[Senate Hearing 110-1146]
[From the U.S. Government Publishing Office]
S. Hrg. 110-1146
OVERSIGHT OF AVIATION SAFETY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY
OF THE
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
APRIL 10, 2008
__________
Printed for the use of the Committee on Commerce, Science, and
Transportation
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SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
DANIEL K. INOUYE, Hawaii, Chairman
JOHN D. ROCKEFELLER IV, West TED STEVENS, Alaska, Vice Chairman
Virginia JOHN McCAIN, Arizona
JOHN F. KERRY, Massachusetts KAY BAILEY HUTCHISON, Texas
BYRON L. DORGAN, North Dakota OLYMPIA J. SNOWE, Maine
BARBARA BOXER, California GORDON H. SMITH, Oregon
BILL NELSON, Florida JOHN ENSIGN, Nevada
MARIA CANTWELL, Washington JOHN E. SUNUNU, New Hampshire
FRANK R. LAUTENBERG, New Jersey JIM DeMINT, South Carolina
MARK PRYOR, Arkansas DAVID VITTER, Louisiana
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
CLAIRE McCASKILL, Missouri ROGER F. WICKER, Mississippi
AMY KLOBUCHAR, Minnesota
Margaret L. Cummisky, Democratic Staff Director and Chief Counsel
Lila Harper Helms, Democratic Deputy Staff Director and Policy Director
Christine D. Kurth, Republican Staff Director, and General Counsel
Paul Nagle, Republican Chief Counsel
------
SUBCOMMITTEE ON AVIATION OPERATIONS, SAFETY, AND SECURITY
JOHN D. ROCKEFELLER IV, West KAY BAILEY HUTCHISON, Texas,
Virginia, Chairman Ranking
JOHN F. KERRY, Massachusetts JOHN McCAIN, Arizona
BYRON L. DORGAN, North Dakota OLYMPIA J. SNOWE, Maine
BARBARA BOXER, California GORDON H. SMITH, Oregon
BILL NELSON, Florida JOHN ENSIGN, Nevada
MARIA CANTWELL, Washington JOHN E. SUNUNU, New Hampshire
FRANK R. LAUTENBERG, New Jersey JIM DeMINT, South Carolina
MARK PRYOR, Arkansas DAVID VITTER, Louisiana
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
CLAIRE McCASKILL, Missouri ROGER F. WICKER, Mississippi
AMY KLOBUCHAR, Minnesota
C O N T E N T S
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Page
Hearing held on April 10, 2008................................... 1
Statement of Senator Hutchison................................... 53
Prepared statement........................................... 54
Statement of Senator Inouye...................................... 57
Prepared statement........................................... 57
Statement of Senator Klobuchar................................... 68
Statement of Senator Lautenberg.................................. 62
Statement of Senator McCaskill................................... 71
Statement of Senator Rockefeller................................. 1
Prepared statement........................................... 1
Statement of Senator Snowe....................................... 65
Statement of Senator Stevens..................................... 55
Prepared statement........................................... 56
Witnesses
Barimo, Basil J., Vice President, Operations and Safety, Air
Transport Association of America, Inc.......................... 43
Prepared statement........................................... 45
Brantley, Tom, President, Professional Aviation Safety
Specialists, AFL-CIO........................................... 34
Prepared statement........................................... 35
Chealander, Hon. Steven R., Member, National Transportation
Safety Board................................................... 26
Prepared statement........................................... 27
Sabatini, Nicholas A., Associate Administrator for Aviation
Safety, FAA; accompanied by Hank Krakowski, COO, Air Traffic
Organization, FAA.............................................. 2
Prepared statement........................................... 5
Scovel III, Hon. Calvin L., Inspector General, U.S. Department of
Transportation................................................. 9
Prepared statement........................................... 11
Appendix
Casanovas, Karen E., Executive Director, Alaska Air Carriers
Association, prepared statement................................ 85
Response to written questions submitted by Hon. Daniel K. Inouye
to:
Hank Krakowski............................................... 88
Nicholas A. Sabatini......................................... 87
OVERSIGHT OF AVIATION SAFETY
----------
THURSDAY, APRIL 10, 2008
U.S. Senate,
Subcommittee on Aviation Operations, Safety, and
Security,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:19 a.m., in
room SR-253, Russell Senate Office Building, Hon. John D.
Rockefeller IV, Chairman of the Subcommittee, presiding.
OPENING STATEMENT OF HON. JOHN D. ROCKEFELLER IV,
U.S. SENATOR FROM WEST VIRGINIA
Senator Rockefeller. I apologize to everybody.
The four of us will forego our opening statements, and I
hope the others will too. I plan to make mine at some point.
But we are faced with an 11 o'clock vote, and it strikes me
that there is a very strong connection between hearing each of
the witnesses make their statements and then, in return,
ensuring that all members will have 7 minutes to question
rather than 5 minutes to question. And that is about as fair as
I can get for the moment.
So we will start out. We have Mr. Nicholas Sabatini,
Associate Administrator of Aviation Safety at FAA, and I have
some nice questions for you. Mr. Hank Krakowski, Chief
Operating Officer, Air Traffic Organization, ATO; the Honorable
Calvin Scovel, Department of Transportation Inspector General,
in other words, the IG; the Honorable Steven Chealander. Did I
say that right----
Mr. Chealander. Yes, sir.
Senator Rockefeller --of the National Transportation Safety
Board, a position which used to be held by this lady here
Senator Hutchison. And Mr. Tom Brantley, President,
Professional Aviation Safety Specialists; and Mr. Basil Barimo,
Vice President of Operations and Safety, Air Transport
Association.
[The prepared statement of Senator Rockefeller follows:]
Prepared Statement of Hon. John D. Rockefeller IV,
U.S. Senator from West Virginia
The Federal Aviation Administration's lax oversight of Southwest
Airlines has cast a serious pall over the agency's ability to execute
its core mission--the safety of the Nation's aviation systems.
It is our job today to ask, is this just an isolated incident as
some at the FAA and Southwest contend, or is this part of a larger,
systemic problem facing both the agency and the industry?
When it comes to the safety of the air traveling public, the
American people have put their trust in the men and women of the
Federal Aviation Administration and the mechanics of the commercial
airlines. They, like many of us in Congress, look to them to make sure
that the planes that take the skies are safe.
But in recent weeks, that that trust has been put to the test--
first, with the disturbing reports surrounding the lack of FAA
oversight over Southwest, and the revelations involving the FAA's
Southwest Region office.
Almost nightly, there are news stories of major commercial airlines
grounding hundreds of flights for maintenance inspections which result
in tens of thousands of frustrated and stranded passengers.
Bottom line--each passing day brings more questions, and not enough
answers. Despite the growing questions surrounding the FAA's oversight
of the airline industry, the White House and Department of
Transportation remain inexplicably silent. When the Administration
should be assembling a task force to investigate this issue and make
recommendations for improving aviation safety, the Administration seems
content to disregard the concerns of the traveling public.
The FAA has taken some steps to rebuild the public's confidence in
the agency's core mission of maintaining the safety of the Nation's
aviation system. And moving forward, the FAA needs to take a good long
look at itself to begin to understand how internal failures, and the
agency's external relationships with commercial air carriers,
contributed to current situation.
Many, including myself, have long-criticized the agency for being
too close to the industry it regulates. In 1996, to stave off efforts
to privatize the agency, Congress grudgingly accepted provisions that
would allow the FAA to operate more like a business--in the hopes that
it would cost less to operate.
Well, the FAA is not a business. It's a government agency. The FAA
does not provide commercial services. It provides public goods--air
traffic control, aircraft certification, and safety oversight. We pay
taxes for these services.
Clearly, it's time to start thinking about the FAA differently.
Toward that end, we need the FAA to operate as the most efficient and
effective government agency it can be. It's a subtle distinction, but
one that I think is incredibly, deeply important. Bringing about
institutional change is never easy, but I think that this Committee and
the aviation community must make it a priority.
The air traveling public wants solutions--and they want to be
reassured that our Nation's aviation system is still the safest in the
world.
