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Reforming A Moribund Agency

Given the many instances in which the Federal Aviation Administration (FAA) has been chastised in this publication for ineptitude and industry coddling, some readers wonder what can be done to make the agency more effective at ensuring the safety of the traveling public? Herewith are my recommended actions. They are not in order of priority; in fact, all of these actions should be adopted in a comprehensive effort to shake the agency out of its regulatory torpor.

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All non-binding publications foisted in the aircraft industry should be cancelled forthwith, and such future publications should be halted. These publications include advisory circulars (ACs) and special airworthiness information bulletins (SAIBs). As the heading of an SAIB indicates, “This is information only. Recommendations aren’t mandatory.” The same applies to ACs. In the overwhelming majority of cases, these documents refer to manufacturer service bulletins which operators routinely receive.

Below is a typical SAIB for 5 April 2011 affecting Airbus and Boeing airliners:

“The airworthiness concern is not an unsafe condition that would warrant airworthiness directive action … Following a routine maintenance check, an airplane was found with a fault message that required replacing a fuel filter. The subsequent leak check found a leaking fuel nozzle … If not corrected, the incomplete weld in these fuel nozzles may lead to a fuel leak and eventual uncommanded in-flight shutdown of the engine.”

Sure sounds like an unsafe condition, but operators are referred to a Parker Hannifin Corporation service bulletin for corrective action. As the heading to the SAIB states, “Recommendations aren’t mandatory.” The only way to impose mandatory corrective action is to issue an airworthiness directive (AD), which requires corrective action.

If an issue does not rise to the level of AD action, the FAA need not clog operators’ mailboxes with advisory material.

Issue ADs and enforce compliance. Operator advice of compliance can be as simple as a tear-off coupon returned to the FAA office, sporting the aircraft’s tail number, a signature, completion date and a chief engineer’s stamp certifying completion of the AD. Falsifying such a document would amount to fraud and could be jail-worthy so compliance would be pretty much 100%.

At the same time, the FAA does not enforce compliance with worthy programs it does have. Airlines are required to submit service difficulty reports (SDRs) to the FAA on problems with aircraft encountered during flight. For example, the SDR database reveals dozens of instances of premature fuselage cracking which adequately demonstrate that the hole blown in the top of a Southwest Airlines B737 as just an extreme example of cracking found throughout aging fleets. If anything, the problem of imminent structural failure may be worse than suspected because the FAA does not insist on SDR reporting. Airline compliance ranges from 90%+ to 0%. That is correct: zero – for reports that are ostensibly required.

The FAA would have a much better idea of what is going on in the fleet if it enforced SDR filing.

The FAA has investigators looking into aircraft accidents – a job which duplicates that of the National Transportation Safety Board (NTSB). Unlike the NTSB, which produces detailed reports for the public, it is extremely rare for the FAA’s investigators to issue a public report, much less to hold a public hearing (as does the NTSB).

Terminate the FAA’s accident/incident investigation activity and divert/devote the scarce resources to the NTSB.

Speaking of the NTSB, one might recall that this agency issues comprehensive recommendations to the FAA and other entities following each accident it investigates. A small percentage of these recommendations rise to the importance of being placed on the NTSB’s “Most Wanted” list of aviation safety improvements. There are currently seven such aviation-unique “Most Wanted” recommendations. The NTSB has color-coded five of these recommendations as red, for unacceptable response. The other two are color coded yellow, denoting glacial progress. Note that not a single one of the NTSB’s “Most Wanted” recommendations has been complied with in a prompt manner by the FAA (these recommendations being coded green – for acceptable response, progressing in a timely manner).

One of the recommendations coded red is to: “Reduce dangers to aircraft flying in icing conditions.” Presently, an aircraft can be dispatched into icing conditions with which it may not be able to cope. This is an unconscionable situation.

The FAA gets more than one hundred recommendations annually from the NTSB; most are handled promptly because they are not controversial or hard to implement. The “Most Wanted” recommendations are usually both, but they are also the most significant – and they languish on the list for 10 to 15 years, if not longer. The usual suspicion is that these languishing recommendations would be too costly for the industry to implement, but such cost-benefit calculations are terribly prone to manipulation by agents of the status quo.

The “Most Wanted” recommendations are probably the most carefully crafted of the NTSB’s work. The FAA should be ordered to enact these recommendations within 18 months.

Recommendations languish on the list

Recommendations languish on the list

The FAA maintains a Technical Center in Atlantic City, NJ, which performs fire, electrical wiring, thermal acoustic insulation and fuel tank safety research on behalf of the agency. One cannot name a single item – not one – in which the Technical Center’s work has resulted in a fleet-wide safety improvement mandated by the FAA. Some individuals may cite the Technical Center’s work on fuel tank safety, performed in the wake of the 1996 TWA Flight 800 disaster. However, as far back as 1977 Boeing patented a fuel tank inerting system for transport category aircraft which was more capable than the stripped down design advocated by the Technical Center. Boeing kept quiet about this system, which was never deployed on its airliners.

For having nil impact on the safety of flight, the Technical Center should close its doors. Either that, or keep the doors open under a more honest moniker of FAA Training Center.

The FAA's William J. Hughes Technical Center in Atlantic City, NJ

The FAA's William J. Hughes Technical Center in Atlantic City, NJ

The FAA often refers knotty problems to the Aviation Rulemaking Committee (ARC). The ARC is comprised of industry insiders and will spend months crafting recommendations to the FAA. Before it was renamed, the ARC was known as the Aviation Rulemaking Advisory Committee (ARAC). The standing joke inside the FAA is that the ARAC acronym really stood for “All Rulemaking Activity Ceases.” There’s truth in humor for you.

An ARAC examination of fuel tank safety never knew of the Boeing patent, suppressed a cost estimate of 25 cents per passenger ticket, and concluded that fuel tank inerting (injecting the void spaces in the tank with inert gas) was too expensive. A recent ARC wrestled with the issue of pilot fatigue, but never came to grips with the issue of pilots commuting cross-county to their place of work.

The ARC appears to guarantee proscription inaction (“proscriptive” – conveying an imposed restraint or restriction upon action or consideration). Abolish the ARC. FAA officials can deliberate themselves, without a heavy industry presence gumming up the works.

Occasionally FAA officials seem to get tough with the airlines. For example, the FAA proposed a $10.2 million forfeiture against Southwest Airlines for AD non-compliance. This penalty was negotiated down to $7.5 million on Southwest’s promise to rewrite some maintenance manuals. First of all, why is the FAA negotiating the size of the penalty? Second, why is the FAA reducing the penalty in exchange for corrective actions the carrier should have taken anyway?

These negotiations with the airlines always result in a lesser penalty in exchange for some token quid pro quo. Better to stick to the original penalty; do that once and the airlines will get the message – comply or else.

