The 
NTSB is concerned that cost of living at some bases can affect a 
pilot's ability to live nearby or identify suitable accommodations. The 
NTSB discussed this issue in its Colgan Flight 3407 report and issued a 
recommendation. Specifically, recommendation A-10-16 asks the FAA to 
address fatigue risks associated with commuting, including identifying 
pilots who commute, establishing policy and guidance to mitigate 
fatigue risks for commuting pilots, using scheduling practices to 
minimize opportunities for fatigue in commuting pilots, and developing 
or identifying rest facilities for commuting pilots. However, it is 
important to note that although their wages were different, the pilots 
for both the Colgan and the U.S. Airways accidents were commuters. 
Therefore, low pilot pay is not the only driver of the safety issue 
addressed (commuting) in the NTSB's recommendation. The extent to which 
pay affects other aspects of pilot performance has not been determined 
in our investigations.

    Question 2. Regional airlines operate half of all domestic 
departures and move more than 160 million of our Nation's passengers 
each year. If we are to have one level of safety for both regional and 
major network carriers, shouldn't the pilots of regional carriers be 
trained and compensated at the same level as pilots for major network 
carriers, particularly if they are flying identical routes?
    Answer. In 1997, the FAA required what were then known as commuter 
airlines to conform to the certification standards of 14 CFR Part 121, 
which applies to major airlines, and to thereby achieve one level of 
safety throughout the airline industry. The Colgan investigation 
revealed low levels of pilot experience, inadequate training records, 
non-existent remedial programs, and immature safety programs as well as 
strained FAA oversight resources at that airline. Even though airlines 
are now regulated to the same minimum standards, it appears that not 
all airlines are equal. The NTSB will examine code share safety 
standards later this year in a symposium. As to compensation at 
regional carriers, bargaining methods between pilots and companies are 
long established and outside the scope of our investigation.

    Question 3. One airline has a program where pilots that commute 
long distances to their duty station are provided with free air travel, 
as well as hotel accommodations at their assigned station. This is in 
stark contrast to the First Officer of Colgan Flight 3407, who had to 
commute from Seattle to Newark flying stand-by on a ``red-eye'' flight. 
In the wake of the Colgan crash and other fatigue-related incidents, 
what should airlines be doing to provide a stable, predictable commute 
and proper accommodations for their pilots?
    Answer. The NTSB believes that airlines need to take action to 
identify and understand the extent to which commuting affects the 
safety of their operation. In its report on the Colgan Flight 3407 
accident, the NTSB issued Safety Recommendation A-10-16 which asked the 
FAA to ``address fatigue risks associated with commuting, including 
identifying pilots who commute, establishing policy and guidance to 
mitigate fatigue risks for commuting pilots, using scheduling practices 
to minimize opportunities for fatigue in commuting pilots, and 
developing or identifying rest facilities for commuting pilots.''

    Question 4. The Captain of Flight 3407 failed five proficiency 
tests before he was hired--a fact he never disclosed to Colgan. At what 
point should the FAA revoke a pilot's license for failing proficiency 
or training tests?
    Answer. Certificate revocation is a punitive enforcement action 
which is not appropriate for training failures. However, the NTSB 
believes that complete disclosure of a pilot's certificate history and 
any prior training problems is an essential part of the commercial 
pilot employment process. In addition, air carriers and commercial 
operators must maintain detailed, accurate training records and must 
proactively address pilot proficiency issues as they occur, and the FAA 
must aggressively police such issues.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                          to Margaret Gilligan