No doubt, many of our witnesses will remind the Committee that
there has not been a fatal airline accident in almost 2 years, and that
statistically this is the safest time to fly. I don't disagree--but I
still have serious concerns that there are an increasing number of
safety challenges facing the FAA and the industry that, left
unaddressed, could lead to a catastrophic accident.
For instance, the number of serious runway incursions remains
unacceptably high and is trending in a troubling direction. We have all
read and seen stories of near misses at our Nation's airports. Let's be
honest, had it not been for the quick-thinking and actions of a few air
traffic controllers and pilots, our Nation would have had one, if not
several, major accidents claiming the lives of hundreds of people.
I don't mean to be dramatic, but I'm afraid that our aviation
system is operating on borrowed time.
Airlines take the right action 99 percent of the time when it comes
to safety. But, that's not good enough. As we all know too well, the
margins of error in aviation are far too small. It is the 1-percent
that can result in tragedy. Our incredible safety record is fragile
enough at the moment that we need to be working together to make sure
we maintain and strengthen the world's finest aviation system.
And Mr. Sabatini, we will start off with you.
Is that all right with the members?
Senator Inouye. Fine.
Senator Rockefeller. I want the panel to be able to be
finished by the time we have to go vote. Then we can come back
and we will have a select number of statements.
Please proceed.
STATEMENT OF NICHOLAS A. SABATINI, ASSOCIATE
ADMINISTRATOR FOR AVIATION SAFETY, FAA; ACCOMPANIED BY HANK
KRAKOWSKI, COO, AIR TRAFFIC ORGANIZATION, FAA
Mr. Sabatini. Good morning, Chairman Rockefeller, Chairman
Inouye, Senator Hutchison, and Senator Stevens. I appreciate
the opportunity to appear before you today to discuss some of
the FAA's many important safety initiatives and how they
contribute to extending the safest period in aviation history.
With me today is Hank Krakowski, the Chief Operating Officer of
the Air Traffic Organization at the FAA.
Let me first begin by describing how we have achieved this
unprecedented record of safety.
We did not get here by accident. We did not get here by
happenstance. We did not get here by good luck, and it is not a
miracle. We got here because of the hard work and dedication of
thousands of aviation safety professionals in the industry and
in the government, including many of the people in this room.
But while the FAA takes great pride in the fact that on-
board fatalities have dropped to a rate of about 1 fatal
accident in every 15 million passenger flights, neither Hank
nor I nor the other committed aviation safety professionals we
deal with are satisfied with these numbers.
I recently ordered a special emphasis surveillance,
essentially an audit of the safety programs, the first phase of
which was just completed. We found we had achieved 99 percent
safety compliance, but it is the other 1 percent that keeps me
up at night and it is that 1 percent we are trying to achieve.
Last week, Acting Administrator Sturgell and I announced a
five-point plan that addresses the issues of responsibility,
accountability, communication, and ethics among our workforce
to ensure that our oversight issues with Southwest Airlines are
not repeated. These initiatives will help ensure that our rules
are being followed and reemphasize to our workforce the
importance of consistency and adherence to national policy.
While the FAA has hundreds of safety initiatives ongoing at
any given moment, I would like to highlight two areas that I
know are of interest to this subcommittee: our oversight of
aircraft maintenance and our efforts to reduce runway
incursions.
As we have previously discussed with this committee, the
FAA has changed the way we oversee aircraft maintenance, moving
to the Air Transportation Oversight System, or ATOS, model,
which goes beyond simply ensuring regulatory compliance. This
oversight approach leverages FAA inspector workforce experience
and knowledge by focusing their oversight on areas that will
maximize the safety benefits. Our inspectors develop safety
surveillance plans for each air carrier based on data analysis
and adjust plans periodically based on identified risk and
their own random observations.
I am happy to report we recently completed moving all Part
121 air carriers to this oversight system.
I am also very aware of your concern with U.S. carriers
having more of their maintenance performed by repair stations
both foreign and domestic. For clarification, when an air
carrier uses a contract maintenance provider like a repair
station or an engine manufacturer to provide all or part of its
aircraft maintenance, that entity becomes an extension of the
air carrier's own maintenance organization. The air carrier
must define the scope and limitations of the outsourced work,
ensure that the personnel are competent and have the necessary
facilities and equipment to properly execute that work, and
supervise or direct the work to ensure that the work is
accomplished and meets all requirements of the air carrier's
maintenance program.
Additionally, the FAA has established a new training course
for its field maintenance inspectors and supervisors. This
course will give our entire maintenance inspector workforce the
knowledge and skills necessary to properly conduct surveillance
on contract maintenance providers. This 4-day course instructs
inspectors on how to access the data collected from the
airlines and contract maintenance providers and then use that
data to properly assess the risk or potential risk of each
contract maintenance provider used by the air carrier.
I would like to turn our discussion now to FAA's efforts to
reduce the number and severity of runway incursions which Mr.
Krakowski can address in further detail.
Runway safety starts with preventing runway incursions,
whether these mistakes are made by pilots, which is about 60
percent of the time; by controllers, about 30 percent of the
time; or by pedestrians or ground vehicle operators, about 10
percent of the time. The FAA has an aggressive runway safety
program that has reduced the number of serious runway
incursions by 55 percent since 2001. We investigate every
reported runway incursion as fully as possible and use the data
mined from these investigations to help us find the right
solutions.
The FAA has been working with aviation leaders to research
and implement these solutions. On August 15, 2007, more than 40
representatives from a cross section of the aviation industry
answered the Acting Administrator's call to action and agreed
to an ambitious plan focused on improving cockpit procedures,
airport signage and markings, air traffic procedures, and
technology.
The result is that our Nation's busiest airports are now
being equipped with runway surveillance technology that
improves controller situational awareness on the airport
movement area. For example, Runway Status Lights, which were
developed as a result of the NTSB Most Wanted List of safety
improvements, are a fully automated system that integrates
airport lighting equipment with surveillance systems to provide
a visual signal to pilots and vehicle operators when it is
unsafe to enter, cross, or begin takeoff roll on a runway. This
system is already preventing potential accidents.
Just a couple of weeks ago at Dallas-Ft. Worth, a plane was
cleared for takeoff, while at the same time air traffic control
cleared another aircraft to cross that same runway on a
taxiway. The first plane did not initiate its takeoff roll
because the pilot saw the red lights of the runway status light
system.
In addition to testing other runway safety systems at Long
Beach Airport and Spokane, Washington, we are also implementing
quick and relatively inexpensive solutions such as improving
airfield markings, adding targeted training for controllers and
air crews, and fine tuning air traffic procedures.
The FAA is also seeking input from NATCA on revamping
policies for issuing taxi clearances and working with the union
to implement a voluntary reporting system for air traffic
controllers similar to the Aviation Safety Action Program,
ASAP, with airlines, pilots, airport operators, and the FAA.
The bottom line is that we committed to designing an end-
to-end system that seeks to eliminate runway incursions while
accommodating human error. We all have a role in the solution.
Every reported runway incursion will be taken seriously,
investigated thoroughly, and analyzed to determine the causal
factors in order to apply any knowledge gleaned toward finding
the right solutions. The FAA continues to seek ways to improve
awareness, training, and technologies, and we look forward to
working together with airlines, airports, air traffic control,
pilot unions, and aerospace manufacturers to curb runway
incursions.
Mr. Chairman, the FAA's commitment to improving safety and
extending the excellent safety record we are currently
experiencing is our number one priority. I hope that some of
what I have shared with you today exemplifies that commitment.
This concludes my remarks, Mr. Chairman.
[The prepared statement of Mr. Sabatini follows:]
Prepared Statement of Nicholas A. Sabatini, Associate Administrator for
Aviation Safety, FAA; Accompanied by Hank Krakowski, COO, Air Traffic
Organization, FAA
Chairman Rockefeller, Senator Hutchison, Members of the
Subcommittee:
I am pleased to appear before you today to discuss some of the
Federal Aviation Administration's (FAA) many important safety
initiatives and how they contribute to extending this unprecedented
aviation safety record. Some people may dismiss claims like ``this is
the safest period ever'' because they have heard this claim in the
past. For at least the past 70 years, aviation safety has improved by a
third or more every decade. In fact the pace of improvement has
accelerated recently and we believe the pace of improvement will
continue to accelerate for the next decade or more.