The FAA could better utilize the expertise of its unions. The National Association of Air Traffic Controllers (NATCA) and the Professional Airways System Specialists (PASS) have many thoughts about how to improve safety. The FAA’s relationship with these entities is one clouded by mistrust. These organizations should be an integral part of FAA safety deliberations.

Instead of punishing or ostracizing whistleblowers within the FAA, the agency should take a more creative, positive approach. In many cases, whistleblowers are people of integrity speaking out because they have found no recourse through official agency channels. One or more whistleblowers should be appointed to prominent positions within the FAA. A counterweight to the overwhelming majority of “yes men” is essential for the agency’s credibility and vitality.

The FAA’s main tool for exercising compliance of the airlines is the Air Transport Oversight System (ATOS). This program entails FAA inspectors checking records, not actual airplanes, maintenance activity or flying procedures. The FAA would be better informed if it scrapped ATOS and ordered its inspectors to assess actual activity.

Lastly, the top official at the FAA should not come from within the agency or the industry. For ensuring a proper focus on the safety of the flying public, a plaintiffs’ lawyer experienced in aviation litigation should be appointed to head the agency. Of course, the airline industry would be horrified, but a plaintiffs’ lawyer – appointed from the President’s home state – would have detailed knowledge of safety deficiencies which have killed and maimed. A former plaintiffs’ lawyer will not mouth incorrect platitudes about airline travel being the safest mode of transportation (it is not).

A plaintiffs’ lawyer just might shake the FAA out of the industry-friendly torpor which has plagued the agency for years.

Skin Rupture Explodes Myth That Safety Is Under Control

Up on the top of the fuselage, tiny hairline cracks were creeping between the rivets; suddenly, the cracks connected and a 5-foot section blew open with the sound of a thunderclap as air in the fuselage rushed out. The emergency oxygen masks dropped down to the startled and frightened passengers.

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The manner in which the cracks suddenly connected together, growing a quarter-inch or more in fractions of a second, is known in engineering parlance as the “fast fracture” phenomenon. It has been seen before, notably in an Aloha Airlines B737 in 1988, when cracks, observed outside the fuselage by passengers while boarding, connected and caused complete loss of structural integrity. The walls and roof of a section of fuselage ripped off. Stewardess Clarabelle Lansing, serving passengers at the time, was sucked out of the airplane. Her body was never found.

From a made-for-TV movie, the Aloha Airlines accident.

From a made-for-TV movie, the Aloha Airlines accident.

In the case of Southwest Airlines flight 812 on 1 April 2011, while the flight attendants were taking drink orders, the fuselage of the 15-year old B737-300 ripped open at a lap joint where fuselage panels are held together by three rows of rivets. Fortunately, no one was ejected from the airplane. Emergency oxygen masks dropped from their overhead compartments and the pilot began a rapid descent from 34,000 feet to a lower altitude where the ambient air is dense enough to sustain life. The 118 people aboard scrambled to don the masks. One passenger said, “People were dropping” (fainting). At the cruising altitude of 34,000 feet, the so-called “time of useful consciousness” is on the order of 10-20 seconds, so one does not have much time to fiddle with the unfamiliar oxygen mask.

It is not known if the emergency oxygen had been de-activated in the lavatories, or if anyone was in the lavatory at the time pressurization was lost. The airlines had until 4 April 2011 to remove or exhaust the lavatory oxygen canisters. (See Aviation Safety Journal, “ ‘Huge Favor’ to Airlines Ordering Emergency Oxygen Removed From Lavatories”)

The airplane made an emergency landing at Yuma, AZ, and passengers clapped and cheered when the captain emerged from the cockpit.

The accident aircraft in better times.

The accident aircraft in better times.

The Aloha accident set in motion the Federal Aviation Administration’s (FAA) supplementary structural inspection program (SSIP) for older jets. They were to be inspected for signs of fuselage skin cracking and patched up. Jet transports that had accumulated 75% of their design life were subject to the SSIP requirements, which meant more than 75,000 flights. This particular Southwest jet was well short of that threshold, which would have required about 20 years of hard airline service.

The SSIP clearly did not work – and did not apply – to Southwest Airlines flight 812. Investigators with the National Transportation Safety Board (NTSB) pored over the plane, using various eddy-current and other instruments to chart the extent of cracking.

Robert Sumwalt, NTSB Member on scene, said there was evidence of extensive cracking in the area of the rupture. A 9-foot section of the fuselage, covering the area of the rupture, was removed from the airplane on 3 April 2011 and sent to NTSB headquarters for detailed analysis. The rupture occurred in a different area than on the Aloha B737 but involved the same joint design: three rows of rivets, each row about ¾ inch from the next, and the rivets along each row about the same distance of ¾-inch apart from one another. As in the case of the Aloha B737, the failure began in the lowest row of rivets, where the stresses are highest. In this case, crack stopper straps halted the failure at the rib-stringer intersection.

NTSB investigators also conducted inspections of other portions of the lap joint along the fuselage and found evidence of additional cracks.

Southwest Airlines cancelled 600 flights to inspect its remaining B737-300 aircraft. There are 288 B737-300s in U.S. registry, of which 79 are operated by Southwest. As of this writing, 21 have been inspected and three of the planes were found with small, subsurface cracks.

“What we saw with Flight 812 was a new and unknown issue,” said Mike Van de Ven, Southwest’s executive vice president and chief operating officer.

The “fast fracture” phenomenon is hardly “new and unknown” for older aircraft with highcycles. By high cycles is meant take-offs and landings; during each flight the fuselage is inflated like a balloon, and the flexing is akin to the repeated bending of a paper clip until it breaks. The lap joint features three rows of rivets to contain the stress, but periodic inspection for signs of cracking is essential.

The airplane underwent overhaul in March 2010. During this so-called D-check, the cabin seats, sidewalls and other appurtenances were removed to facilitate inspection of the aluminum structure for cracking. The records of that D-check will be closely scrutinized by the NTSB, as the cracking found on the accident airplane was clearly extensive enough to predate that overhaul of a year ago. Were cracks discovered? Were they repaired?

According to the dictates of the SSIP, crack growth is slow enough such that they can be missed entirely during one teardown – as long as crack growth is detected and rectified at the next overhaul. These D-checks occur at approximately four year intervals. If the cracks were detected during the last D-check for the Southwest B737-300 but not corrected, were Southwest maintainers seduced by optimistic predictions of crack growth? If the airplane was stripped to bare metal and the cracks were not discovered, why not?

If only visual inspections were conducted – as opposed to more advanced non-destructive testing (NDT) techniques – it is possible but not plausible that cracking was not detected. Of interest, NTSB investigators employed NDT on the aircraft on the ground at Yuma and immediately concluded that widespread fatigue cracking was present. Under the controlled conditions of an overhaul, Southwest technicians should have been able to detect the cracking.

Southwest’s maintenance has been under a cloud before. In March 2008 the Federal Aviation Administration (FAA) proposed a fine of $10.2 million against Southwest for operating 59,000 flights with airplanes out of compliance with a structural airworthiness directive (AD).