    Question 1. The problems experienced with the FTI programs--
specifically outages in key components of the FAA's communication 
systems--raises concerns about the agency's ability to implement large 
modernization projects in a timely and cost-effective manner. What 
steps are you taking to ensure the FAA has the capacity to effectively 
manage the modernization programs in cost-effective manner?
    Answer. We agree that Air Traffic Control modernization programs 
require proper management and oversight to ensure success. Over the 
years, the agency has taken major steps to ensure that modernization is 
managed in an effective manner and we have successfully fielded 
multiple new systems into operation throughout the country, including 
new air traffic displays, runway safety systems, and weather processing 
systems. In addition, we have met our cost and schedule goals for 
modernization programs for the past 5 years.
    In January 2009, the Government Accountability Office (GAO) 
recognized the major improvement in FAA's management of Air Traffic 
Control Modernization and removed the FAA from the GAO's High Risk 
List.
    In removing the FAA from the High Risk List, the GAO determined 
that the FAA had addressed weaknesses in managing modernization and 
that FAA executives, managers, and staff had demonstrated a strong 
commitment to--and a capacity for--resolving risks. The GAO recognized 
the FAA for: (1) improved management capabilities on major projects; 
(2) development of an enterprise architecture--a blueprint of the 
agency's current and target operations and infrastructure; (3) 
implementation of cost estimating methodology and a cost accounting 
system; (4) implementation of a comprehensive investment management 
process; and (5) assessment of human capital challenges and plans to 
address critical staff shortages.

    Question 2. Do you have the personnel with the expertise to manage 
these complex modernization projects?
    Answer. Yes. In fact, the FAA requires program managers for major 
acquisition programs to be certified program managers, which means they 
have the education, training, experience and demonstrated competencies 
to manage complex systems acquisition. FAA's certification standards 
exceed the Federal Acquisition Certification for Program and Project 
managers.
    Additionally, the FAA began publishing the Acquisition Workforce 
Plan in 2009. This plan is updated annually and focuses on the 
technical and acquisition workforce that is engaged in the design and 
development of mission critical National Airspace System (NAS) systems, 
including program managers, engineers/system engineers, business and 
financial analysts, contracting officers and specialists; Contracting 
Officer's Technical Representatives (COTRs); and other specialized 
support disciplines. The Acquisition Workforce Plan serves as FAA's 
guide for workforce hiring and development, to ensure FAA maintains the 
staffing and skills needed to successfully manage complex modernization 
projects.
    The FAA has also recently taken the following actions to strengthen 
the management skills of FAA acquisition personnel and meet the 
challenges of complex modernization programs:

   Established the Acquisition Career Management (ACM) Group to 
        institutionalize these efforts. For example, the ACM monitors 
        the Agency's overall certification compliance.

   Strengthened the overall governance of the Acquisition 
        Workforce and the management practices by establishing both an 
        Acquisition Workforce Council (AWC) and an Acquisition 
        Executive Board (AEB). The AWC provides oversight for the 
        development and implementation of acquisition workforce 
        development strategies and the AEB oversees the complete 
        institutionalization of acquisition management practices. The 
        two entities work closely to ensure the FAA meets its 
        objectives for establishing and maintaining a well-trained 
        acquisition workforce.

   Building the skills and talents of its Acquisition Workforce 
        through career management programs for contracting officers, 
        COTRs, Program Managers, Systems Engineering, Systems Test and 
        Evaluation, Cost Estimating, and Procurement Attorneys. The 
        programs define competency requirements for each role and 
        related curricula and training to support skills and competency 
        development. FAA policy requires certification for acquisition 
        program managers, Contracting Officers, and COTRs.

   Strengthening practices used to develop and implement 
        acquisition programs with the introduction of Acquisition 
        Management Practices toolkits that were developed by FAA 
        subject matter experts and are based upon industry best 
        practices. They contain practical guidance for implementing the 
        FAA's Acquisition Management System (AMS).