This context is important. Over the past 5 years, onboard
fatalities have occurred at a rate of about 1 fatal accident in every
15 million passenger flights. We see no reason why that figure cannot
become one in 30 million or even one in 40 million flights within 10 or
15 years. The system's performance now is so strong that we decided
several years ago to develop a new measure to express the risk of
fatality in commercial aviation. In addition to traditional data on
fatal accidents per 100,000 flight hours or 100,000 departures, the FAA
now uses fatalities per 100 million persons flown as a basic measure of
the system's performance. This includes all fatalities, whether they
occur onboard a passenger or cargo flight, or whether they occur off
the aircraft on the airport surface or elsewhere.
To offer a sense of scale, immediately after World War II, that
measure yielded nearly 1,500 fatalities per 100 million persons flown.
By the early 1960s, the measure had improved to about 500 fatalities
per 100 million persons flown. By the mid-1990s, that measure had
fallen to about 45 fatalities per 100 million persons flown. Now, in a
typical year, we experience rates of 5 to 8 fatalities per 100 million
persons flown and we fully expect to reach long-term rates of 4 or
fewer fatalities per 100 million persons flown within the next decade.
By comparing that level of safety to where we were just 20 years ago,
or even a decade ago, we begin to get some sense of scale on how safe
the system has become--and it will only continue to get better over the
long term.
Yet, although we take great pride in the results of the efforts of
aviation safety professionals in both government and industry, we
remain ever mindful of the need to continue to push ourselves to find
ways to improve a system that, by any standard, is performing
remarkably well.
I would briefly like to put into context an incident involving
Southwest Airlines that has received a great deal of attention
recently. In March of last year, the FAA Principal Maintenance
Inspector (PMI) charged with overseeing Southwest Airlines
inappropriately, and in violation of existing FAA policy and regulatory
requirements, accepted a voluntary disclosure under the Voluntary
Disclosure Reporting Program (VDRP). The disclosure was the fact that
46 Southwest Airlines aircraft had continued flight operations past the
due date for a required inspection of the aircraft airframe for cracks.
These aircraft had overflown an Airworthiness Directive (AD) requiring
the inspection.
Despite this determination, and, again, in violation of existing
FAA policy and regulatory requirements, the airline, even after
reporting this safety violation under VDRP, did not ground these
aircraft immediately, but instead continued to operate the aircraft.
Subsequently, the airline conducted the required inspections and six
aircraft were discovered to have cracks, five of which were ultimately
determined to have the type of crack the AD was designed to detect. A
total of 1,451 commercial operations were conducted by Southwest
Airlines in violation of the law, putting thousands of passengers at
risk. That this was done with the implicit consent of the FAA PMI
overseeing the carrier is beyond my comprehension.
On March 6, 2008, the FAA issued a $10.2 million proposed civil
penalty to Southwest Airlines for its decision to knowingly continue to
operate noncompliant aircraft in commercial operations. The FAA is in
the process of taking appropriate personnel actions with respect to FAA
employees in response to the findings of the ongoing investigation of
this matter.
Last week, Acting Administrator Sturgell announced a five point
plan that addresses the issues of responsibility, accountability,
communication, and ethics. I believe these initiatives will help ensure
that our rules are being followed and reemphasize to our workforce the
importance of consistency and adherence to national policy.
Also, on March 13, 2008, to ensure that what happened with
Southwest Airlines was an isolated problem and not a systemic one, I
ordered a Special Emphasis Surveillance, the first phase of which has
just been completed. While a second, more comprehensive phase is
ongoing, our initial findings validate that our systems safety approach
of oversight is working as intended. We expect to complete the second
phase by June 30th and will continue to analyze the incoming data to
discover if and where other problems in the system exist and to
immediately correct any problems identified.
As the FAA addresses these issues of responsibility,
accountability, communication, and ethics, we also have hundreds of
safety initiatives ongoing at any given moment. As we continue to
examine the broader issue of aviation safety in this hearing, I will
focus my remarks on two areas that I know are of interest to this
Subcommittee, our oversight of aircraft maintenance and our efforts to
reduce runway incursions.
When FAA last testified before this Subcommittee on safety
oversight, we discussed how the agency has changed the way we oversee
aircraft maintenance. We moved from a paradigm where FAA's inspectors
were required to complete a prescribed number of oversight activities
to one where we used the Air Transportation Oversight System (ATOS)
model, which goes beyond simply ensuring regulatory compliance. The
goal of the oversight model is to foster a higher level of air carrier
safety using a systematic, risk-management-based process to identify
safety trends and prevent accidents. ATOS has improved safety because
it identifies and helps manage risks before they cause problems by
ensuring that carriers have safety standards built into their operating
systems.
This oversight approach leverages FAA's inspector workforce
experience and knowledge by reducing the likelihood of repeating
inspections of the same aircraft or function, unless deficiencies were
found in prior inspections of the aircraft or function. Our inspectors
develop safety surveillance plans for each air carrier based on data
analysis, and adjust plans periodically based on identified risks. For
example, with the cost of fuel increasing daily so many of our legacy
carriers are dealing with how to manage these unexpectedly large costs.
In light of this reality, FAA inspectors can adapt their surveillance
plan to increase their focus on areas that might be at risk due to
rising fuel costs, such as flight planning, dispatch, and fuel loading.
Additionally the system can be adjusted when emphasis areas need to be
addressed such as our recent efforts to review Airworthiness
Directives. I know that the Inspector General (IG) agrees with the FAA
that it is a priority that our inspectors have the tools and
information necessary to be flexible in our oversight of carriers as
their financial and operational situation changes.
I also know that the IG agrees with us that our new approach to
oversight is a better way to make the best use of agency resources as
well as to improve safety. We recently completed moving all air
carriers to this oversight system. In 2005, we committed to a
transition plan to move all remaining FAR Part 121 air carriers
operating under ATOS by the end of calendar year 2007. This was no
small undertaking. At the time we had only 16 air carriers that were
under ATOS. I am happy to report we have met this goal and that all
Part 121 carriers have made this most important transition.
Additionally, we have improved upon the original system and
successfully implemented those improvements. The initial reactions to
the modifications and improvements we have made have been extremely
positive. However, our work is not done. We must now be vigilant in
using the system to manage identified risks, and take appropriate
actions.
This change in oversight recognizes that FAA cannot be expected to
provide quality control for every airline or effectively police
millions of flights. The safety laws that Congress passes and the
regulations we implement all place the responsibility for safety on the
airlines. The FAA has regulatory oversight responsibilities to ensure
that air carriers comply with safety standards and requirements. The
FAA's role is an important one, and we see the new approach under ATOS
as providing more effective and efficient use of our resources. By
focusing on risk we can determine how well the airline is managing its
processes and whether or not the processes are performing as designed
to meet the safety standards. Our inspection tools are designed to
collect data for these purposes. Our oversight systems engage air
carriers in the management of their safety issues.
I am very aware of your concern with U.S. carriers having more of
their maintenance performed by repair stations, both foreign and
domestic. I want to clarify the roles and responsibilities of air
carriers, repair stations, and the FAA. When an air carrier uses a
contract maintenance provider (a certificated Part 145 repair station
or a non-certificated provider) to provide all or part of its aircraft
maintenance, that maintenance provider's organization becomes an
extension of the air carrier's maintenance organization. The air
carrier must define the scope and limitations of the outsourced work,
provide the applicable sections of the carrier's maintenance manual,
ensure that the personnel are competent and have the necessary
facilities and equipment to properly execute that work, and supervise
or direct the work to ensure that the work is accomplished and meets
all requirements of the air carrier's maintenance program. We are
reviewing how we could clarify how an air carrier can demonstrate that
all of its maintenance has been properly performed, regardless of
whether it is done by the carrier itself or by another entity. We may
pursue rulemaking on this issue in the near future.
