Distracting Attention From Systemic Safety Shortcomings

The recent fines proposed to be levied on US Airways and United Airlines by the Federal Aviation Administration (FAA) give the impression that the agency is in charge and getting tough on safety transgressions. The alternative view is one of the FAA grandstanding, involved in token penalties to demonstrate that it is on top of the safety situation.

Credence for this dour interpretation comes from the FAA’s total lack of rigorous enforcement of the Service Difficulty Report (SDR) system, by which carriers are supposed to report significant maintenance problems. Reporting is spotty and does not focus on serious problems; rather, the SDR database is clogged with minor, frivolous reports having negligible impact on flight safety (e.g., burned out light bulbs).

There is a way to clean up SDR reporting and to make it a more useful cross-comparison of safety-related events and trends.

On 14 October the FAA announced a $5.4 million fine against US Airways and a $3.8 million penalty against United Airlines. One gets the impression that in both cases the FAA is acting capriciously and in a manner calculated, if anything, to discourage the airlines from reporting problems.

US Airways was fined for failing to comply with three airworthiness directives (ADs) and for failing to conduct maintenance inspections. The proposed fine escalated due to multiple flights conducted by the same aircraft without the requisite inspections. Meanwhile, the larger issue goes unaddressed: US Airways submitted SDRs only 16% of the time for incidents of smoke, fire, cracked windshields, blown tires, engine and landing gear problems that were found in a Google database search. SDRs are required to be submitted to the FAA, not only for trend analysis at an airline, but for spotting trends across the industry. Focusing, as the proposed penalty does, on a few isolated transgressions is really beside the point then US Airways SDR reporting discipline is woefully lacking.

The proposed penalty on United Airlines is similar – over 200 flights of one B737, which was forced finally to return to the departure field due to low oil pressure indications. Upon teardown, it was found that two shop towels, rather than protective caps, had been used to cover openings in the oil sump area when maintenance was performed in December 2007.

In this case, United filed an SDR in a timely manner, which said in part:

“RTFL (return to field) DUE TO LOW QTY/PRESSURE INDICATIONS FOR NR 2 ENGINE. FOUND RAG BLOCKING THE FRONT COMPARTMENT SUMP AS WELL AS A RAG IN THE SCAVENGE TUBE. REPLACED THE ENGINE. SHOP FINDINGS: RAGS IN OIL SCAVENGE SYSTEM. ENGINE MADE SERVICEABLE.”

Even though United filed the SDR, it got fined anyway. This seems a perverse way to encourage SDR reporting, especially since United’s filing rate is only about 30%, per the method used to determine the 16% reporting rate above for US Airways.

Both carriers have 30 days from receipt of the civil penalty letter to file rebuttals. If the past is any predictor, the fines will be adjusted downward by 25% to 50%, or voided entirely. The FAA’ announcement of the proposed fines could be interpreted as indicative of a “get tough” attitude when, in fact, the ultimate financial penalty is both substantially less and a disincentive to report anything via the SDR system.

Simply put, the FAA is not enforcing its most powerful and prominent self-reporting system. With full reporting of SDRs, the FAA would have a means of measuring, across the board, maintenance impacts on air safety. Let the record reflect that United contracts out its maintenance, which saves money. But everything has a price. Contract maintainers can use non-licensed mechanics to perform work, so long as the job is overseen by a licensed power plants and airframe mechanic. By just publicly fining United, we learn nothing about how the error came to be made in the first place. Was this a case of non-licensed maintainers making a mistake? If so, how was it missed by a certified mechanic, assuming he was actively overseeing the work of the non-licensed juniors.

Indeed, it is not clear that the SDR generated the proposed fine. If the penalty was the result of a whistleblower call to the FAA’s hot line, that draws attention to a non-functioning SDR reporting system. This certainly does not engender public confidence that the FAA is on the ball, so the whole effort focuses on proposed fines for isolated transgressions, rather than the FAA’s systemic negligence regarding SDR reporting and the use of the database for useful analysis.

Let me give three examples of high-profile cases where SDR reporting was either nonexistent or superficial:

1. Recall the 15 January 2009 ditching in the Hudson River of the US Airways A320 struck by birds. (See Air Safety Journal, ‘Hearings Reveal Definition of Ditching Needs Upgrading’) Two days before, there was a “loud noise” of an engine compressor stall noted in the media. Under the FAA rules for filing under the SDR system, this type of engine anomaly is a reportable event. What’s in the SDR database? Nothing.

2. Remember the 13 July 2009 event where a hole popped open in the roof of a Southwest Airlines B737? (See Air Safety Journal, ‘Torn Metal Skin on Southwest Jet To Be Evaluated’) Southwest did file an SDR, but misstated the problem, saying that the skin was cracked. That’s quite a gloss on a rupture that opened a 1.5 foot hole over passengers who say blue sky where the ceiling was supposed to be. Although no required supplemental report followed a promised evaluation, three others have been filed for loose exit light lenses and a flashlight battery replacement.

The ruptured skin as viewed from inside the rear of the passenger cabin.

The ruptured skin as viewed from inside the rear of the passenger cabin.

