Committee Vows to Legislate Changes to Strengthen Oversight of Airlines

Thursday, 10 April 2008

Putting the flying public at risk, the relationship between airlines and regulators is too collegial – quite cozy in fact – to the detriment of safety, according to disclosures at a Congressional hearing.

At a 3 April hearing of the House Committee on Transportation and Infrastructure, Chairman James Oberstar (D – Minn.), vowed, “Congress should enact legislation to establish a long ‘post-service’ cooling off period for FAA inspectors before they are allowed to go to work for the airlines.”

His remark was in reference to an FAA inspector assigned to the Southwest Airlines (SWA) Certificate Management Office (CMO) who was hired by the carrier the day after he retired from the FAA.

That event was just the tip of the iceberg in a scandal that Oberstar said is “The most serious lapse in safety I have been aware of at the FAA in the past 23 years.”

Whistleblower Bobby Boutris, who was allowed uninterrupted time to give his compelling testimony.

He was referring to revelations, brought to his committee by FAA whistleblowers, that the airline flew at least 117 aircraft with passengers in violation of Federal Aviation Regulations (FARs). The story they told was one of incestuous collusion between the airline and the regulators that was to the benefit of the airline’s convenience at the expense of the public unwittingly traveling in airplanes that had not completed required structural and flight control inspections.

The whistleblowers’ assertions led not only to the hearing, but to FAA actions in damage control; specifically, a token inspection of airworthiness directive (AD) compliance at other carriers. As expressed in this newsletter, the FAA’s activity in this regard is focused on too small a sample to be statistically sound, and it allows regional offices to cherry-pick at least some of the hundreds of ADs for which compliance is easy (see Aviation Safety & Security Digest, ‘As Hearing Looms, FAA Launches Investigation of Carriers’).

What is clear from the committee’s investigation is that the situation at Southwest did not happen overnight, and it is not an isolated case (see box A).

However, based on the testimony of other FAA inspectors – officials assigned to oversee other airlines – the situation at SWA was not unique. Charalambe “Bobby” Boutris was an FAA inspector at SWA, and his testimony to the committee documents a chronic pattern of looking the other way (see box B).

Any notion that the situation at the SWA CMO was uniquely bad was dispelled by the testimony of Richard Andrews, a retired FAA inspector from the American Eagle (AMR) CMO:

“Eighteen months ago, the operations unit was staffed with 13 FAA employees and the number dwindled down to five inspectors. However, in February 2008, when the FAA learned of this hearing, the operations unit was completely re-staffed with new hires and crossovers from General Aviation. While the additional staffing is an improvement, the new hires are not fully trained and require over a year of training, which will create even more work for the remaining inspectors at the facility.

“As FAA inspectors, we are a workforce trained to focus only on the safety of the system. It is beyond frustrating when we discover a problem with an air carrier and are prevented from doing anything about it. We are usually stopped in our tracks by several layers of management and the FAA’s focus on pleasing the airlines.

“In addition, inspectors are now assigned so much administrative work that it is chaining us to our desks when we should be out in the field as the eyes and ears of the FAA. Thirty-one years ago, I was out in the field with my hands on the airplanes looking for safety problems and I had the power to make a difference. Now, in the age of self disclosure and the tight relationship between FAA management and the airlines, inspectors are sitting at their desks entering information into a computer. Unfortunately, what suffers most from all this is the safety of the system.”

And for insight into the circular logic that led to a fatal accident being logged into the ASAP program, instead of being properly investigated, the testimony of Joseph Thrash, a retired inspector at the Continental Airlines Certificate Management Office (COA CMO) is instructive:

“A Continental Airlines contract mechanic was killed during ground operations of a Continental B737 on January 16, 2006 at El Paso, Texas. This was a fatal aircraft accident and the flight crew’s actions were accepted into the FAA’s ASAP program during the week following the accident.

“As the FAA’s B737 Aircrew Program Manager in the Continental CMO, I sent a February 14, 2006 e-mail of my professional disagreement with the ASAP’s decision to FAA Administrator [Marion] Blakey.