On 3 April 2008 the House Transportation and Infrastructure Committee held hearings on the alleged “cozy relationship” between Southwest Airlines and other carriers with the FAA. Then committee chairman Rep. James Oberstar (D-MN) complained to top Southwest executives at the hearing, “Southwest Airlines allowed 117 planes to fly without AD compliance … the most egregious lapse of safety that I’ve seen in 23 years.”

Despite Oberstar’s concern, in March 2009 the FAA announced that the $10.2 million fine had been reduced to $7.5 million on condition that Southwest would rewrite all its maintenance manuals.

On a per flight basis, the FAA originally proposed a penalty of $172.00 for each non-compliant flight, negotiated down to $127.00 per flight – less than the price that a passenger pays for a ticket on the carrier. A token proposed penalty was reduced further based on Southwest meeting certain minor demands.

This penalty did not arrest the structural problems at Southwest. On 13 July 2009, the very next month after the reduced fine was announced, a Southwest B737-300 experienced a rupture in its ceiling, forcing an emergency landing. The NTSB removed the ruptured component and after due metallurgical analysis it was determined that the probable cause was “Fuselage skin failure due to preexisting fatigue at a chemically milled step.”

The piece from the 2009 rupture.

The piece from the 2009 rupture.

A chemically milled step is one where metal is removed during manufacturing to minimize aircraft weight.

Boeing issued a service bulletin (SB) covering inspection of the area where the rupture occurred (on the roof, near the tail) and the FAA published an AD making the inspection mandatory.

From 2009 through 2010 Southwest filed 6 Service Difficulty Reports (SDRs) with the FAA recounting depressurization events. Below is the one for July 2009 involving a B737-300 (the same model as this most recent pressurization emergency):

“Declared emergency/diversion. Pressurization event at 33,000 feet. Masks dropped, emergency descent … Found fuselage cracked between BS [body station] 827 to BS 847, STR [stringer]. Repaired skin per SWA [engineering order].”

On 28 December 2010 the FAA published AD 2010-25-06 concerning structural problems for early model B737s (including the -300 variant). The summary is instructive:

“This AD requires repetitive inspections for cracking of certain fuselage frames and stub beams, and corrective actions if necessary … This AD results from reports of the detection of fatigue cracks at certain frame section, in addition to stub beam cracking, caused by high flight cycle stresses from both pressurization and maneuver loads … This reduced structural integrity can increase the loading in the fuselage skin, which will accelerate skin crack growth and could result in rapid decompression of the fuselage.”

The inspections must be performed within 4,500 flight cycles, or within 9,000 cycles after the previous inspection. Southwest complained to the FAA that “the specified threshold will pose a significant burden [as] half of its model 737-300 and -500 fleet will require an out-of-sequence maintenance visit …”

At 4 flights per day, the 4,500 cycle threshold implies a 3-year time to accomplish the inspection.

Meanwhile, in an apparent effort to demonstrate it is on top of the situation, the FAA announced on 4 April that it will issue an emergency AD requiring structural inspections of older B737 using NDT. Randy Babbitt, head of the FAA, said, “This action is designed to detect cracking in a specific part of the aircraft that cannot be spotted with visual inspection.”

Why cracking on the top of the fuselage is not amenable to visual inspection was not explained.

From a B737-300 diagram, it appears that the skin panel which ruptured open begins around station 663 and continues past station 706 and ends before station 727. The rupture is close to, but not exactly correlated with, the location cited in AD 2010-25-06. There is a lap joint at that location. It was corrosion, a substandard repair, scribing or a similar scrape in the surface of the aluminum which cracked from pressurization cycles.

As one aviation industry insider remarked: “I would like to hang anybody I see scraping lap joints with metallic or non-approved scrapers.”

This observation is not presented to suggest that such practice was condoned at Southwest Airlines. Rather, it illustrates the sensitivity of the metal skin to unauthorized abuse when flight cycles are measured in the thousands.

Given the extreme danger presented by even a scribe line, allowing 4,500 flights – much less 9,000 – seems overly generous. Whatever “significant burden” imposed on Southwest, that mandate seems lax in the extreme. Consider the ongoing out-of-sequence inspections, the 600 cancelled flights (at least), the likely lawsuits from the passengers aboard Flight 812, and the cancelled bookings from a frightened public, not to mention the loss of confidence in FAA oversight, then the “cost” of this incident progresses to erosion of confidence in the safety of air travel. This lost confidence is not simply restored by quickly fixing this particular problem.

‘Huge Favor’ to Airlines Ordering Emergency Oxygen Removed From Lavatories

Emergency oxygen canisters were recently ordered removed from aircraft lavatories by the Federal Aviation Administration (FAA). The agency asserts a would-be terrorist in the lavatory could tear through the ceiling panel and retrieve the canister for nefarious purposes.

The FAA has ordered emergency oxygen removed from airliner lavatories.

The FAA has ordered emergency oxygen removed from airliner lavatories.

Not a peep from the airlines about the loss of emergency oxygen to innocent passengers.

By taking out the generators, passengers who are in a lavatory during a rapid decompression event will not be able to use the oxygen mask that drops from the overhead. They will have to run out of the lavatory – in the middle of a confusing emergency situation – back to their seats. If the depressurization was caused by a hole in the fuselage, loose objects will be flying about the cabin before they are sucked out the hole.

Members of the flying public are not persuaded of the FAA’s action, as evidenced by these reactions:

“Can’t these canisters be redesigned so they are tamper-proof? That would be the logical requirement.”

“I would think they could try to ruggedize the door that protects the canister.”

“Assuming that a terrorist could get tools, plastic bags, and some flammable liquids aboard, they could make up a bundle – with the [oxygen] generator inside, and then trigger it off. [The terrorist] would suffer dying like everyone else, so it’s only a suicide weapon. The real problem is an economic one. These airplanes were designed with a minimum consideration of security and anti-tampering. So rather than redesign and refit all the aircraft to better protect these devices from unauthorized access, the FAA merely did the airlines a huge favor (as usual) and allowed their removal.”

 “Move the generator out of the [lavatory] and into an area where tampering would be noticed. Like, just leave the [oxygen] tube going to the [lavatory].”

“FAA kept it under wraps until it was a done deal! ‘To protect the public’ or to KEEP THEM IN THE DARK? I wonder why ANYONE FLIES ANYMORE!”

“Someone should be able to sue the FAA if this [action] gets someone killed.”

“Surely this will make all these [U.S. registered] aircraft fail the airworthiness test of other countries.”