3. Then there is the case of the United Airlines B777 that had the electrical failure at London’s Heathrow Airport on 26 February 2007. Arcing inside a power panel in the lower bay caused molten metal droplets to fall down onto insulation blankets below. The blankets ignited and a fire spread underneath a floor panel to the opposite electrical panel, causing fire damage to structure, cooling ducts and wiring. The case was investigated by the UK’s Air Accidents Investigation Branch. (See Air Safety Journal, ‘Regulatory Lassitude Contributed to Electrical Fire’) United filed an SDR, which said only, “Smoke coming from fwd outflow valve after engine start.” No apparent cause or supplemental reports were filed, although both are required by FAA rules. Insulation blankets, we should note, are supposed to be fireproof, so the fact that the full-fledged fire was spread by burning insulation is noteworthy and quite serious. Given improved standards for qualifying insulation blankets, why are we dealing with insulation fires in these new-generation B777s anyway?

Burnt aircraft structure and insulation blankets located below the B777's power panel on the right side. The fire spread to the left side of the belly hold.

Burnt aircraft structure and insulation blankets located below the B777's power panel on the right side. The fire spread to the left side of the belly hold.

Here’s a reporting system with about 30% compliance across-the-board in 2008 for the airline industry, where the reports that are submitted are incomplete and outright misleading as to severity. Reporting compliance for 2009 is estimated at 40% — still less than half.

The partial SDR database is also clogged with what can only be described as frivolous reports. Frivolous here means those reports filed that result from the expected wear and tear of the operating environment. These frivolous reports comprise anywhere from 53% to 92% of filings submitted by the airlines.

For example, some carriers report all structural cracks, regardless of acceptability. According to a retired licensed FAA structures mechanic, formerly with the late Eastern Airlines, perhaps 5% of corrosion or cracks found exceeded the acceptable limits. The SDR regulations say reporting should be for “cracks, permanent deformation, or corrosion of aircraft structures, if more than the maximum acceptable to the manufacturer or the FAA.”

Emergency lighting systems are another category where frivolous reports abound. Emergency egress lighting, a network of floor lighting, emergency lights and exit signs, powered by rechargeable batteries, are kept in a charged state by the normal aircraft electrical system. When that source fails, or a switch is turned on, the battery-powered lighting system activates. The floor lighting wiring is subject to foot traffic and damage to the wires. Both the chargers and the light bulbs are subject to failures.

Failures of the lighting system must be reported via SDR. However, routine replacement of bulbs and batteries may constitute anywhere from 15% to 78% of a carrier’s SDR filings. Such filings should be comparable per airplane among carriers. They are not.

Frivolous filings waste more than half of the FAA’s time and labor for inclusion into the database. For the carriers, these filings serve to “prove” that SDR improvement initiatives through the years are all too costly. There’s nothing like unchallenged padding of the database to demonstrate the burden of further reporting.

The National Transportation Safety Board (NTSB) has written the FAA at least four times during the period 1993-2002 complaining that the SDR database is incomplete (and this is in the face of a mountain of frivolous reports, mind). Its 1993 letter was the most explicit:

“Attempts to effectively use the SDR data base in recent Safety Board investigations have revealed that the current program is incomplete and of limited value in identifying accurate service defect histories because many reportable service difficulties are not reported to the FAA.

“This situation was identified during the Board’s investigation of an accident involving the failure of a Cessna 208 landing gear shimmy damper and cracking of the engine/nose gear mounting structure. The FAA SDR database revealed only two reports of engine mount cracking and no prior reports of shimmy damper failure; however, data supplied by the airplane manufacturer [Cessna] showed 17 reports of engine mount cracking and 250 reports of shimmy damper failure.”

The Government Accountability Office (GAO) has also detailed many shortcomings of the SDR system:

— It contains only a small percentage of actual occurrences.

— Vagueness in reporting requirements and airlines’ concerns about public access to SDR data contribute to low SDR reporting.

— Doubt about the system’s capabilities and effectiveness has discouraged SDR reporters …

— FAA analysis of SDRs occurs rarely or not at all.

One can easily see how the current practice of levying fines against the airlines can be viewed as capricious, arbitrary and even counterproductive (why submit an SDR that could be used to impose a fine?).

There may be a better way. To encourage all operators to submit SDRs, the FAA could impose a civil penalty of, say, $10,000, for each occurrence where a required SDR is not submitted. One submits that a penalty of $10,000 for not submitting a piece of paper will, in short order, result in SDR submissions. The FAA’s principal maintenance inspectors (PMIs) at each airline can audit submissions for noncompliance. Absent SDR reports can be identified through Google incident searches, or through manufacturer’s reports that are not found on the FAA’s SDR database.

Frivolous reports that needlessly pad the database can be handled similarly. Any report submitted that is not in compliance with FAA reporting requirements can be the subject of a $5,000 fine.

After about a year, reporting rigor will be much improved, and the FAA will have a much more usable database for identifying problems and trends across the industry.

The current method of levying civil penalties on the airlines gives the impression that the FAA is getting tough on the airlines. This toughness is illusory.

Imposing real discipline in SDR reporting is far more meaningful. The public might not understand the significance, but the airlines, the FAA, and the NTSB definitely will comprehend the difference between token oversight and a truly “data driven” safety program.