Additionally, the FAA has established a new training course for its
field maintenance inspectors and supervisors. This course will give our
entire maintenance inspector workforce the knowledge and skills
necessary to properly conduct surveillance on contract maintenance
providers. This is a four-day course that instructs the inspectors how
to access the data collected from the airlines and contract maintenance
providers and then use that data to properly assess the risks or
potential risks of each contract maintenance provider used by the air
carrier.
I am confident that the changes we have made in our oversight
philosophy and the work we continue to do with input and assistance
from the aviation community, Congress, and the international community
has contributed to this historically safe period of commercial aviation
safety. Our safety oversight must keep pace with the industry as it
changes and I believe we are well positioned to accept that challenge.
Turning to another of the FAA's top priorities, I would like to
discuss FAA's efforts to reduce the number and severity of runway
incursions. Runway safety starts with preventing runway incursions,
whether these mistakes are made by pilots, controllers or ground
vehicle operators.
Recently, the National Transportation Safety Board (NTSB) and the
Government Accountability Office (GAO) have issued recommendations on
areas where the FAA could make improvements in runway safety. In
November, the NTSB announced that improving runway safety will remain
on the Board's ``Most Wanted'' list of improvements for 2008. FAA
believes that the technologies we are now testing and deploying will be
responsive to address the problem of runway incursions. Also, the GAO
reported on how the FAA has taken steps to address runway and ramp
safety. We appreciate the work that the GAO and NTSB have done, and we
welcome their analysis and feedback. The FAA has actively and
consistently invested in programs and technology development to address
this serious aviation safety issue.
An aggressive and effective FAA runway safety program has reduced
the number of serious runway incursions by 55 percent since 2001. In
Fiscal Year 2007, we saw a 25 percent reduction in serious runway
incursions from 2006: there were 24 serious runway incursions (referred
to as Category A and B incursions) during 61 million aircraft
operations, a significant reduction from the 31 incursions in FY 2006
(and the 53 incursions in FY 2001). But while we have made improvements
with the most serious categories of the runway incursions, overall
runway incursions increased in FY 2007 to 370, up from 330 in FY 2006.
While most of these incursions are Category C and D incidents, which
pose little or no risk to the public, the increase in incursions and
the fact that serious incursions are still occurring, prompted the
Acting Administrator to issue a ``Call to Action'' on runway safety
last August.
On October 1, 2007, the FAA adopted the definition of runway
incursion as used by the International Civil Aviation Organization
(ICAO), a United Nations organization charged with promoting safety and
security in international aviation. This new definition, which FAA
helped develop for ICAO, is much more inclusive and counts every single
mistake made on the airport operational surface, even if another
vehicle, pedestrian or aircraft is not involved. As a result, we will
have more data to analyze trends and improve safety.
The FAA investigates every reported runway incursion and assigns a
reason for the incursion. The investigation includes a review of the
airport information; radar data and voice tapes, if they are available;
statements from individuals involved; and, in the case of serious
incursions, we send teams to conduct on-site investigations at the
facility. There are three broad categories to which we attributed
runway incursions that happened since October 1, 2006. About 60 percent
are as a result of pilot error. Operational errors and deviations by
air traffic controllers represent about 30 percent of causes of runway
incursions. The rest are attributed to pedestrian or vehicle errors.
The FAA continues to work with aviation industry leaders to
research and implement new technologies, and mine and interpret safety
data with the focus on improving airport safety. I would like to
highlight some of our recent efforts in this area. As noted earlier, on
August 15, 2007, more than 40 representatives from a cross-section of
the aviation industry agreed to an ambitious plan focused on solutions
in improving cockpit procedures, airport signage and markings, air
traffic procedures, and technology. Within 60 days of this ``Call to
Action'' on runway safety, Acting Administrator Sturgell announced that
the aviation community had completed significant short-term actions and
were making strides in the mid- and long-term goals.
Our nation's busiest airports are now being equipped with runway
surveillance technology that improves controller situational awareness
on the airport movement area. The FAA has spent over $404 million to
date to acquire and deploy the next generation of ground surveillance
technology, known as Airport Surface Detection Equipment--Model X or
ASDE-X for short. Twelve towers in the system have ASDE-X operational,
and we have accelerated our installation schedule by 1 year--the target
completion date for the last system is now September 2010. The FAA will
commit more than $806 million over a 30-year period on equipment,
installation, operations and maintenance of the 35 ASDE-X systems.
Runway Status Lights, which were developed as a result of the
NTSB's ``Most Wanted'' list of safety improvements, are a full-
automated system that integrates airport lighting equipment with
surveillance systems to provide a visual signal to pilots and vehicle
operators when it is unsafe to enter/cross/or begin takeoff roll on a
runway. Airport surveillance sensor inputs are processed through light
control logic that command in-pavement lights to illuminate red when
there is traffic on or approaching the runway. The FAA has spent nearly
$25.8 million on this initiative.
The system is being tested at Dallas-Fort Worth and San Diego. We
have selected Los Angeles International Airport as an additional test
site and are working to select several other large airports for
continued testing of this system in ``complex'' airport environments.
The system is preventing potential accidents today. Just a couple of
weeks ago, at Dallas-Ft. Worth, a plane was cleared for take-off, while
at the same time air traffic control cleared another aircraft to cross
that same runway on a taxiway. The first plane did not initiate its
takeoff roll, because the pilot, ``saw the red lights'' of the Runway
Status Light System.
We are also testing a runway safety system at the Long Beach
Airport, known as the Final Approach Runway Occupancy Signal (FAROS).
This system is similar to Runway Status Lights in that it provides
immediate information to pilots on approach to land that the runway is
occupied or otherwise unsafe for landing. The FAROS system determines
the occupancy of the runway by detecting aircraft or vehicles on the
runway surface. If a monitored area on the runway is occupied, FAROS
activates a signal to alert the pilot that it is potentially unsafe to
land. We are developing a plan for implementing FAROS at larger
airports, and expect to begin operational trials at Dallas-Fort Worth
by the end of FY 2008.
The FAA is testing two low-cost ground surveillance systems at
Spokane, Washington, that would provide ground situational awareness to
controllers at airports other than the 35 slated to get ASDE-X systems.
To date, we have spent $4.5 million on this project and we are
assessing if it is an alternative safety measure for less busy airports
not scheduled to receive the ASDE-X system.
Twenty of the busiest airports in America were identified for
targeted Runway Safety Action Team visits based on a combination of a
history of runway incursions, wrong runway events and wrong runway risk
factors. The Runway Safety Action Team visits involved service analysis
meetings with air traffic control, both management and controllers,
safety inspectors from FAA and the airports, and airport managers and
operators. These meetings identified over 100 short term fixes that
could be accomplished within 60 days, including new or improved
signage, improved marking, driver training, and other actions. This
concerted effort is proving effective.
Not all measures to improve runway safety will involve fielding
expensive equipment and new systems. Quick and relatively inexpensive
solutions include improving airfield markings, adding targeted training
for controllers and aircrews, and fine-tuning air traffic procedures.
Incorporating the lessons learned through the meetings with the initial
20 airports, FAA has identified a second tier of 22 airports we will be
expanding this program to cover next.
Finally, the FAA is seeking input from the National Air Traffic
Controllers Association (NATCA) on revamping policies for issuing taxi
clearances. We also recently signed an agreement with NATCA to
implement a voluntary reporting system for air traffic controllers
similar to the Aviation Safety Action Program (ASAP) with airlines,
pilots, airport operators and the FAA. This type of reporting system,
which is in place throughout the industry, will help to create an
atmosphere where controllers and managers can identify, report and
correct safety issues. This will go a long way in helping us further
improve our safety record.
