As a result of the intense Congressional and media attention brought to the FAA, and its Southwest Regional Office, which also has oversight responsibility for American Airlines (AMR), that carrier grounded hundreds of its aircraft, resulting in thousands of cancelled flights and the stranding of hundreds of thousands of ticket-holding passengers. Apparently, the heat generated in the kitchen by the SWA debacle was too hot for AMR and they decided to try to get ahead of an issue that they knew also affected them.

The FAA embarrassment over this massive disruption to our country’s air transportation system, and still untallied economic damage, prompted FAA Associate Administrator for Aviation Safety, Nicholas Sabatini, and his hand-picked Director of Flight Standards, Jim Ballough, to devise a hasty FAA self-audit of air carrier AD compliance. 

Sabatini and Ballough’s performance, under questioning by the Congressmen, was so poor that some committee members even accused them of providing misleading testimony.  Incredibly, Sabatini, testified that the myriad of problems that others had testified to at the hearings were “not evident as [his] level.” Sabatini’s desperate attempt to get himself and Ballough off the hook of gross mismanagement and malfeasance produced the pathetic paperwork AD audit exercise.

Rather than request an independent audit by the Government Accountability Office (GAO), which would have taken control of the results out of their hands, Sabatini and Ballough used the internal, self-controlled audit.  It had to be conducted by the same agency that had just been exposed for complicity in endangering passengers’ lives.  They created an opportunity to fill out their own report card and give themselves all “A” grades, without any credible independent verification.

This paperwork audit called for a 10% sampling of ADs by FAA inspectors with responsibility for air carrier oversight. (See Aviation Safety & Security Digest, ‘Amid Proud Declarations, No Answer About Accountability for Safety’) One problem with this approach is any inspector finding non-compliance with ADs would be admitting to not having done his/her job, and possibly being guilty of the same behaviors exposed during the Congressional hearings.  Also, any non-compliance found and entered into the programmatic maze of the Air Transport Oversight System (ATOS) would create an immense additional workload. The ATOS data entry burden alone has already been testified to consuming 70% to 80% of an inspectors’ time.  Interestingly, Sabatini and Ballough never issued any guidance to these inspectors on what to do if they found the same violations that SWA is being fined $10 million for, and that kicked off this exercise.

The scathing Congressional hearings not only launched the FAA into its predictable damage control activities, they also spurred Secretary of Transportation Mary Peters to commission a panel of experts to explore these issues and provide her with recommendations.  This panel, called the “Independent Review Team” (IRT), just released a report titled, “Managing Risks in Civil Aviation: A Review of the FAA’s Approach to Safety,” dated 2 September 2008.  Secretary Peters has enthusiastically endorsed all of the IRT’s 13 recommendations.

The IRT was comprised of five experts who have impressive credentials, to be sure, but they are all industry insiders. The IRT would have been more balanced if it had included a member with actual internal FAA operational experience within the past ten years. Their recommendations would have been more focused and action oriented with a better understanding of day-to-day life inside the agency and its current problematic culture. Without FAA operational experience, the IRT lacked a full appreciation for the internal factors that bring whistleblowers to critical decisions, and brought Inspectors Bobby Boutris and Douglas Peters to the Congressional testimony table. The report does, however, acknowledge significant disclaimers that the IRT members “could only interview volunteers,” and also that they “cannot produce any statistically significant empirical evidence on prevailing attitudes or practices.” These are big admissions.

It is noteworthy that the IRT’s report, “Appendix 4: List of interviewed stakeholders,” identifies Anthony Broderick as one of the industry experts that was interviewed by the panel. Broderick is a previous FAA Associate Administrator whose “hands-off philosophy” toward air carriers was well-known, and culminated with the 1996 ValuJet tragedy.  Broderick and then-Administrator David Hinson left the agency as a result of this crash, which caused an unprecedented shake-up of the FAA. Not surprisingly, the National Transportation Safety Board (NTSB) identified “lack of FAA oversight” as a contributing factor to that crash.

An internet search reveals that Mr. Anthony Broderick is identified as a “Principal Advisor” to a company called Eclat Consulting, and IRT member J. Randolph Babbitt is listed as Chairman and Chief Executive Officer of Eclat Consulting on the Eclat website. In his IRT biographical sketch, Mr. Babbitt identified himself as a Partner in the Aviation & Aerospace section of Oliver Wyman; however, there is no mention of the Eclat relationship with Oliver Wyman.

Eclat Consulting claims, “Eclat specializes in the economics of Commercial Aviation.”  Their website also states, “We help position clients in a competitive marketplace and guide them in developing new markets or establishing policy by providing: economic, labor, financial and operational analysis; infrastructure assessment; asset valuations: and forecasts.” 

Secretary Peters was certainly responsible to know this information when commissioning her panel of experts. With the “coziness” between the air carriers and the FAA identified by Congress as a major impediment to effective FAA oversight, it appears that Peters has engaged at least one individual who “specializes in the economics of commercial aviation” for his livelihood to give her counsel on how to structure the regulatory agency that is responsible for oversight of that industry.