“On February 27, 2006 I was interviewed by the Assistant Manager of the FAA’s American Airlines CMO, Mr. Don Klos, regarding my e-mail concerns at the request of Mr. Thomas Stuckey, who is the FAA’s Southwest Regional Division Manager of Flight Standards … During the interview, Mr. Klos stated that the previous week he had visited Stuckey … who indicated that the FAA Administrator Blakey and the FAA’s Associate Administrator for Safety, Mr. [Nicholas] Sabatini, had told Mr. Stuckey to investigate ‘how the El Paso matter had been accepted into ASAP.’ Mr. Klos stated during the February 27, 2006 interview that the accident should not have been accepted into ASAP, but that ‘Washington FAA’ would have the final call. … [The final call was to accept the El Paso accident into ASAP.]

“FAA Associate Administrator for Safety, Mr. Nicholas Sabatini, signed FAA Regulation 14 CFR Prt 193, under provisions of 49 USC 40123, to essentially prohibit the release of ASAP and certain other FAA accepted ‘voluntary disclosure’ aviation safety information on January 26, 2006.

“This regulation essentially protects ASAP, a non-regulatory, voluntary program created by an FAA Advisory Circular, from the public’s right and freedom for information regarding their safety.”

What to do about the situation? Thrash recalled that ferrets were used in sailing ships to hunt down rats, and that the task now is to ferret out all those “rats” responsible for the current state of affairs in the FAA.

A vivid and tempting metaphor, but one lacking in specificity. Calvin Scovel, the Inspector General for the Department of Transportation (DOT/IG) offered instead what appears to be a useful menu of corrective actions:

h Establishing an independent organization within FAA to investigate safety issues identified by its inspector workforce. Scovel noted:

“FAA agreed to establish a new internal review capability [and] plans to implement this capability by September 30, 2008. As currently proposed by FAA, the reviews would be under the direction of [Sabatini’s] Flight Standards organization. However, in light of recent events at SWA – where, again, we have seen evidence of poor FAA reviews of inspectors’ safety concerns – FAA should develop an independent body outside of the FAA Aviation Safety organization to conduct these reviews.”

h Periodically rotate supervisory inspectors, such as the Principal Maintenance Inspector, to ensure reliable and objective oversight of airlines.

h Implement a process for secondary review of airline self-disclosures before they are accepted and closed. These steps should not rest solely with one inspector.

h Revise its post-employment guidance to require a “cooling-off” period when an FAA inspector is hired by an air carrier he or she previously inspected.

All good and useful ideas. Scott Bloch, head of the Office of Special Counsel (OSC), which has jurisdiction over whistleblower disclosures and protection, went further:

“I am recommending that this committee establish an expert commission to examine how the FAA, from a systemic standpoint, from a management standpoint, and from an organizational standpoint, could allow these cover ups and frauds to occur on the flying public. Such a commission should also investigate the complicity of the airline industry, in combination with the FAA, or separately, and to make concrete recommendations for comprehensive reform of oversight and airline safety for the next decade.”

Unfortunately, while various committee members vowed the FAA must do a better job, not one of them picked up on Bloch’s proposal. Maybe, upon reflection, the legislators will see the merit in Bloch’s proposal: something that should be done to keep the heat on the FAA