The FAA is committed to designing an end-to-end system that seeks
to eliminate runway incursions while accommodating human error. We all
have a role in the solution. Every reported runway incursion will be
taken seriously, investigated thoroughly, and analyzed to determine the
causal factors. The FAA continues to seek ways to improve awareness,
training, and technologies and we look forward to our collaboration
with airlines, airports, air traffic control and pilot unions, and
aerospace manufacturers to curb runway incursions. We appreciate the
Subcommittee's interest in safety, and welcome your counsel and
assistance in our efforts to reduce runway incursions and improve
safety in our Nation's aviation system.
Mr. Chairman, the FAA's commitment to improving safety and
extending the excellent safety record we are currently experiencing is
our number one priority. I hope some of what I have shared with you
today exemplifies that commitment. Of course, as I stated at the
outset, FAA is involved in hundreds of important safety initiatives and
what I have highlighted represents only a small fraction of what we are
doing and what has contributed to today's impressive safety record.
This concludes my remarks, and my colleague and I would be happy to
answer any questions the Subcommittee may have.
Senator Rockefeller. Thank you.
Mr. Krakowski, Chief Operating Officer, Air Traffic
Organization, ATO.
Mr. Krakowski. My comments were incorporated in Mr.
Sabatini's.
Senator Rockefeller. So you are the lone person speaking?
Mr. Scovel?
STATEMENT OF HON. CALVIN L. SCOVEL III, INSPECTOR GENERAL, U.S.
DEPARTMENT OF TRANSPORTATION
Mr. Scovel. Good morning, Chairman Rockefeller, Senator
Hutchison, Chairman Inouye, Vice Chairman Stevens. We
appreciate the opportunity to testify today on the key safety
challenges facing FAA and its stakeholders.
A number of high profile events, including fundamental
breakdowns in FAA oversight at Southwest Airlines, have raised
legitimate concerns about whether FAA's overall approach to
safety oversight is effective and what changes are needed. We
see three broad areas where actions need to be focused over the
next several years.
First, FAA's oversight of the aviation industry. Recent
events at Southwest Airlines brought to light serious lapses in
FAA's oversight of air carriers. For example, we found that
FAA's Southwest inspection office developed an overly
collaborative relationship with the air carrier and allowed
repeated self-disclosures of Airworthiness Directive, or AD,
violations without ensuring that the carrier had addressed the
underlying problem. The balance tipped too heavily in favor of
collaboration at the expense of oversight and appropriate
enforcement.
We also found that weaknesses in FAA's national oversight
allowed the problems at Southwest to go undetected for several
years. As early as 2003, an FAA inspector one of the
whistleblowers in this case, expressed concerns about
Southwest's compliance with ADs.
In 2006, this whistleblower urged FAA to conduct system-
wide reviews, but FAA did not begin these reviews until after
the details of the March 2007 disclosure became public. In
fact, we found that FAA inspectors had not reviewed Southwest's
system for compliance with ADs since 1999. At the time of the
Southwest disclosure, 21 key inspections had not been completed
in at least 5 years. As of March 25, 2008, FAA still had not
completed five of these required inspections; in some cases,
inspections had not been completed in nearly 8 years.
We have identified problems with FAA's national program for
risk-based oversight in the past. For example, in 2005, we
found that inspectors did not complete 26 percent of planned
inspections. Half of these were in identified risk areas. We
recommended at that time and previously in 2002, that FAA
needed to provide for greater national oversight; this is still
needed today.
Additionally, we found serious problems with FAA's
processes for conducting internal reviews and ensuring
appropriate corrective actions. FAA did not attempt to
determine the root cause of the safety issue at Southwest or
begin enforcement action against the carrier until November
2007. Too much attention was focused on the messenger and not
on solutions for legitimate safety concerns.
This also raises questions about FAA's ability to
investigate safety allegations raised by inspectors. Corrective
actions are urgently needed to strengthen FAA's oversight and
prevent similar problems from recurring. FAA took actions but
only after events became public last month.
In addition to steps underway, we recommend that FAA revise
the Voluntary Disclosure Reporting Program to ensure that air
carriers take corrective actions to address violations
identified through self-disclosures; implement a process for
second-level review of self-disclosures before accepting and
closing them; periodically transfer supervisory inspectors to
ensure reliable and objective air carrier oversight; require an
appropriate post-employment cooling-off period for inspectors;
implement a process to track field office inspections and alert
local, regional, and Headquarters offices to overdue
inspections; and establish an independent body to investigate
inspector concerns.
FAA has agreed to work with us to address our
recommendations.
The second area requiring action is runway safety. Aviation
stakeholders have expressed growing concern regarding the rise
in severe runway incidents. Recent close calls on the ground
underscore the need for proactive actions to improve runway
safety.
New technology is considered the primary solution for
improving safety in this area, but our work on the three major
FAA acquisitions for improving runway safety has shown
significant concerns as to what can be effectively deployed
within the next several years.
The uncertain timeline of FAA's runway safety technologies
underscores the need to explore other near-term solutions to
improve runway safety. These include implementing relatively
low-cost, airport-specific changes such as improving runway
signage and airport operations, reinvigorating FAA's national
plan for runway safety, and addressing human factors issues
such as fatigue and situational awareness.
The final area I will discuss is attrition in two of FAA's
critical workforces: air traffic controllers and aviation
safety inspectors. The long-expected surge in controller
retirements has begun. Since 2005, 3,300 controllers have left
the Agency, which is 23 percent more than projected. FAA has
accelerated its hiring efforts and hired 3,450 new controllers
since 2005. However, this will remain a critical issue for FAA
over the next 10 years since it must hire and train at least
17,000 new controllers through 2017.
FAA also faces challenges to its oversight mission due to
attrition in the inspector workforce. Last year, FAA's hiring
efforts kept pace with retirements, and the Agency ended the
year with 133 additional inspectors over Fiscal Year 2006
levels. However, FAA must closely oversee this effort since
nearly half of the inspector workforce will be eligible to
retire within the next 5 years.
That concludes my statement, Mr. Chairman. I would be happy
to address any questions you or members of the Subcommittee may
have.
[The prepared statement of Mr. Scovel follows:]
Prepared Statement of Hon. Calvin L. Scovel III, Inspector General,
U.S. Department of Transportation
Mr. Chairman and Members of the Subcommittee:
We appreciate the opportunity to testify today on the key safety
challenges facing the Federal Aviation Administration (FAA) and its
stakeholders. Aviation safety oversight is--and must remain--FAA's
highest priority. For more than 10 years, our work has focused on
actions needed to maintain the integrity and safety of our aviation
system. Our statement today is based on our previous reports and
investigations as well as our ongoing work.
As this Committee is aware, safety is a shared responsibility among
FAA, aircraft manufacturers, airlines, and airports. Together, all four
form a series of overlapping controls to keep the system safe. The U.S.
has achieved an impressive safety record over the past several years.
This is a remarkable feat given all the changes that have occurred
within the industry. For example, network carriers face considerable
uncertainty with a softening economy, increasing fuel prices, and
competition from low-cost carriers, who now possess one-third of the
market in terms of available passenger seats.
Network carriers have moved aggressively away from high cost
structures by reducing in-house staff, re-negotiating labor agreements,
and increasing the use of outside repair facilities. There also is
considerable discussion regarding mergers and further consolidation
within the industry.
At the same time, demand for air travel has increased and aircraft
load factors are nearly 80 percent--an all-time high. In 2007, U.S.
airlines transported over 700 million passengers and this number is
forecasted to grow to more than 1 billion by 2016.
However, a number of high-profile events, including fundamental
breakdowns in FAA oversight at Southwest Airlines (SWA), have raised
legitimate concerns about the effectiveness of FAA' s overall approach
to safety oversight and what changes are needed. These concerns have
been amplified by the fact that airlines have grounded nearly 700
aircraft since FAA began industry-wide assessments of compliance with
safety directives. There is an urgent need to assess what went wrong,
identify root causes, and proactively examine how to maintain and
ultimately enhance the margin of safety.
Mr. Chairman, it is against this backdrop that we would like to
discuss the following three key safety challenges facing FAA and its
stakeholders, as we see them:
Strengthening FAA's oversight of the aviation industry,
Improving runway safety, and
Addressing attrition within two of FAA's critical
workforces.