“The pilots have their own independent air supply that’s not a chemically generated system. So why can’t the toilets have a similar supply, activated only in emergencies and not subject to local tampering? They’ve got water lines going to these [lavatories]. And electricity for lighting. Hmmm. Maybe those could be misused as a weapon, somehow. Better replace [the water and electricity] with moist towelettes, chemical toilets and glow sticks. Now everyone is totally safe …”

The italicized quote above seems to be the real reason for the FAA’s secretive and peremptory action. Some individuals cited above suggest options for providing emergency oxygen safely, without the security risk. Not mentioned is that new technology could replace the oxygen canisters now used, which have their roots in emergency breathing devices aboard submarines. For example, pressure swing adsorption (PSA) technology would provide emergency oxygen without the risk posed by canisters. A small, briefcase size PSA device could be installed in the lavatory and activated either by a drop in pressure or by a cockpit switch. (See Aviation Safety Journal, “Emergency Oxygen Need Not Come From a Chemical Canister”)

Simply removing emergency oxygen from lavatories is the least-cost option for the airlines, but it is also the course that leaves open the safety issues for installing the lavatory generators in the first place. With respect to safety being the FAA’s “job 1”, the agenda seems to be one of increasing the difficulties for terrorists while doing nothing for passengers.

Sleeping Controller Unaware of Airplane Landings

The head of the Federal Aviation Administration, Randy Babbitt, said he is “personally outraged” that a sleeping controller in Washington’s Reagan National Airport (DCA) tower caused two airliners to land without benefit of guidance or assistance. Perhaps the outrage should be focused on FAA policies that caused the lone controller to fall asleep. This fiasco was organizationally-induced.

The controller was apparently drifting in dreamland shortly after midnight on 23 March, alone in the darkened control room high above the airport.

The control tower at Washington's Reagan National Airport

The control tower at Washington's Reagan National Airport

The pilots of an American Airlines B737 from Dallas-Ft. Worth, operating as flight 1012 with 97 people aboard, were unable to raise the controller via radio shortly after midnight. The pilots executed a missed approach to sort things out. The Potomac TRACON (Terminal Radar Approach Control) was contacted.

The TRACON controller informed the American pilot on the radio, “The tower is apparently not manned … you can expect to go into an uncontrolled airport.”

“Is there a reason it’s not manned?” queried the American pilot.

“The controller got locked out. I’ve heard of it happening before,” the TRACON controller advised.

The American B737 then landed at Washington National and pulled up to the gate without any assistance from the controller. The controller was not locked out of the control room; he admitted he was asleep.

About 15 minutes later, a United Airlines A320 from Chicago, operating as flight 628T with 68 people aboard, was also unable to raise the tower. The pilot made position reports and landed.

The FAA has suspended the supervisory controller (with pay), who awakened after the two planes landed.

“As a former airline pilot, I am personally outraged that this controller did not meet his responsibility to help land these two airplanes,” said Babbitt.

It should be noted that this controller, as an FAA supervisor, was not a member of the National Air Traffic Controllers Association (NATCA).

NATCA President Paul Rinaldi issued the following statement after the incident:

“During the incident at DCA on the midnight shift Wednesday morning, there was one FAA supervisor on duty, instead of a front-line controller. This was an FAA management supervisor …

“NATCA has long been outspoken in its opposition to one-person staffing on any shift … One-person shifts are unsafe. Period. The most horrifying proof of this came on August 27, 2006, when 49 people lost their lives aboard Comair flight 191 in Lexington, KY, when there was only one controller assigned to duty in the tower handling multiple controllers’ responsibilities alone. One person staffing was wrong then and it’s wrong now.”

The practice is routine at about 30 airports nationwide, including at Washington DC.

The controller indicated he was on his fourth consecutive overnight shift (10 p.m. to 6 a.m.) when he fell asleep. This time period is known as known as the “circadian low” when people are particularly sleepy.

Just two days before the Washington National event, the National Transportation Safety Board (NTSB) recommended to the FAA that supervisory personnel not concurrently perform operational air traffic control duties. The recommendation cited a fatal aircraft accident and two incidents in a 23-month period between 2007 and 2009.

The NTSB recommendation letter to the FAA said:

“In [one} event, a controller was on duty alone during the midnight shift and was therefore responsible for supervising himself. The particular difficulty of supervising oneself is amply demonstrated in most of the events discussed in that the controller committing the error was also action as CIC [controller-in-charge].”

The NTSB has also placed fatigue, and eliminating same, on its “Most Wanted” list of aviation safety improvements. Details of this “Most Wanted” recommendation include:

“Set working hour limits for flight crews, aviation mechanics, and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements. [Emphasis added]

“Develop a fatigue awareness and countermeasures training program for controllers and those who schedule them for duty.”

This “Most Wanted” recommendation is color-coded red, meaning an unacceptable response from the FAA.

Former NTSB Chairman Jim Hall says:

“This incident represents the tip of an iceberg that needs to be carefully monitored by safety interests. The confluence of the retirement of the core of experienced controllers, the failure to ramp up hiring and training to anticipate this challenge, as well as the uncertainty of FAA appropriations and increased traffic were brought together in this incident. The fact that no one at the FAA had enough political awareness to ensure the proper staffing of the Washington Reagan Airport tower, especially after the attacks of 9/11, make one wonder: who is in charge?”

The NTSB is now investigating the Washington National event. Transportation Secretary Ray LaHood has ordered that two controllers be on duty in the airport tower at all times. He has not directed a change to the 29 other airports were single staffing is permitted by the FAA.

Emergency Oxygen Need Not Come From a Chemical Canister

For an “all or nothing” solution, the option of “nothing” is an unnecessary risk. Yet this option is the preferred choice in the recent action by the Federal Aviation Administration (FAA) to eliminate emergency oxygen from aircraft lavatories. (See Aviation Safety Journal, “Emergency Oxygen Ordered Removed From Lavatories”)

On 10 February 2011 the FAA ordered airlines to render nonfunctional in 6,000 planes’ lavatories the oxygen supply to the “little yellow cups” that ordinarily drop from the overhead in the event of loss of pressurization. The emergency oxygen supply to regular passenger seats will be unaffected.

There is an apparent fear on the part of federal authorities that terrorists could utilize the oxygen generators above the lavatories as a means to accelerate a fire. The oxygen generators stowed above passengers’ heads utilize burning sodium chlorate to produce oxygen, which then travels down a plastic tube to the yellow oxygen mask. The oxygen canister gets hot, so the fear is that an ignited canister could not only ignite nearby flammable materials but also the oxygen produced could worsen the flames.

Exactly how a terrorist in a locked lavatory could get access to a canister stowed in the overhead is not clear. The fact is that rendering the canister “safe” from terrorist use also means the lavatory has no emergency oxygen. A passenger in the “loo” responding to a call of nature has approximately a minute or two to don an oxygen mask before losing consciousness. This is the reason why lavatories were outfitted with emergency oxygen; there is not time to complete one’s “business”, unlock the door, and dash to the little yellow cup dangling over the passenger’s seat. Elderly and infirm passengers with slow mobility may not win the race from the lavatory to their seat, losing consciousness in the lavatory or in the aisle.