Box A

Evolution & End of a Cozy Relationship (Abbreviated) The airlines, the Federal Aviation Administration, and the inspectors who unraveled it all
DATE	EVENT
26 July 2005	Bobby Mills issues memorandum to his FAA subordinates shortly after his arrival as manager of the Southwest Airlines (SWA) Certificate Management Office (CMO), which said in part: “Over time, familiarity with our counterparts at the carrier, combined with our intermingling with their freewheeling and informal culture, have perhaps influenced us to settle for winks, nods, verbals and e-mails as acceptable methods by which we do our business as regulators … What we want to avoid at all costs is a relationship so comfortable that the line of distinction blurs between the regulator and the regulated …. We are hired by the taxpayers to look over Southwest’s shoulder and ensure they conduct their business with safety as the uppermost consideration at all times – nothing more, nothing less.”
January 2006	Mr. Bobby Boutris, FAA Partial Program Manager, SWA CMO, began reviewing SWA maintenance records with an emphasis on AD compliance for the B737-700 fleet. In the course of that review, he discovered numerous discrepancies with SWA aircraft AD compliance records, determined that the airline’s records did not meet FAR (Federal Aviation Regulations) compliance requirements, and he informed the appropriate SWA maintenance official. Mr.Boutris also recommended to the FAA SPMI (Supervisory Principal Maintenance Inspector), Mr. Douglas Gawadzinski, that a letter of investigation be issued, but Mr. Gawadzinski refused to issue the letter to the carrier.
January 2007	Boutris was assigned to conduct an AD management safety attributes inspection (SAI). SAI inspections are required every 5 years by FAA policy, and the last inspection on SWA was accomplished in 1999. Evidence supplied to the Transportation & Infrastructure Committee indicates that when SWA maintenance officials learned that Boutris had been assigned to lead the inspection, they met with Gawadzinski and actively sought his removal. Gawadzinki then instructed Boutris to delay the review until he gave permission for it to proceed at a later date.
15 March 2007	SWA notified Gawadzinski, by telephone, in the SWA CMO, of a voluntary disclosure that potentially up to 100 aircraft were overdue the required inspection for one AD. Under VRDP (Voluntary Disclosure Reporting Program) guidelines, it was mandatory that the SWA non-compliance with the FARs should have immediately ceased on the date of disclosure. This clearly did not occur. Once airline maintenance officials were able to evaluate and define the scope of the problem, the number of aircraft involved was later revised to 47 aircraft.
20 March 2007	Another 70 aircraft were self-disclosed as having missed a separate mandatory rudder check. Overall, 47 aircraft under the AD and 70 aircraft under the rudder check were allowed to keep flying with full knowledge of the FAA SPMI for a number of days until SWA could schedule them for inspections without disrupting their commercial schedule. Grounding these aircraft immediately, as required by the FARs, would have cancelled hundreds of SWA commercial flights.
28 March 2007	Boutris met with SWA managers and documented to them 21 negative findings from the SAI inspection. He reported these findings to SPMI Gawadzinski, who instructed him not to enter them into the Air Transportation Oversight System (ATOS) database (note: filing the negative findings in ATOS could have led to enforcement action against SWA).
April 2007	Douglas Peters, another FAA inspector became aware of a SWA self-disclosure that the airline had over-flown a mandatory maintenance check of the Standby Rudder Power Control Unit Hydraulic System Internal Leakage Check on 70 aircraft.
9 April 2007	Boutris advised he was being removed from his position because of an anonymous complaint filed against him, per FAA guideline.
18 April 2007	Kermit Teppen and Cecil Woodcock, of the American Airlines (AMR) CMO, investigated SWA’s over-flight of the AD and concluded that Gawadzinski neither ensured that the non-compliance ceased nor did he inform upper management of this significant event. Teppen and Woodcock reported, “The SWA CMO has a relaxed culture in maintaining and substantiating data as well as any documentation that would support any decisions made by the airworthiness unit.”
9 May 2007	CMO Manager Mills and SPMI Gawadzinski were temporarily reassigned.