Strengthening FAA's Oversight of the Aviation Industry. The recent
events at SWA brought to light serious lapses in FAA's oversight of air
carriers. As this Committee knows, FAA's handling of whistleblower
concerns regarding SWA's failure to follow a critical FAA Airworthiness
Directive (AD) has had a cascading effect throughout the industry.
While the critical safety lapses indicated problems with the airline's
compliance, they are symptomatic of much deeper problems in several key
areas of FAA's oversight.
We found FAA's SWA inspection office developed an overly
collaborative relationship with the air carrier that allowed
repeated self-disclosures of AD violations through FAA's
partnership program. These programs are intended to facilitate
cooperation between FAA and air carriers to identify and
address safety issues. Yet, FAA allowed SWA to repeatedly self-
disclose AD violations without ensuring that SWA had developed
a comprehensive solution for reported safety problems--which is
required for FAA to accept the disclosure and absolve the
carrier of any penalty.
We also found that the events at SWA demonstrate weaknesses
in FAA's national program for risk-based oversight--the Air
Transportation Oversight System (ATOS). This allowed AD
compliance issues in SWA's maintenance program to go undetected
for several years. As early as 2003, one of the whistleblowers
expressed concerns to FAA about SWA's compliance with ADs. In
2006, he began urging FAA to conduct system-wide reviews, but
FAA did not begin these reviews until after the details of the
March 2007 disclosure became public. In fact, FAA inspectors
had not reviewed SWA's system for compliance with ADs since
1999. At the time of SWA's disclosure, 21 key inspections had
not been completed in at least 5 years. As of March 25, 2008,
FAA still had not completed five of these required inspections,
in some cases inspections had not been completed in nearly 8
years.
We previously identified system-wide problems with ATOS. In
2005,\1\ we found that inspectors did not complete 26 percent
of planned ATOS inspections--half of these were in identified
risk areas. We recommended, among other things, that FAA
strengthen its national oversight and accountability to ensure
consistent and timely ATOS inspections. However, FAA has still
not fully implemented our recommendations.
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\1\ OIG Report Number AV-2005-062, ``FAA Safety Oversight of an Air
Carrier Industry in Transition,'' June 3, 2005. OIG reports and
testimonies are available on our website: www.oig.dot.gov.
Our ongoing work at SWA and our 2007 audit at Northwest
Airlines (NWA) also have identified weaknesses in FAA's
processes for conducting internal reviews and ensuring
appropriate corrective actions. In the SWA case, FAA's internal
reviews found, as early as April 2007, that the principal
maintenance inspector (PMI) was complicit in allowing SWA to
continue flying aircraft in violation of the AD. Yet, FAA did
not attempt to determine the root cause of the safety issue,
nor initiate enforcement action against the carrier until
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November 2007.
We also have concerns regarding FAA' s failure to protect
employees who report safety issues from retaliation by other
FAA employees. For example, in the SWA case, after one
whistleblower voiced his concerns to FAA, an anonymous hotline
complaint was lodged against him. According to the inspection
office manager, the PMI indicated that a SWA representative
submitted the complaint. The complaint was non-specific and
never substantiated, but the whistleblower was removed from his
oversight duties for 5 months while he was being investigated.
Yet, FAA did not suspend other inspectors who were subjects of
similar complaints, including the PMI, who admitted that he
allowed SWA to continue flying in violation of the AD.
Our work at NWA found the same problem with FAA' s handling of the
inspector who reported safety concerns. As with the inspector
in the SWA case, FAA managers reassigned an experienced
inspector to office duties, after a complaint from the airline,
and restricted him from performing oversight on the carrier's
premises. At NWA, FAA's reviews of an inspector's safety
concerns were limited and overlooked key findings identified by
other inspectors. Although some of the inspector's safety
concerns were valid, FAA informed him that all of his concerns
lacked merit.
Both the SWA and NWA cases demonstrate that FAA must pursue a more
reliable internal review process and protect employees who
bring important safety issues to light.
Recently, FAA announced several actions to address the SWA safety
directive violation. These include initiating a review of AD compliance
at SWA and other air carriers. FAA also proposed to fine SWA more than
$10 million. While FAA' s actions are necessary, albeit long overdue,
the issues we have identified will require immediate and comprehensive
changes in FAA's air carrier oversight. These actions include the
following:
--Ensuring that its Voluntary Disclosure Reporting Process requires
inspectors to (a) verify that air carriers take comprehensive
actions to correct the underlying causes of violations
identified through self-disclosure programs, and (b) evaluate,
before accepting a new report of a previously disclosed
violation, whether the carrier developed and implemented a
comprehensive solution.
--Implementing a process for second level supervisory review of self-
disclosures before they are accepted and closed--acceptance
should not rest solely with one inspector.
--Periodically rotating supervisory inspectors to ensure reliable and
objective air carrier oversight.
--Revising its post-employment guidance to require a ``cooling-off ''
period before an FAA inspector is hired at an air carrier he or
she previously inspected.
--Implementing a process to track field office inspections and alert
the local, Regional, and Headquarters offices to overdue
inspections.
--Establishing an independent organization to investigate safety
issues identified by its employees.
--Developing a national review team that conducts periodic reviews of
FAA's oversight of air carriers.
FAA committed to implement these recommendations. Follow through
will be critical to demonstrate FAA's commitment to providing effective
oversight.
Our work also has shown that FAA needs to make similar improvements
in its oversight of repair stations and its risk-based system for
overseeing aircraft manufacturers' suppliers. A key issue in both cases
is that FAA's oversight was inadequate in keeping up with dynamic
changes occurring in those industries. We will continue to examine
FAA's oversight approach of the aviation industry from a national
perspective, and will keep the Committee apprised of our progress with
this review, as well as other actions FAA should take to ensure safety.
Improving Runway Safety. Aviation stakeholders are expressing
growing concerns regarding the rise in severe runway incidents. Recent
incidents such as close calls on the ground in Baltimore, Chicago, and
San Francisco, underscore the need for proactive actions to improve
runway safety. In fact, the last fatal commercial aircraft accident in
the United States (in 2006) occurred because the pilots of Comair
Flight 5191 attempted to take off from the wrong runway.
A significant threat to runway safety is runway incursions (any
incident involving an unauthorized aircraft, vehicle, or person on a
runway). Reducing the risk of runway incursions has been on the
National Transportation Safety Board's (NTSB) Most Wanted List of
Safety Improvements since the list's inception in 1990. Because runway
incursions can be caused by controllers, pilots, or ground vehicles,
responsibility for their prevention falls on all users of the National
Airspace System--FAA, airlines, and airport operators--and there are a
mix of actions needed to address this critical safety issue.
New technology is considered by many to be the primary
solution for improving runway safety but is years away from
effective deployment. Our work on three major FAA acquisitions
for improving runway safety has shown that there are
significant concerns as to what can be effectively deployed
within the next several years. For example, a key technology
for preventing runway accidents--the Airport Surface Detection
Equipment-Model-X (ASDE-X)--may not meet its cost and schedule
goals to commission all 35 systems for $549.8 million by 2011.
One of the most promising technologies on the horizon is the
Automatic Dependent Surveillance-Broadcast (ADS-B)--a
satellite-based technology that allows aircraft to broadcast
their position to other aircraft and ground systems. When
displayed in the cockpit, ADS-B information can provide a
``second set of eyes'' by including the pilot in the loop to
detect and alleviate hazardous surface situations. However, as
we testified in October,\2\ ADS-B ground infrastructure will
not be in place until 2013, and users will not be required to
equip with the needed avionics until 2020.
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\2\ OIG Testimony Number CC-2007-100, ``Challenges Facing the
Implementation of FAA's Automatic Dependent Surveillance-Broadcast
Program,'' October 17, 2007.
The uncertain timeline of FAA's runway safety technologies
underscore the need to explore other near-term solutions to
improve runway safety. We found that there are several
relatively low-cost, simple, airport-specific changes that can
help reduce the risk of runway incursions. These include
airport infrastructure changes as well as procedural changes to
---------------------------------------------------------------------------
daily airport operations.