A plaintiff’s lawyer will have a straightforward case to plead: my client is brain damaged/dead because there was no emergency oxygen. It will cost the airlines about $1 million to deactivate all lavatory emergency oxygen canisters. The settlement from one deceased passenger could total $10 million or more. The airlines are not being exempted from liability at the same time they have been directed by the FAA to nullify emergency oxygen in the lavatories.

One gets the impression that the FAA has not considered an option which avoids the heat generated by the present canisters while providing a supply of oxygen-enriched air to a passenger caught by a surprise decompression in the lavatory. The steel oxygen canister stuffed with sodium chlorate and other chemicals dates back to at least World War II; the canisters were used for emergency oxygen aboard submarines.

Advances in technology have made possible a new means of providing emergency oxygen: pressure swing adsorption (PSA). Special adsorptive materials, notably zeolites, are used to preferentially adsorb target gasses at high pressure. When the pressure is reduced, the trapped gas is released, or desorbed. Thus, ambient air passed through a PSA device will capture the nitrogen and the output gas will be enriched in oxygen.

Zeolite, whose unigue properties are at the heart of PSA gas separation.

Zeolite, whose unigue properties are at the heart of PSA gas separation.

When the capacity to adsorb nitrogen is reached, pressure is reduced and nitrogen is released. Two adsorbent vessels allow for near-continuous production of a target gas.

Schematic of the PSA process. Zeolite is used as a molecular sieve, preferentially adsorbing the target gas at high pressure. When the pressure is reduced, the target gas is released.

Schematic of the PSA process. Zeolite is used as a molecular sieve, preferentially adsorbing the target gas at high pressure. When the pressure is reduced, the target gas is released.

This is exactly the process featured in portable oxygen concentrators used by emphysema patients and others who require oxygen enriched air to breathe.

The system operates at near-ambient temperature; in other words the danger of fire is greatly reduced, and the PSA technology is not a flame accelerant. Since the system is electrically powered, it can be turned off in the cockpit, if not by a designated switch then by a circuit breaker. For any person in a locked lavatory suspected of trying to gain access to the PSA oxygen generator, the malign intentions can be foiled by switching the PSA off. In fact, the terrorist could be restrained in the locked lavatory until landing.

Innocent passengers caught in the lavatory during a cabin decompression event would have emergency oxygen, and terrorists would be denied a hot generator emitting oxygen.

This situation is a “best of two” solutions. Replacing the chemical canister with a PSA device is much preferable to the “nothing” adopted by the FAA in a dubious scenario involving terrorists.

The Statistical Orphan of Aviation Safety

Statistics abound on aircraft incidents and accidents, except for “public use” fixed-wing and rotary-wing flying machines. We are left with anecdotal reports, such as the number of accidents in a period of time, but nothing like events per so many flying hours. Without such a denominator, the comparative record of public use operations cannot be usefully compared to the rest of the aviation industry.

This is just another way in which public use operations are an orphan, with no effective oversight by the Federal Aviation Administration (FAA), which has indicated it has “no intention” of changing the state of affairs. Moreover, there are no equivalent statistics maintained by the National Transportation Safety Board (NTSB) on lives lost and mangled aluminum.

Just to refresh memories, public use operations involve contract flights on behalf of federal and local government entities. For example, the “water bombers” flying in support of U.S. Forest Service firefighting efforts are in the unregulated public use category. Another example: helicopters flying for local entities as the Maryland State Police.

If one asks the NTSB for the number of public use accidents, one will get a stack of accident summaries, from which one can glean 17 dead and five accidents since 2007 involving public use aircraft flying for the Forest Service. To be sure, this is an horrific record, reflecting the price paid by the FAA’s hands-off attitude.

How this toll compares to the other main sectors of aviation remains unknown. What is needed for the public use category is an accident rate per 100,000 flight hours and/or per 1,000,000 miles flown.

Review the NTSB statistics (www.ntsb.gov/aviation/stats.htm). The searcher will look in vain for any information regarding the public use category. Yet there are ample, detailed statistics on every other category of aviation, presented in the 12 tables.

For Part 121, scheduled airlines: data as far back as 1990 on the number of accidents, fatalities, accidents per 100,000 departures, per 100,000 flight hours, per 1,000,000 miles flown, and more.

For Part 135, non-scheduled air taxi and on demand operations, less detailed information but still accidents per 100,000 flight hours.

For Part 91, general aviation, a real eye-opener on the mayhem in this category – such as 1,474 accidents in 2009 (the most recent year data is presented) with 474 people aboard killed. There is an average of 1.3 deaths a day in general aviation. More importantly, there is data on the accidents per 100,000 flight hours.

Hence, useful comparisons between Part 121, Part 135 and Part 91 flying are easily made:

ratescompared

For public use operations? Nothing. No table. No data. No comparisons possible. I am willing to bet that public use operations have an accident rate somewhere above that of Part 135 and below that of Part 91. For instance, the “water bombers” flying for the Forest Service are generally being flown in old, converted military airplanes, with sketchy maintenance records and a substantial amount of metal fatigue and corrosion. These firefighting aircraft are operating in areas of high turbulence (updrafts from fires), which puts a strain on their structure (wings have been breaking off). Flying at low altitude in these conditions is not as safe as an airliner benignly cruising at 30,000 feet, but how much less safe has firefighting flying been? Statistically, we have no idea.

One cannot make policy decisions without good data. One cannot focus regulatory resources in the absence of data.

Senior FAA officials proclaim that their priorities will be “data driven.” In the absence of data about public use operations, it is not surprising that the agency ascribes a non-priority to oversight of public use aircraft and helicopter operations.

All operators of public use aircraft maintain records of flying hours per machine. The information is necessary because many maintenance actions are linked to accumulated flying hours.

The NTSB can provide the accident data, as reporting of even less-than-fatal accidents is required.

The hours flown divided by the number of accidents can be used to derive the rate per 100,000 flying hours. This information can be displayed on another line in the table above for public use. My wager is that public use operations will have a fatal accident rate 10 times greater than for scheduled airline operations. Is this an acceptable rate for the FAA to continue its regulatory neglect? Or would such a tenfold rate galvanize FAA officials into adopting the public use orphan now sitting on the curb, ignored by the government as a no-data non-entity?

Comforting Statistics and the Reality of Air Safety

In its latest assessment on the safety of air travel, the International Air Transport Association (IATA), a lobby group representing more than 230 airlines globally, proclaimed flying is so safe that if one were to take an airline flight every day it would be approximately 4,400 years before one would be involved in a fatal accident. (See Aviation Safety Journal, “Accident Trend Data Show Improved Safety Still Needed”)

Believing the above statement, flying then is much safer than open-heart surgery. If one were to undergo coronary surgery on a daily basis (with no complications from the previous day’s procedure), one would die on the operating table in less than one year.

The risk of open heart surgery is much greater than that of flying, but this is not as valid as comparing flying to other modes of transportation

The risk of open heart surgery is much greater than that of flying, but this is not as valid as comparing flying to other modes of transportation

Both in terms of time between accidents and operating room risks, these measures of air safety are misleading. The former misleads by racking up a hugely convenient denominator; the latter by comparing a perfectly healthy airline passenger to a patient with severe heart disease.