This conflict may partially explain the IRT’s rejection of the same two Inspector General (IG) recommendations that the FAA does not want to accept, namely; rotating inspector responsibility for assigned carriers to impede “coziness,” and establishing an independent office out of Sabatini and Ballough’s sphere of control, for inspectors to report safety problems without having to run the gauntlet of career ruin that whistleblowers endure.

It’s significant to note that Congress has also supported these two IG recommendations and has included them in their legislation; H.R.6493-Aviation Safety Enhancement Act of 2008, which passed the House unanimously on July 15, 2008.

These two actions alone would result in a more accountable FAA and in turn, a more accountable industry environment.

Without a truly independent office to handle safety complaints, there can be no real checks and balances on the demonstrated and ongoing FAA problems.

Having so enthusiastically accepted the IRT’s recommendations, Secretary Peters is overruling her own IG and turning her back on the legislation on these two critical safety recommendations.

Airworthiness Directives

Two of the IRT’s 13 recommendations (1 & 2) address ADs. The IRT has taken a fairly comprehensive look at the significance of ADs, what they are, and how they relate to the determination of airworthiness of an aircraft. They have also introduced the concept of “progress-towards-compliance audits,” designed to assist the FAA and carriers to identify and resolve discrepancies and questions in advance of required compliance dates. This is a good concept that can become a helpful practice if integrated into the carriers’ maintenance management practices.

However, the AD problem that surfaced as a result of the whistleblowers disclosures was not one of misunderstanding or AD interpretation. It was a problem of the avoidance of completing the ADs, and the lack of accountability to insure they were complied with.

The IRT report identifies the SWA PMI (Principal Maintenance Inspector) as stating, “I permitted unairworthy SWA aircraft to operate in revenue service, and I was wrong to do so. However, politically, I felt that grounding the SWA aircraft would have negative consequences for the FAA.” This admission speaks volumes. He is saying that FAA appearances and the political effect on his FAA career were more important than living up to his oath, and protecting the public from known risks. Risks known to him and SWA, but not the trusting passengers; citizens, children, and families that bought tickets for safe passage.

The IRT report states, “Safety, which is the absence of risks, is quite different from quality, which is the absence of process errors.” That being said, the IRT’s recommendation on ADs has to do with process. The missing ingredient is the accountability to take action to comply with the ADs; that is the “safety” the public has a right to expect. 

Voluntary Disclosure Programs

Five of the IRT’s 13 recommendations (3, 4, 5, 6 & 7) address Voluntary Disclosure Reporting Programs (VDRP).  The IRT conducted an extensive analysis of the value of VDRPs in today’s complex aviation operating environment.

It should be noted that the analysis overlooked the Service Difficulty Reporting (SDR) system. This program was designed to provide the carriers with a path to report difficulties they encounter during their operations that affect safety.  Unfortunately, an analysis of the SDR program shows that the FAA has been content with a low air carrier compliance rate (20% - 30%), with the program demonstrating that the FAA has a real blind eye for potentially serious trends.  Incredibly, access to the SDR program was recently taken off-line, a further demonstration of FAA intent to preserve the illusion that reported safety issues are sporadic aberrations and not systemic.

The positive value of this type of free-flowing information exchange between the regulated and the regulator cannot be overstated.  The report states, “The IRT emphatically reaffirms the value of these programs.  Equally emphatically, we reaffirm the importance of the controls designed to prevent the erosion of compliance.  For these programs to survive, and for them to operate in a healthy manner, strict and demonstrable adherence to the rules is crucial.”  Regarding the rules of the VDRP game, the IRT goes on to say, “The problem, if there is one, is in the FAA’s adherence to these rules, and not in the nature of the programs, or in the adequacy of the rules themselves.”

This is a very interesting observation, because it also applies to the FAA’s mishandling of its AD responsibilities.  So what is the problem?  The common denominator for adherence to the AD and VDRP requirements is the inspector in the field who is given the oversight responsibility for the proper conduct of these programs.  Why would FAA inspectors, who are safety experts, consistently have problems with executing these programs to the point where they finally have Congressional attention?  The FAA culture in which they must function has to be examined.  The IRT report contains considerable discussion about the culture of the FAA; however, it is the Congressional testimony of whistleblowers Boutris and Peters that hits the nail on the head, describing in the most basic and human terms the difficulties encountered operating in the current FAA culture.  This is an area where having someone with internal FAA operational experience as a member of the team would have been of great benefit to the IRT.

Air Transport Oversight System (ATOS)

Although the IRT met with several hundred inspectors at 15 different field offices who wanted to talk about ATOS, only one of the IRT’s 13 recommendations (number 13) addresses this program, although it governs the great majority of the safety inspectors’ time.  The inspectors expressed great dissatisfaction with multiple aspects of this program, which the IRT recognized, and it referenced GAO Report Number GAO-06-266T, issued in November 2005 and titled, “FAA’s Safety Oversight System Is Effective But Could Benefit From Better Evaluation of Its Programs’ Performance.”