    Question 3. The recent Northwest Airlines flight that overflew 
Minneapolis was quite alarming. The hand-off of the plane between air 
traffic controllers raises questions about procedures that (are) in 
place to track aircraft as they transit the national airspace. What 
steps is the FAA taking to make certain that hand-offs between 
controllers do not delay responses to potential problems with aircraft?
    Answer. The FAA's investigation of the incident involving Northwest 
Airlines flight 188 (NWA 188) resulted in several recommendations to 
improve awareness, communications and internal notification procedures 
to the FAA's domestic event network (DEN). A workgroup, including 
representatives from the FAA and National Air Traffic Controller 
Association (NATCA) was formed to implement those recommendations.
    The workgroup developed changes to FAA orders to require that the 
communication status of aircraft be included in the information 
exchanged when responsibility transfers from controller to controller. 
FAA orders are also being amended to require the usage of available 
methods to provide a visual indication to controllers of the 
communication status of an aircraft. The revised orders are currently 
in coordination and will be effective in the third quarter of FY 2010.
    In addition, training was developed based on the NWA 188 incident 
highlighting radio communication status and notification procedures 
when communication is lost. This training was implemented in February 
2010.
    The FAA is researching the feasibility and options for providing a 
visual indication of the communication status of aircraft to controller 
displays. We expect to complete the research by September 30, 2010.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Byron Dorgan to 
                           Margaret Gilligan

    Question. Administrator Babbitt's Call to Action took a number of 
important first steps to address the safety risks that came to light as 
a result of the crash of Flight 3407. The DOT IG, however, recently 
noted that many of the Call to Action initiatives have fallen behind 
the FAA's self-imposed deadlines. Further, the DOT IG has criticized 
the FAA for failing to impose clear deadlines or milestones for the 
implementation of the voluntary programs by air carriers and labor 
unions. What is the FAA currently doing to make certain that the Call 
to Action initiatives do not fall behind schedule and are implemented 
in the near future?
    Answer. We have already completed a number of the initiatives 
developed through the Call to Action meetings. Specifically, the FAA 
has completed a two-part focused review of air carrier flight 
crewmember training, qualification and management practices. The FAA 
inspected 85 air carriers to determine if they had systems to provide 
remedial training for pilots. Based on the information from these 
inspections, the FAA has finalized a Safety Alert for Operators (SAFO) 
with guidance material on how to conduct a comprehensive training 
program review in the context of a safety management system (SMS) and 
publication of this SAFO is imminent. A complementary Notice to FAA 
inspectors will provide guidance on how to conduct surveillance.
    We have also obtained commitments from air carriers and pilot 
employee organizations for voluntary implementation of best practices. 
With respect to voluntary programs such as Flight Operations Quality 
Assurance (FOQA) and Aviation Safety Action Programs (ASAP), the Call 
to Action has encouraged greater participation. Since we launched the 
Call to Action initiative, the FAA has approved 12 new FOQA programs. 
Three air carriers that had no ASAP program have now established them. 
Four more air carriers have established new ASAP programs for 
additional employee groups.
    Since the issuance of the final report on the Call to Action, we 
have also published an ANPRM seeking recommendations from the public on 
enhanced certification and training requirements for pilots who fly 
passenger aircraft. In addition, the FAA has continued to consult with 
pilot employee organizations on practical ways to facilitate transfer 
of experience, or mentoring, in a structured way. We have also 
completed a survey to follow up on the results of our focused 
inspection initiative. This survey revealed additional improvement in 
the number of carriers who have remedial training programs. At the 
beginning of our efforts, 15 carriers had partial remedial training 
programs and 8 had none, but as of last week, 93 of the 95 carriers 
with active certificates have complete remedial training programs and 
the remaining two have partial programs.
    To ensure that we continue to follow through on the Call to Action 
initiatives, we have very aggressive time frames for the two rulemaking 
projects. The draft Notice of Proposed Rulemaking on Flight Duty and 
Rest is currently in executive review. Although we have not met our 
target timeline, this rule is being developed on an extremely expedited 
schedule with the utmost commitment from the rulemaking team. 
Similarly, the supplemental NPRM on crew training requirements has been 
drafted and is in the review process.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Frank R. Lautenberg to 
                           Margaret Gilligan