Safety across all modes of transportation is usually measured by the fatality rate per billion miles travelled. By this measure, airplanes do not score nearly as well as trains:

 rates

The comparison between airliners and passenger trains is apt because both represent very public forms of transportation, with government oversight and licensed crews. Comparing the safety of airline travel to automobile travel is really mixing the proverbial oranges and apples. Automobile travel is private, with varying degrees of driver alertness and competence and with highly variable maintenance of the vehicle (ranging from rigorous fanaticism on the part of some car owners to others not knowing what the amber “check engine” light on the dashboard signifies).

A train derailment, even at high speed, may be less catastrophic in terms of lives lost than an airplane crash from 30,000 feet, which usually ends with crumpled aluminum and bodies “commingled” – in the euphemistic phrase employed by accident investigators – with the wreckage.

Air crashes involve mass death that unnerves the public, as in the case of the 228 killed in the 2009 loss of Air France flight 447

Air crashes involve mass death that unnerves the public, as in the case of the 228 killed in the 2009 loss of Air France flight 447

The train travel statistic cited above is for all trains, globally. If high speed trains are singled out – Japan’s “Bullet” trains or France’s TGV – the air/train comparison is even more appropriate. High speed trains operate at roughly the same takeoff and landing speeds of airliners. In this respect, high speed trains are eight times safer, per miles travelled, than planes. Japan’s “Bullet” trains have operated since the early 1970’s without a single fatality (not counting the occasional despondent who commits suicide by throwing himself in front of a hurtling train). Similarly, France’s TGV, operating on special, fenced-off tracks, has never had a fatal accident.

High speed trains, like Germany's Intercity Express (ICE), are much safer than airliners

High speed trains, like Germany's Intercity Express (ICE), are much safer than airliners

Decades pass between accidents involving high-speed trains. If the aviation industry passes a year without a fatal accident, that is cause for self-congratulatory rhetoric about how the “enhanced commitment” to safety is paying off. In truth, a year’s gap between air crashes remains an anomaly worthy of mention.

The 2006 midair collision between a GOL 737 (shown here) and a business jet killed all 157 on the airliner. The accident reflects the positive and negative aspects of technology. Improved navigation accuracy meant the two airplanes, flying in opposite directions, could operate much closer together on aerial 'highways'. But the collision alert transponder on the business jet inadvertently was switched off, making an accident more likely

The 2006 midair collision between a GOL 737 (shown here) and a business jet killed all 157 on the airliner. The accident reflects the positive and negative aspects of technology. Improved navigation accuracy meant the two airplanes, flying in opposite directions, could operate much closer together on aerial 'highways'. But the collision alert transponder on the business jet inadvertently was switched off, making an accident more likely

The hard fact of the matter is that there has not been a step-increase in air safety since the advent of the gas turbine powerplant.

High speed trains are now approaching planes in the amount of power at their disposal. For example, the Acela Express train, operating in the Northeast Corridor of the U.S., features a locomotive at each end of a six-car articulated train set. The two locomotives provide over 12,000 combined horsepower – a lot for six passenger cars but necessary for quick acceleration and for maintaining high continuous speeds.

Comparing the horsepower of Acela’s electric motors to pounds of thrust in a jet turbine is slightly problematic, but 1 hp equates to approximately 75-110 pounds of thrust. The Acela musters close to the horsepower of a B747 jumbo jet, depending on the particular model jet engine selected. It should also be mentioned that modern jets feature a large amount of electric generation capacity to power ever more flight systems.

The Acela is a variant of France’s TGV high-speed train and has yet to experience a fatal wreck.

Accounting for the variability of weather, traffic, and other unique features of air travel, it would seem reasonable to establish a goal of, perhaps, one fatality per billion miles of airline flying. The rate of 1.0 is less than the current rate of 0.5 for all forms of train travel, and it makes much more sense than comparing today’s crash rate to that of yesterday’s. By this measure, even open heart surgery is safer today, as is just about everything else.

Current aviation statistics are clouded by big and misleading numbers (sometimes expressed in even more confusing powers of ten, as in 1 x 10-9). Comparing safety across modes of transportation is the only way to objectively and meaningfully quantify the risk of air travel.

Required Safety Checks Were Not Done Despite Six Year Compliance Time

Almost 100 jets were grounded to accomplish required safety checks, raising serious questions about federal oversight of the airline that was at least eight months late doing the work.

On 15 February United Airlines announced that it was grounding 96 of its B757s to check and validate software and hardware changes for the airplane’s air data computer systems.

UAL B757-200

UAL B757-200

“We apologize for any inconvenience and ask customers to check their flights status … before going to the airport,” said United spokeswoman Megan McCarthy. The work reportedly will take 12-24 hours to complete, so the airplanes should be returned to service as of this writing.

According to media reports, during a routine maintenance check, United discovered that it had not followed all the steps required in an airworthiness directive (AD) issued by the Federal Aviation Administration (FAA) in 2004.

End of story? Not a big problem? Hardly. Rather than soothing reports of how well United did getting these grounded aircraft back on the flight schedule, the story should have been of the utter failures demonstrated here and the lack of assurances that this latest problem isn’t part of a systemic FAA absence of oversight.

The AD in question (AD 2004-10-15) was published in the Federal Register in May 2004. Extracts below set forth the work to be done and the reasons therefore:

“This [AD] requires a modification of the air data computer (ADC) system, which involves installing certain new circuit breakers, relays, and related components, and making various wiring changes in and between the flight deck and main equipment center …

“This action is necessary to ensure that the flightcrew is able to silence an erroneous overspeed or stall aural warning. A persistent erroneous warning could confuse and distract the flightcrew and lead to an increase in the flightcrew’s workload. Such a situation could lead the flightcrew to act on hazardously misleading information, which could result in loss of control of the airplane …

“For Model 757-200 … airplanes: Install a circuit breaker and replace an existing lightplate assembly with a new, improved lightplate assembly in the flight compartment; install two relays and remove a certain relay in the main equipment center; make various wiring changes in the flight compartment and main equipment center; and perform tests of the flight data acquisition unit, flight data recorder system, and stall and overspeed warnings.”

The work was required within 6 years of the AD’s effective date of June 22, 2004. United had performed the hardware changes within that period, but failed to perform the functionality tests, hence the grounding for the required tests.

The period of non-compliance with the AD appears to be from June 2010 to February 2011.

United’s public announcement of the belatedly required checks may be an attempt to forestall a civil penalty of millions of dollars, since the out-of-compliance fine is based on the number of airplanes times the number of flights made in a noncompliant condition. Recall that in October 2009 the FAA proposed a $3.8 million fine against United for flying a B737 over 200 flights with shop towels, rather than protective caps, covering openings in the oil sump on the right-side engine. Recall, also, the $24.2 million fine proposed against American Airlines in August 2010 for failing to follow an AD affecting 286 MD-80 twinjets.