In May 2007, we reported \3\ on runway safety efforts at four
airports that had experienced a surge in runway incursions in
2005 and 2006--Boston, Chicago, Philadelphia, and Los Angeles.
We found that airport operators at all four locations responded
to the rise in runway incursions by improving airport lighting,
adding better signage, and improving runway and taxiway
markings. This included upgrading surface-painted, hold-short
surface markings in advance of FAA's mandatory date of June
2008.
---------------------------------------------------------------------------
\3\ OIG Report Number AV-2007-050, ``Progress Has Been Made in
Reducing Runway Incursions, but Recent Incidents Underscore the Need
for Further Proactive Efforts,'' May 24, 2007.
FAA also needs to take actions to reinvigorate its national
program for runway safety. This was a key focus in 2001 when
runway incursions reached an all-time high. However, we found
that many important national initiatives for promoting runway
safety (undertaken by FAA as early as 2000) had waned as the
number of incidents declined and FAA met its overall goals for
---------------------------------------------------------------------------
reducing runway incursions.
Finally, addressing human factors issues, such as fatigue
and situational awareness, is important to improving runway
safety. Training new controllers on human factor issues as well
as technical aspects of air traffic control (such as airspace,
phraseology, and procedures) will become increasingly important
as FAA begins to address the vast influx of new controllers, as
large numbers of veteran controllers retire.
Addressing Attrition Within Two of FAA's Critical Workforces. A key
issue that will affect FAA for at least the next 10 years is addressing
attrition in two of its critical safety workforces--air traffic
controllers and aviation safety inspectors. Since 2005, 3,300
controllers have left the Agency-23 percent more than projected. FAA
has accelerated its hiring efforts and has hired 3,450 new controllers
since 2005-25 percent more than projected. Still, FAA faces a major
challenge as it must hire and train at least 17,000 new controllers
through 2017.
As a result of the high level of controller attrition, FAA
is facing a fundamental transformation in the composition of
its controller workforce. The overall percentage of
controllers-in-training has grown substantially during the past
3 years. New controllers now represent about 25 percent of the
workforce (up from 15 percent in 2004). However, that
percentage can vary extensively by location--from as little as
2 percent (e.g., Boston TRACON) to as much as 50 percent (e.g.,
Las Vegas TRACON).
A major challenge in addressing the attrition surge will be to
train new controllers to the Certified Professional Controller
(CPC) level at their assigned locations--a process that can
take up to 3 years. Training new controllers to the CPC level
is important for two reasons: (1) only CPCs are qualified to
control traffic at all positions of their assigned area, and
(2) only CPCs certified for at least 6 months (at their
assigned location) can become on-the-job training (OJT)
instructors for other new controllers. FAA must have enough OJT
instructors at all locations if it is to achieve its ambitious
hiring and training plans for the next 10 years and beyond.
FAA also is facing challenges to its oversight mission due
to attrition in its inspector workforce. FAA has about 4,100
inspectors to oversee a dynamic and rapidly changing industry,
which includes 114 commercial air carriers, almost 5,000
foreign and domestic repair stations, more than 700,000 active
pilots, and more than 1,600 approved manufacturers. Last year,
FAA's hiring efforts kept pace with retirements, and the Agency
ended the year with 133 additional inspectors compared to
Fiscal Year (FY) 2006 levels. However, FAA must continue to
closely oversee this effort since nearly half of the inspector
workforce will be eligible to retire in the next 5 years.
To maximize its limited inspector resources, FAA has been working
toward risk-based safety oversight systems for air carriers,
repair stations, and manufacturers. These systems target
inspector resources to areas of greatest risk. However, unless
FAA develops a reliable staffing model, it will not be able to
effectively use its inspectors.
I would now like to discuss these areas in further detail.
Strengthening FAA'S Oversight of the Aviation Industry
Recent Events at Southwest Airlines Underscore System-wide Weaknesses
in FAA's Oversight of Air Carriers
The recent events at SWA have exposed significant weaknesses in
FAA's oversight of air carriers and problems with its partnership
programs. The FAA directive \4\ in this case required SWA to inspect
the fuselages of its Boeing 737s for potential cracks. FAA issued this
directive after an Aloha Airlines 737 lost a major portion of its hull
while in flight at 24,000 feet in 1988, resulting in one fatality and
multiple injuries.
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\4\ FAA Airworthiness Directive 2004-18-06 requires that Boeing
737s (series 200, 300, 400, and 500) be inspected for fuselage cracks
every 4,500 cycles (1 cycle equals 1 take-off and landing) after they
reach 35,000 cycles.
---------------------------------------------------------------------------
According to FAA, when an air carrier determines that it has not
implemented an AD, it is required to immediately ground all non-
compliant aircraft. FAA inspectors share this responsibility--if an
inspector becomes aware that an air carrier has violated the terms of
an AD, the inspector is required to ensure that the aircraft are
grounded.
To meet this requirement, air carriers need a system to help them
perform repetitive inspections of aircraft fuselages in a timely
manner. However, we found that SWA did not have an adequate system to
ensure it completed these inspections. As a result, SWA operated 46
aircraft that were not inspected for fuselage cracks. These aircraft
flew in violation of the AD on more than 60,000 flights for up to 9
months. We estimate that these aircraft carried 6 million passengers
during this period.
According to SWA, it discovered it had violated this directive on
March 14, 2007. SWA notified an FAA PMI the following day. However, the
inspector did not direct SWA to ground the affected planes, and SWA
continued to operate them on 1,451 flights for 8 more days, carrying an
estimated 145,000 passengers.
The PMI permitted--and encouraged--SWA to formally self-disclose
the AD violation through its Voluntary Disclosure Reporting Program
(VDRP), which would allow the airline to avoid any penalties. FAA
accepted the self-disclosure, even though it had already accepted
multiple disclosures on AD violations--this should have prompted
concerns regarding whether underlying problems were corrected.
Once it formally self-disclosed the violation on March 19, 2007,
SWA stated that it was in compliance with the AD, meaning it had
inspected or grounded all affected aircraft. However, two FAA
inspectors (the whistleblowers in this case) reported that their
supervisor, the PMI, knowingly permitted SWA to continue flying the
identified aircraft even after SWA's self-disclosure. SWA officials
confirmed this and stated that the PMI gave them verbal permission to
continue flying the aircraft.
During our review, we found that--after SWA self-disclosed the
overflight--several of these aircraft flew into airports multiple times
where they could have received the required inspections. When SWA
finally inspected the aircraft, it found fuselage cracks in five of
them. The AD specifies that these cracks could potentially lead to
fuselage separation and rapid aircraft depressurization if left in
disrepair.
While these critical safety lapses indicate problems with SWA's
ability to comply with safety directives, they are symptomatic of much
deeper problems with FAA's oversight (the timeline below shows the
events of the SWA disclosure and FAA actions).
We found that FAA's SWA's inspection office developed an overly
collaborative relationship with the air carrier that allowed repeated
self-disclosures of AD violations through its partnership program.
Partnership programs are intended to encourage data-sharing between FAA
and air carriers to identify and address safety issues. Yet, FAA
allowed SWA to repeatedly self-disclose AD violations without ensuring
that SWA had developed a comprehensive solution for reported safety
problems--which is required for FAA to accept the disclosure and
absolve the carrier of any penalty.
However, SWA's proposed solutions, which FAA has repeatedly
accepted, have failed to solve AD compliance issues, as it has violated
four different ADs eight times since December 2006, including five in
2008. FAA's oversight in this case appears to allow, rather than
mitigate, recurring safety violations.
FAA maintains that disclosure programs are valuable, as they can
help to identify and correct safety issues that might not otherwise be
obtainable. However, we are concerned that FAA relies too heavily on
self-disclosures and promotes a pattern of excessive leniency at the
expense of effective oversight and appropriate enforcement. Further, a
partnership program that does not ensure carriers correct underlying
problems is less likely to achieve safety benefits.