The IRT recommended, “The FAA commission a time-and-motion study of its front line inspection operation, to empirically assess the time-demands of ATOS and other IT [information technology] implementations.”  The FAA accepted this recommendation and said, “The study will commence in March 2009 and be completed within one year.  Time frame for implementation will depend on the recommendations.”

ENOUGH!!!  The FAA has been tweaking ATOS for 10 years, through several GAO reports of its inadequacies, and the agency still can’t get it right. A time-motion study will take up further time at a point where the FAA needs a truly functional safety oversight and inspection system.  The current FAA leadership, namely Sabatini, Ballough and company have proven themselves to be incapable of this in spite of the millions of taxpayer dollars that have been poured into a program that handcuffs and impedes the inspectors’ ability to conduct their safety oversight responsibilities. In short, it is obstructive in its inherent design, and an army of inspectors is locked in irons because of its flaws.

The ATOS program needs an overhaul, not just another ineffective gimmick-ridden rewrite of computer entry codes and a coat of alumigrip paint.  The weight placed on the actual inspector’s findings needs to be increased for analysis.  As it stands, the ATOS program is nothing more than a time consuming administrative processing of information that the air carriers want the FAA to have, and the subsequent FAA rubber-stamping of that information without any verification process.  In other words, it is nothing more than an illusion of an inspection program.  A time-and-motion study will not fix this.

IRT’s Recommendations 8, 9, 10, 11, and12

These remaining recommendations are all variations on the theme of the FAA reviewing itself, recognizing and admitting its own problems, and implementing corrective actions. They amount to a mish-mash of activities that the FAA readily agrees to implement by various dates ranging from 30 December 2008 to before the end of 2010. If the FAA’s demonstrated history of program management under Sabatini is any indicator, the good ideas that are contained in these recommendations will be lost in a muddle of activities, directed by imbedded Sabatini operatives, and result in no real accomplishments.

For there to be any chance of measurable accomplishment, the FAA needs real leadership with integrity. Pseudo-leaders that throw organizational subordinates under the bus and claim that exposed problems weren’t evident at their lofty levels are not compatible with a prescription for organizational success. We’ll check back at the end of 2010.

Depressing Conclusions

There is much more that can be said about the IRT’s report; basically, it falls short of demanding accountability from FAA leadership for the poor state of affairs at the agency that put thousands of passengers at risk and caused untold economic damage to the country.

The IRT’s executive summary blatantly suggests that the 3 April Congressional hearing caused the FAA to “overreact,” and the subsequent AMR groundings were “extraordinary coincidences” that created a “perfect storm” for the FAA.  However, what is extraordinary is offering a suggestion like this to obfuscate the risk posed to thousands of passengers, and the severe disruption and economic damage caused by the FAA leadership. 

What actually happened is that Congress and the public were afforded a rare peek under the covers at the FAA’s malfeasance.  This look wasn’t provided by any of the taxpayer-funded FAA inspection or safety programs, but rather by two FAA whistleblowers who risked their careers to expose the truth.  The FAA management had been successfully suppressing whistleblowers’ attempts for years, which is why establishing an independent office to examine whistleblower complaints is so threatening to the FAA’s upper level management. 

Now that the truth has been partially exposed, the FAA damage control efforts are trying to push the blame as far down in the FAA organization as they can.  Remember Sabatini’s testimony to Congress, “These problems weren’t evident at my level.”  That’s the same vacuous defense that Ken Lay used in the Enron criminal case.  We can’t afford to accept this from Sabatini either.

The IRT did define its task as, “More forward-looking and prescriptive than backward-looking and investigative.” However, you can’t write an effective prescription without identifying and examining the source of the problem. Accountability for problems and identification of effective solutions to the problem can’t be separated. If the source of the problem is not removed, the problem persists, regardless of the prescriptions used to suppress the symptoms.

Because the FAA leadership has so pervasively corrupted the agency and its mission, the anonymity that their bureaucracy normally provides must be removed and they need to be brought out from behind the FAA logo to stand in the light of accountability. By not demanding accountability, Sabatini and company are given a “pass” on gross mismanagement and malfeasance.

The IRT has done an impressive amount of analysis, but its report only opens the book on FAA leadership’s dysfunction. There needs to be clear definitive action taken to re-establish an effective FAA presence. With all of the FAA programs that are being analyzed and tweaked, the leading source of disclosure of safety problems continues to be conscientious FAA whistleblowers.

Byline: Gabe Bruno is a retired FAA manager and is now an independent safety consultant. His 28-year FAA career included serving nine years at FAA Headquarters in Washington DC and also managing two Flight Standards District Offices (FSDOs) in the FAA’s Eastern and Southern Regions. He received numerous recognitions including Manager of the Year and Office of the Year awards during his career. He may be contacted at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it