One has to ask why the full AD compliance was not tracked in a timely manner by United. After all, software for alerting when data (invoices) becomes “past due” is available at all office supply stores.

And where was the FAA principal maintenance inspector (PMI) in this fiasco? If he didn’t notice the noncompliant aircraft, then where were the assigned certificate management folks assigned by the FAA to oversee United’s operating certificate (which includes AD compliance in support of that operating certificate). Lastly, if oversight at these field levels was lacking, where was the FAA’s Washington DC headquarters in all of this?

Pertinent questions go well beyond feel-good statements.

Every month that this AD went beyond compliance is not just an indictment of United’s programs for continuing safety analysis accepted by the FAA, but also of the FAA’s entire oversight program – from the PMI to Washington headquarters.

Advisory Committee: Nil Value for the Money

For almost a quarter million dollars, the taxpayers of this country and the Secretary of Transportation sure didn’t get much for the money. In fact, what they got is another toothless study which will lie moldering on the shelves.

I am referring to the latest “work” of the Future of Aviation Advisory Committee (FAAC). On 9 December 2010 the FAAC presented 23 recommendations to Transportation Secretary Ray LaHood on how to ensure the strength and safety of aviation. The wording of recommendation #23 is enough to give a flavor of the FAAC’s effort:

“The Secretary [of Transportation] should:

1. Utilize the full resources of his office to continuously educate the flying public about the dangers of flying with lap children.

2. Update the economic and safety data concerning families travelling with small children, including incidents and accidents involving injuries and deaths [and]

3. Based on the information provided by these finding, the Secretary should take necessary action, which may include a rule-making or other appropriate next steps.”

The giveaway words here are “may include a rule-making.” As written, it is just as likely the Secretary of Transportation will cave in to airline industry pressure and may not institute rule-making. The words “or other appropriate next steps” are imprecise and just guarantee that the whole subject of lap children will be dragged to oblivion.

The 2010 FAAC meets in Washington DC

The 2010 FAAC meets in Washington DC

If the FAAC had looked at the issue in any depth, free of airline industry influence, it could have recommended something useful:

“Given the inherent dangers of unrestrained lap children, the Secretary should institute rulemaking within three months, with the intent of ending this hazardous practice within 18 months of publishing the Notice of Proposed Rulemaking (NPRM).”

A recommendation along this line, with specified deadlines, would have been worth something – maybe even a quarter million dollars given the statistical value of a life. But the FAAC is comprised of academics, airline executives and others who completely outweigh representatives such as the president of the Association of Flight Attendants (AFA), who gave an impassioned plea for action to curtail the practice of lap children. (See Aviation Safety Journal, “Advisory Group Punts on ‘Lap Children’ in Airliners”)

Other FAAC recommendations on safety are equally superficial. (See Aviation Safety Journal, “Safety Recommendations Fall Short”)

Secretary LaHood waxed appreciation for the FAAC’s report, lauding the committee’s “valuable service” providing a “blueprint” for the industry. Some blueprint; more like a glossing over of key problems.

For this, the Department of Transportation (DOT) paid $220,775 for travel and miscellaneous expenses; basically, a quarter million dollars for five FAAC meetings.

The members are not paid, but appointment to the committee allows members to shape the debate.

Here’s a breakdown of 2010 FAAC costs:

$145,308 Drafting and recording the minutes of all meetings, and drafting support for each of the subcommittee reports.

$50,012 Travel expenses outside of Washington DC for federal employees.

$25,455 Costs of webcasts, printing, supplies, and meeting-specific costs.

$220,775 Total

Given that a FAAC is appointed yearly, the expenses over time would clearly run to the millions of dollars. Not once has the Secretary of Transportation convened a press conference to announce: “Based on the recommendations of the FAAC, I am today taking action to end the practice of carrying lap children when laptop computers and coffee pots must be secured for takeoff, landing and in-flight turbulence.”

The FAAC is testament to the Washington habit of visiting a problem, not solving it. The FAAC could disappear and aviation would not be one whit less safe, much less materially safer.

Safety Recommendations Fall Short

For the pretense of progress, look no further than the recommendations submitted by an advisory committee and breathlessly endorsed by the Secretary of Transportation. Really, we could eliminate the committee and save tens of thousands, if not hundreds of thousands, of taxpayer dollars.

On 9 December 2010 the Future of Aviation Advisory Committee (FAAC) presented 23 recommendations to Transportation Secretary Ray LaHood on how to ensure the strength, competitiveness and safety of aviation. The committee’s 19 members came from airlines, airports, manufacturers, labor, academia and general aviation stakeholders. With members like Glenn Tilton, president and CEO of United Airlines, the line-up was a guarantee for conventional, status quo thinking. This was evident in the FAAC’s recommendations on “lap children” aboard airliners, in which the committee recommended more “education” of the flying public about the dangers of flying with lap children. The committee could have called for regulatory action to end the practice of “lap children” and properly restraining them in their own seats. (See Aviation Safety Journal, “Advisory Group Punts on ‘Lap Children’ in Airliners”)

lead-in_faac_500x300

LaHood waxed appreciation for the FAAC’s report, saying, “This committee has provided a valuable service to all members of the aviation community with this blueprint for the industry.” But did LaHood carefully review the FAAC’s recommendations? Apparently not, because in the next breath he said, “I look forward to thoroughly reviewing the recommendations.”

We will save him the time, focusing on the FAAC’s specific safety recommendations (other than lap children restraints discussed in elsewhere in this publication):

Item:Delivering the benefits of NextGen. The Secretary should fully endorse and focus on ensuring that FAA delivers the operational capabilities, procedures, and approvals necessary for operators to realize the benefits from the NextGen air traffic control system as quickly as possible..” The discussion goes on for more than a page in this vein, with not one word about the improved safety the system is supposedly going to provide.

Comment: NextGen rests on the capabilities of ADS-B (automatic dependent surveillance, broadcast) to cram more airplanes into the nation’s crowded skies and airports. The system is automatic in the sense that airplane avionics do not have to be queried by radar. Rather, the system on the aircraft relies on navigation signals from global positioning system (GPS) satellites in space, and other on-board avionics, to automatically generate key elements of the airplane’s location, altitude, speed, and so forth.

It is dependent, in the sense that ground stations rely on the aircraft to reliably broadcast its navigation solution and other identifying parameters. Many of these factors, such as the aircraft’s horizontal (i.e., lateral/longitudinal) position have heretofore been determined by ground radar.

The term surveillance refers to the need for ground control to know where airplanes are in relation to each other.

The term broadcast refers to the airplane’s new role in providing this information, making the airplane a much more active – as opposed to traditionally passive – participant in the air traffic “solution,” as it were.