August 2007	Boutris and Douglas Peters, another FAA inspector, file for whistleblower protection with the U.S. Office of Special Counsel (OSC).
20 December 2007	Boutris’ and Peters’ whistleblower case is referred to the Secretary of Transportation for investigation and response to the allegations.
22 February 2008	Boutris’ spouse received a package at their residence containing an article entitled, “How to survive the death of your husband…” along with a hand-written note addressed to her suggesting, “Catherine, thought you’d be interested!” FBI brought in to investigate.
3 March 2008	Gawadzinski was assigned to the AMR CMO under the same FAA regional management.
6 March 2008	Just prior to the originally scheduled House Committee on Transportation & Infrastructure, the FAA notified SWA of a $10.2 million civil penalty for 46 aircraft that had over-flown the fuselage inspection AD for up to 30 months.
10 March 2008	Nicholas Sabatini, FAA Assistant Administrator for Safety, sent a special team of FAA inspectors to do a thorough examination of SWA regulatory compliance. Gawadzinski removed from SWA CMO. Transportation & Infrastructure Committee notes, “As a minimum, the evidence seems to demonstrate a long-term pattern of neglect that was reported to FAA regional management with no significant corrective actions taken.”
11 March 2008	SWA announced that it had placed three employees on “administrative leave” pending the airline’s internal investigation of the matter.
12 March 2008	SWA announced it was grounding 41 more aircraft for “inspections.”
13 March 2008	FAA issued a national order (N 8900.36) instructing all FAA regional Flight Standards Offices to conduct a “special emphasis validation of AD oversight.”
1 April 2008	Transportation & Infrastructure Committee memorandum indicates that notions of partnership and the airlines as the FAA’s “customers” have become firmly rooted in the FAA culture. The FAA’s website prominently features the “Our Vision” statement: “Our vision is to improve the safety and efficiency of aviation, while being responsive to our customers and accountable to the public.” (See www.faa.gov/about/mission; as of 15 April, this vision statement remains unchanged.)
2 April 2008	Sabatini briefs press on the status of the AD audit. “Of the total audits, just over 1 percent, or 34, revealed discrepancies. “The bottom line is that this Phase One Special Emphasis review, which is an intensive effort, accomplished what it was intended to accomplish. It validated that the carriers are doing their jobs – they are meeting the Federal Aviation Regulations – and the FAA inspector workforce is doing its job: overseeing compliance.”
3 April 2008	Transportation & Infrastructure Committee hearing. By the date of this hearing, at least six major U.S. airlines have announced the voluntary grounding of hundreds of aircraft for precautionary inspections relating to AD compliance. It is not clear if these groundings reflect self-disclosure, freeing the airlines from any fear of civil enforcement (fines). Note that the FAA on 2 April found only 1 percent noncompliance on 10 ADs, but that the airlines grounded more than 1 percent of the fleet. This points to the trivial nature of inspecting compliance with a selection of just 10 ADs. Committee Chairman James Oberstar (D – Minn.) announces: “This investigation … is not just about improper activities by one airline and one FAA supervisor in the office directly overseeing that airline. It raises serious questions about whether higher officials in FAA are carrying out their safety responsibilities for the entire industry. … “FAA needs to clean house, from the top down, and take corrective action. … “Above all, FAA senior management MUST also develop a better way to monitor local airline oversight offices, to avoid another major lapse in compliance such as those at Southwest.”
7 April 2008	FAA announces that Thomas Stuckey, the director of flight standards for the agency’s southwest regional office, has been reassigned to “an administrative position that doesn’t have safety oversight.” Stuckey was between the SWA CMO and Nicholas Sabatini, the associate administrator for safety in the Washington, DC, headquarters. Stuckey came under intense grilling at the 3 April hearing, at which Sabatini declared rather flippantly he would be removed from safety oversight to “count paperclips” somewhere until the FAA investigation into the situation at the SWA CMO was completed.
Sources: T&I Committee, FAA, Washington Post