    Question 1. The First Officer of Colgan Flight 3407 earned a base 
salary of around $20,000. The salary of Captain Sullenberger, the 
veteran pilot of U.S. Airways Flight 1549, also known as the ``Miracle 
on the Hudson,'' was cut 40 percent in recent years, forcing him to 
take a second job. Given all of the responsibilities that commercial 
pilots shoulder, do you consider low pilot pay a safety issue?
    Answer. The FAA's role is to set the standard that pilots must meet 
in order to fly for a commercial air carrier. Although we do not 
presently have data regarding a correlation between aviation safety and 
pilot pay, on October 16, 2009, the Department of Transportation, 
Office of Inspector General (OIG) announced that it planned to begin a 
review to identify and assess trends in commercial aviation accidents 
including correlations between pilot experience and compensation. We 
look forward to the OIG's findings and will review the results of this 
audit.

    Question 2. Regional airlines operate half of all domestic 
departures and move more than 160 million of our Nation's passengers 
each year. If we are to have one level of safety for both regional and 
major network carriers, shouldn't the pilots of regional carriers be 
trained and compensated at the same level as pilots for major network 
carriers, particularly if they are flying identical routes?
    Answer. The FAA holds all airmen certificated at the commercial 
pilot level and all airmen certificated at the airline transport pilot 
level to the same regulatory standards whether they work for a regional 
or a mainline carrier. As discussed in the response to question five, 
although we do not presently have data regarding a correlation between 
aviation safety and pilot pay, on October 16, 2009, the Department of 
Transportation, Office of Inspector General (OIG) announced that it 
planned to begin a review to identify and assess trends in commercial 
aviation accidents including correlations between pilot experience and 
compensation. We look forward to the OIG's findings and will review the 
results of this audit.

    Question 3. One airline has a program where pilots that commute 
long distances to their duty station are provided with free air travel, 
as well as hotel accommodations at their assigned station. This is in 
stark contrast to the First Officer of Colgan Flight 3407, who had to 
commute from Seattle to Newark flying stand-by on a ``red-eye'' flight. 
In the wake of the Colgan crash and other fatigue-related incidents, 
what should airlines be doing to provide a stable, predictable commute 
and proper accommodations for their pilots?
    Answer. Each air carrier has a responsibility to establish 
commuting policies and guidelines appropriate to its individual 
operational environment. However, the greater issue at hand is that of 
professionalism. As supported by the Aviation Rulemaking Committee 
(ARC), which provided recommendations on how the U.S. should modify its 
existing fatigue rules, each air carrier is responsible for ensuring 
that it does not use a fatigued crewmember. Likewise, crewmembers have 
a professional responsibility to use a rest opportunity for sleep, and 
to be fit for duty.

    Question 4. The Captain of Flight 3407 failed five proficiency 
tests before he was hired--a fact he never disclosed to Colgan. At what 
point should the FAA revoke a pilot's license for failing proficiency 
or training tests?
    Answer. The captain of Flight 3407 was disapproved on three flight 
checks prior to his employment with Colgan (initial check rides for 
instrument rating, commercial single-engine land, and commercial multi-
engine land). He was also disapproved on his initial check ride for an 
airline transport pilot certificate while employed by Colgan. Colgan 
training records show that, during his service as a first officer, the 
captain needed additional training on certain procedures in the Saab-
340 aircraft he was flying at the time.
    The FAA does not revoke pilot certificates for failure of 
proficiency checks or training events. Given the number of training and 
checking events that occur during the course of a normal professional 
flying career, one or more check ride failures is not in and of itself 
a reason to revoke a pilot's certificate. However, the FAA has 
encouraged airlines to conduct a full review of a pilot applicant's 
records in order to make an informed decision. The FAA also encourages 
airlines to make a trend analysis on failure elements. The repetitive 
failure of a single crewmember, or the failure of several crewmembers 
during proficiency or competency checks, may indicate a training 
program deficiency.

                                  
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