Story ID: 035a
Michael Graham Talks Safety Culture at Standdown
By: Amy Wilder
Caption: Influence shapes safety culture in aviation
Word Count: 1039
NTSB board member Michael Graham addressed attendees of Bombardier’s 28th Safety Standdown on how influence shapes safety and what we can learn from recent close calls.  His presentation, “Impacts of Influence,” examined the ways people can influence aviation culture in sometimes surprising ways. To make his point, he delved into two case studies of runway incursions at New York’s John F. Kennedy International Airport and in Austin, Texas, over the past two years.
Graham, referencing the overarching Safety Standdown theme of "Elevate Your Influence," opened by reflecting on the pervasive influence of advertising, government, and social media on buying habits and behaviors. He noted that sometimes simple actions can have a significant influence, which could be either positive or negative.
He played a 90-second 2012 Dollar Shave Club Ad, which he said cost about $4,500 to produce and load to YouTube, and led to a 12,000-person membership increase within two days. “Four years later…they sold the company for $1 billion,” Graham said. “Do you think that when he posted that, he thought it was going to have that much influence? Sometimes it's the real simple things that make a big difference out there.”
Growing up in Albuquerque, Graham was inspired to become an aviator by watching airplanes flying over his home. His parents and teachers helped shape his values and career aspirations. A commanding officer in his first fleet squadron impacted his leadership and career development. Graham drew a line from these critical early influences to the importance of developing younger, inexperienced members of the aviation community and stressed the importance of setting a good example, even when not being watched. 
“I think it's really important that the most influential people in my life are probably not even aware of the things they've taught me,” he said. “And each one of you can be that out there. I'm going to try to influence you today.
“I hope you read our accident reports like I did, and learn from them, and apply the lessons learned there, because that's the most important stuff. It's not what happened, but understanding how and why, so we can prevent future accidents like that from happening again. I'm going to talk to you about a couple of near misses here—and the FAA would call them ‘close calls.’”
Looking at the history of runway incursions, Graham noted that audience members might look at statistics and see a steady state with no recent fatalities domestically. “That doesn’t mean that the potential is not there,” he cautioned.
Recent data shows an uptick in runway incursions, particularly in Alpha and Bravo airports. “We actually have 11 incursions that we’re investigating right now,” Graham said.
He outlined a runway incursion incident at JFK Airport that occurred nearly two years ago, which was impacted by pilot task saturation, changed clearances, and lack of standard operating procedures (SOPs) for verifying which runway the crew was crossing after being cleared to cross. Action by ATC alerted one of the crews to abort its takeoff in time to avoid a collision.
“One of the things that we recommended out of this was for [Part] 91K, 135, 121, operators that you incorporate into your SOP, a better procedural cross-check if you don't have this already, by verbalizing the runway that you're crossing, so others can be tied in, especially if they're doing other tasks at the time, and that should be based on runway signs,” Graham said. “Now, I know some of you have the technology out there that tells you where you're at, so use that. You’ve always got to be vigilant out there.”
The NTSB has also asked that airlines investigate their data to look for surface navigational errors caused by crew performing other tasks at the time, and if so, to work to mitigate it. In addition, “For 24 years now, since 2000, there are two things we’ve been asking for: surface detection equipment in the towers and detection equipment in the cockpit that will visually and orally alert flight crews of traffic on the runway or taxiway, approaching to land, or taking off,” Graham said.
He went on to detail an incident between a Southwest Airlines Boeing 737 and a FedEx Boeing 767 in Austin. The Southwest airplane was given takeoff clearance while on the taxiway and advised of another aircraft on approach; it subsequently taxied onto the runway and then paused for an engine run-up, reducing separation with the approaching FedEx airplane. There were low-visibility conditions, and the air traffic controller could not see aircraft from the tower, on the surface, or on approach. The FedEx airplane, on a low-visibility approach, called for a missed approach just in time.
The incident highlights the importance of pilots informing ATC of additional time needed on the runway for runups or similar procedures—particularly in conditions in which the tower has no visual contact with aircraft. Graham reiterated the call for the installation of surface detection equipment and said the CVR recording had been lost due to the two-hour recording limit. He also emphasized there is a continued need for vigilance among aviation professionals and clear communication between pilots and ATC.
“Anybody who's heard me speak in the last couple of years, or anybody from the NTSB for that case, is probably aware that we were really hounding the FAA on requiring 25-hour CVRs out there,” Graham said. “In 2023, all the incursions that we investigated out of all that, and the one collision we had down at Houston Hobby between the Hawker and the Citation Mustang—you know how many CVR readouts we got from all those? Zero. We got zero.
“The two-hour CVR is old and dated. There's no reason why we can't have 25-hour CVRs. They're doing them over in Europe on the new aircraft. Congress got involved with the reauthorization of the FAA here this year, and they said, ‘Hey, FAA, guess what, you're required now to have these within one year on new aircraft and within six years retrofitted out there.’ So hopefully that will help.”
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