Box B

Testimony of ‘Bobby’ Boutris, FAA Safety Inspector,

to T&I Committee

(Extracts)

Since 2003, I have been raising safety concerns via e-mails, memos, and meetings regarding my Supervisor/Principal Maintenance Inspector (S/PMI) Mr. Douglas Gawadzinski suppressing my inspection findings …. All of my findings were direct violations of the Federal Regulations and the SWA procedures, but under the direction of my supervisor Mr. Gawadzinski I was sending SWA letters of concern in lieu of letters of investigations … via e-mail I informed my supervisor that I did not feel it is ethical as an Aviation Safety Inspector to continue writing letters of concern which are not part of our mandatory guidance to document and correct non-compliance issues with SWA. …{Note: a letter of concern is not placed into the Enforcement Information System (EIS), as opposed to a letter of investigation, which is recorded in the EIS.]

Since ADs address unsafe conditions, their requirements are mandatory and non-compliance is contrary to Title 14 Code of Federal Regulations (14 CFR), and legally enforceable per 14 CFR, Part 39….

In addition to the AD issues, in reviewing the SWA Continuous Airworthiness Maintenance Program (CAMP) I was also finding non-compliance issues … I went to my supervisor, Mr. Gawadzinski, and informed him of my findings, stating that SWA was not keeping us informed and they had stopped submitting the changes/revisions to their CAMP to our office. Mr. Gawadzinski told me that we were out of the approval business because with approval came liability and that the FAA was getting away from that. …

In addition, in reading the VRDP [Voluntary Disclosure Reporting Program] report under THE REASON WHY THIS VIOLATION WAS INADVERTENT, SWA in part states: “Unfortunately, due to the extended time span, we can not definitively determine the exact reason the initial error occurred, and was overlooked during the creation of the document, its revisions, and reviews.” As I stated earlier, this was also one of my findings and concerns back in 2005 when I told my supervisor that we had lost sight of the SWA Maintenance Program and I was concerned because SWA had lost control.

What is interesting here is that in reading this VRDP report, under the INFORMATION OF THE PERSON PREPARING THE COMPREHENSIVE FIX for SWA, is the name of Paul Comeau. Mr. Comeau is an ex-FAA Safety Inspector who was performing oversight inspections for regulatory compliance issues regarding the SWA Certificate at the SWA CMO with Mr. Gawadzinski. While working for the FAA, Mr. Comeau accepted a job offer from SWA as the Manager of Regulatory Compliance. I believe that SWA knowingly hired Mr. Comeau for his FAA connections with inspectors in our office, and to their advantage placed him in the position that directly interfaces with our office on a daily basis in regards to regulatory compliance issues in dealing with aircraft maintenance. …

In one of the statements that were made by the FAA regarding the operation of the SWA aircraft in revenue service with the overdue AD inspections, it was stated that one FAA inspector looked the other way. I am here to report that more than one FAA inspector along with FAA management have been looking the other way for years. …

The FAA is a great organization with many good inspectors and managers, and I am proud to be part of it. However, there is no accountability throughout the ranks … Other than moving personnel around, the FAA has taken no action and everybody involved is still collecting a paycheck….

During the town hall meeting in March 2008, Mr. Sabatini stated that the FAA is working on a solution … and it is my understanding that the FAA is going to put in place a Hot Line process for inspectors to elevate safety concerns. But with all due respect, I have a question here: if FAA management did not respond when I openly and on record raised the serious safety concerns, how is a hot line process going to work? … I like to inform you that for years we have had a similar hot line system in place that inspectors do not trust because Hot Line complaints and safety issues end up on the FAA Administrator’s desk, and then are passed down to the local FAA Regional Office to be investigated … From my experience, I believe the priority of the Regional Office is damage control and I see no interest in accountability, or doing the right thing. At the end of the investigation, no matter what the evidence shows, it’s disregarded by the Division Management Team who cherry pick the information from the investigation reports and, without looking at the big picture, apply Band-Aids instead of fixing the root of the problem.

I would also like to inform you that since the FAA put in place the customer service initiative, the partnership programs such as the Voluntary Disclosure Reporting Program (VDRP) and the Aviation Safety Action Program (ASAP) have become ineffective. We are told that the airlines are our customers and if they do well we do well (more jobs for our office). However, some of us forget that we have another more important customer, the taxpayers, who put their trust in us to ensure that the airlines provide safe transportation for the flying public.

The airlines tak advantage of he customer service initiative and thy constantly remind us they are the customer. The best way to put it is like you are going down the highway committing traffic violations and jeopardizing the safety of others and when the police officer stops you and informs you that you are breaking the law by endangering people’s lives, you tell him that he cannot document the violation because you are his customer. …

I hope the information I have provided today will help bring some overdue changes and help inspectors like myself continue serving the public and give faith to the inspectors that have lost faith in the system.

Last Updated ( Thursday, 10 April 2008 )

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