“ADS-B Out” refers to transmissions from the aircraft to air traffic control to enable aircraft to be spaced closer together in the air routes. But “ADS-B In” would enable an ADS-B equipped aircraft to receive information from other aircraft and from the airport. This “ADS-B In” capability is not being required. Thus, operators have until 2020 to equip their aircraft with “ADS-B Out” but “ADS-B In” will be addressed in separate rulemaking.

Nor has the FAA appear to have addressed the vulnerability of ADS-B to jamming of the GPS signals. It has been demonstrated that a 1-watt jammer will block GPS signals for many miles around an airport, disrupting ADS-B’s central role in descent and landing under the NextGen concept.

There are stacks of reports issued by the Government Accountability Office (GAO) and the Department of Transportation Inspector General (DOT/IG) indicating that NextGen is in trouble. Here are just four comments:

GAO, November 2010: “FAA has yet to make many key decisions reqired to shape and determine the future direction of NextGen.”

GAO, July 2010: “Without specific goals and metrics for the performance of NextGen as a whole … it is not clear whether NextGen technologies, systems, and capabilities will achieve desired outcomes and be completed within the planned time frames.”

DOT/IG, April 2010: “Key multibillion dollar programs have experienced problems, and the FAA has yet to fully determine their NextGen-specific requirements.”

DOT/IG, March 2009: “To highlight trnsition issues and establish requirements, FAA must complete its ongoing ‘gap analysis’ of the current and vastly different NextGen systems and refine the NextGen mid-term architecture.”

This is a program in mounting technical difficulty, with plenty of potential for cost overruns and performance deficiencies. The FAAC limited itself to generalized fretting, along the lines of “fully leveraging … ADS-B” and “the Secretary should require the FAA to develop and commit to a timetable when requirements will be set …”

One gets the impression that the FAAC was not even aware of the absence of “ADS-B In” during initial implementation, or the vulnerability of building the whole NextGen edifice on GPS signals that are easily jammed.

The safety improvements the NextGen is hoped to bring, in terms of incidents or accidents avoided, has yet to receive even token discussion.

 

Item:Legal Protection of Voluntary Safety Data and Information. The Secretary of Transportation should seek comprehensive legal protections for voluntary and mandated safety data programs and information to ensure their continued benefits to safety … the development, analysis, documentation and availability of shared safety information will be inhibited if there is potential that it may be used for other purposes such as out-of-context exposure through the media, admissions in criminal or administrative prosecution, or use in civil litigation.”

Discussion: It is a classic industry ploy to decry “out-of-context exposure through the media” when in truth the agenda here is to keep embarrassing information out of the newspapers and TV news. It should be noted that Aviation Safety Action Program (ASAP) reports are fully available to outside sources and there has never been a concerted industry complaint that media exposure took things “out of context.”

Recall the FAA argument on reporting bird strikes:

“The agency is concerned that there is a serious potential that information related to bird strikes will not be submitted because of fear that disclosure of raw data could unfairly cast unfounded aspersions on the submitter… [and] The complexity of the information warrants care with its interpretation; releasing this information without benefit of proper analysis would not only produce an inaccurate perception of the individual airports and airlines but also inaccurate and inappropriate comparisons between airports/airlines.”

Secretary LaHood overrode these concerns and ordered that bird strike data be made publicly available. These same tired arguments are being raised again about safety programs, and LaHood’s response – contrary to the FAAC views – should be the same as it was for bird strike data.

Moreover, if the FAA were to mandate programs such as Safety Management Systems, rather than encourage their voluntary adoption, and let the results speak for themselves, the public would get a better appreciation for the industry’s commitment to safety.

 

Item:Predictive Analytic Capabilities for Safety Data and Information. Beginning with the FY2012 budget for the FAA, the Secretary should provide focus, priority, and resources to develop improved tools and methods in order to provide a robust aviation system predictive safety risk discovery capability.”

Discussion: Such a program has already been developed and was actively suppressed by the FAA and the aviation industry. In 2007, under the imprimatur of the National Aeronautics and Space Administration (NASA), a program was developed known as the National Aviation Operational Monitoring Service (NAOMS). It was an innovative attempt to identify emerging risks through structured interviews of pilots, air traffic controllers, flight attendants and mechanics.

NASA was criticized by the FAA and industry for releasing the data, which contained a far greater number of incidents of safety problems than reported elsewhere. For example:

  • Hundreds of incidents where aircraft had uncommanded movements of rudders, ailerons, spoilers, speed brakes, etc., in flight.
  • 2,339 incidents where Air Traffic Control refused pilot requests to alter course due to severe weather.
  • Over 4,000 occasions where reserve fuel was required to remain flying.

Industry representatives claimed they already have the ASRS (Aviation Safety Reporting System) reports, and therefore NAOMS was not necessary. But ASRS features only reports submitted and is not a valid measure of system safety or system wide problems.

NAOMS provided just the type of “forward-looking analytical capabilities” called for by FAAC, as it uncovered safety threats that had not yet culminated in an accident. But it died prematurely because its data discomfited the FAA and the aviation industry.

The FAAC obviously did not even look at the NAOMS effort and how it would provide useful information on emerging threats to air safety.

 

Item:Expanding Sources of Voluntary Safety Data. The Secretary and the FAA Administrator, working with aviation system partners and other industry and government advisory committees, should identify potential new and valuable sources of safety data, and establish criteria for when/how those sources would begin to be included.”

Discussion: See remarks above concerning the stillborn NAOMS project. The FAA also has the Service Difficulty Report (SDR) database, but reporting under this required program varies by airline, from non-compliance (0%) to full compliance (100%). Moreover, SDR reports are only required of problems in flight, not on the ground. The industry has resisted FAA efforts to expand SDR reporting to include ground events, rendering the entire SDR database rather arbitrary.

Before going out and reinventing the wheel, the existing problems with SDR reporting should be cleaned up and promising programs like NAOMS should be exploited.

 

Item:Identification of Safety Priorities. The Secretary should quickly review the existing regulatory and safety initiative calendar [and] provide parameters and criteria or the FAA to prioritize its current and future rulemaking program. This review should include industry, or at a minimum seek industry input, and the results should be made publicly available … A fresh identification of priorities is needed to ensure that safety priorities are, in fact, driven by data and information and that there is an overarching sense that the government and industry are focused on the right issues first.”

Discussion: Note the admonition that the FAA should seek industry participation. One might point out that the FAA is a regulatory body providing oversight. Industry participation may lead to obfuscation and delay of efforts deemed discomfiting to the status quo.

A listing of data-driven priorities already exists. It’s the “Most Wanted” safety recommendations published annually by the National Transportation Safety Board (NTSB). It’s definitely data-driven, in that its safety recommendations come out of accidents. It is also an urgent list that is “slow rolled” by the FAA; the “Most Wanted” recommendations are either ignored by the FAA, rejected outright or implemented half-heatedly and belatedly.

most wanted

The FAA does not need a “fresh identification” of priorities; the “Most Wanted” list is the considered opinion of the NTSB based on accident investigation. The recommendations are written in blood; what additional incentive does the FAA need?