Our ongoing work at another carrier has identified concerns with
employees using disclosures to avoid penalties for safety violations.
FAA must take steps to maintain the safety objective of these programs
by actively discouraging improper relationships between inspection
offices and carriers so that these programs do not lapse into an easy
amnesty path for perpetual safety violators.
We also found that the events of SWA demonstrate weaknesses in
FAA's national program for risk-based oversight--the Air Transportation
Oversight System (ATOS). This allowed AD compliance issues in SWA's
maintenance program to go undetected for several years. As early as
2003, one of the whistleblowers expressed concerns to FAA about SWA's
compliance with ADs. In 2006, he began urging FAA to conduct system-
wide reviews, but FAA did not begin these reviews until after the
details of the March 2007 disclosure became public.
In fact, FAA inspectors had not reviewed SWA's system for
compliance with ADs since 1999. At the time of the Southwest
disclosure, 21 key inspections had not been completed in at least 5
years. As of March 25, 2008, FAA still had not completed five of these
required inspections, in some cases inspections had not been completed
in nearly 8 years.
We have previously identified system-wide problems with ATOS. For
example, in 2002,\5\ we found inconsistent inspection methods across
FAA field offices for various carriers. As a result, FAA inspectors
were confused over how to conduct ATOS inspections and assess risks.
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\5\ OIG Report Number AV-2002-088, ``Air Transportation Oversight
System,'' April 8, 2002.
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In 2005,\6\ we found that inspectors did not complete 26 percent of
planned ATOS inspections--half of these were in identified risk areas.
We recommended, among other things, that FAA strengthen its national
oversight and accountability to ensure consistent and timely ATOS
inspections. However, FAA still has not fully addressed our
recommendations.
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\6\ OIG Report Number AV-2005-062, ``FAA Safety Oversight of an Air
Carrier Industry in Transition,'' June 3, 2005.
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Further, our ongoing work and our 2007 report \7\ at NWA have
identified weaknesses in FAA's processes for conducting internal
reviews, ensuring corrective actions, and protecting employees who
report safety concerns. In the SWA case, FAA's internal reviews found
as early as April 2007 that the PMI was complicit in allowing SWA to
continue flying aircraft in violation of the AD. Yet, FAA did not
attempt to determine the root cause of the safety issue, nor initiate
enforcement action against the carrier until November 2007. At NWA,
FAA's reviews of an inspector's safety concerns were limited and
overlooked key findings identified by other inspectors. Although some
of the inspector's safety concerns were valid, FAA informed him that
all of his concerns lacked merit.
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\7\ OIG Report Number AV-2007-080, ``FAA's Actions Taken To Address
Allegations of Unsafe Maintenance Practices at Northwest Airlines,''
September 28, 2007.
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We also have concerns regarding FAA's failure to protect employees
who report safety issues from retaliation by other FAA employees. For
example, in the SWA case, after one whistleblower voiced his concerns
to FAA, an anonymous hotline complaint was lodged against him.
According to the inspection office manager, the PMI indicated that a
SWA representative submitted the complaint.
The complaint was non-specific and never substantiated, but the
whistleblower was removed from his oversight duties for 5 months while
he was being investigated. Yet, FAA did not suspend other inspectors
who were subjects of similar complaints, including the PMI, who
admitted he allowed SWA to continue flying in violation of the AD.
Our work at NWA found the same problem with FAA's handling of the
inspector who reported safety concerns. As with the inspector in the
SWA case, FAA managers reassigned an experienced inspector to office
duties, following a complaint from the airline, and restricted him from
performing oversight on the carrier's premises.
Both the SWA and NWA cases demonstrate that FAA must pursue a more
reliable internal review process and protect employees that bring
important safety issues to light. Recently, FAA announced several
actions to address the SWA safety directive violation. These include
initiating a review of AD compliance at SWA and other air carriers. FAA
also proposed to fine SWA more than $10 million.
While FAA's actions are necessary, albeit long overdue, the issues
we have identified will require immediate and comprehensive changes in
FAA's air carrier oversight programs. These actions include the
following:
Ensuring that its VDRP guidance requires inspectors to (a)
verify that air carriers take comprehensive actions to correct
the underlying causes of violations identified through self-
disclosure programs, and (b) evaluate, before accepting a new
report of a previously disclosed violation, whether the carrier
developed and implemented a comprehensive solution.
Implementing a process for second level supervisory review
of self-disclosures before they are accepted and closed--
acceptance should not rest solely with one inspector.
Periodically rotating supervisory inspectors to ensure
reliable and objective air carrier oversight.
Revising its post-employment guidance to require a
``cooling-off' period when an FAA inspector is hired at an air
carrier he or she previously inspected.
Implementing a process to track field office inspections and
alert the local, Regional, and Headquarters offices to overdue
inspections.
Establishing an independent organization to investigate
safety issues identified by its employees.
Developing a national review team that conducts periodic
reviews of FAA's oversight of air carriers.
FAA committed to implement these recommendations. Follow through
will be critical to demonstrate FAA' s commitment to providing
effective oversight.
Improvements Also Are Needed in FAA's Oversight of Repair Stations and
Aircraft Manufacturers' Suppliers
As with its oversight of air carriers, our work also has shown FAA
must make similar improvements in its oversight of repair stations and
its risk-based system for overseeing aircraft manufacturers' suppliers.
A key issue in both cases is that FAA's oversight was inadequate in
keeping up with dynamic changes occurring in those industries.
Repair Stations
Air carriers have outsourced maintenance for years to both domestic
and foreign repair facilities. These facilities can complete repairs
for less cost and provide services in areas (such as engine repair)
that otherwise would require air carriers to have specialized equipment
and staff. Many air carriers outsource their engine work to the
original equipment manufacturers because of the level of expertise the
manufacturers can provide, and because the manufacturers provide
warranties for their products. However, in recent years, use of
external repair facilities has become more prominent.
As we testified before this Subcommittee in June,\8\ from 1996 to
2006, while total maintenance costs have fluctuated, air carriers
continued to increase the percentage of maintenance dollars spent on
outsourced maintenance--from 37 to 64 percent. In 2006, $3.7 billion of
the $5.7 billion spent on maintenance was outsourced (see figure 2).
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\8\ OIG Testimony Number CC-2007-076, ``Aviation Safety: FAA
Oversight of Foreign Repair Stations,'' June 20, 2007.
Neither FAA nor the Department maintains information on how much
maintenance air carriers outsource to foreign facilities, but our work
shows that the number of foreign FAA-certificated repair stations
repairing U.S. aircraft has increased from 344 in 1994 to 698 in 2007.
We have emphasized that the issue is not where maintenance is performed
but that maintenance requires effective oversight.
However, we have identified challenges in FAA's ability to
effectively monitor the increase in outsourcing. For example, in July
2003, we reported \9\ that FAA had not shifted its oversight of
aircraft maintenance to the locations where the maintenance was
performed. Although air carriers were using external repair stations to
perform more of their maintenance work, FAA still was focusing most of
its inspections on the maintenance work that air carriers performed
within their own facilities.
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\9\ OIG Report Number AV-2003-047, ``Review of Air Carriers' Use of
Aircraft Repair Stations,'' July 8, 2003.
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During the past 8 years, FAA has taken important steps to move its
safety oversight for air carriers and repair stations to risk-based
systems. FAA' s new oversight system applies to both domestic and
foreign repair stations. However, FAA cannot effectively implement a
risk-based system for oversight of aircraft maintenance if it does not
know where the maintenance is performed.
In July 2003 and again in December 2005,\10\ we reported that FAA
did not have good systems for determining which repair facilities air
carriers were using to perform their most critical maintenance. FAA
subsequently developed new inspector guidance and air carrier processes
to address this problem. However, this system does not provide FAA with
the information it needs to target inspections to where the most
maintenance is done because FAA does not require air carriers to report
these data.
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\10\ OIG Report Number AV-2006-031, ``Review of Air Carriers' Use
of Non-Certificated Repair Facilities,'' December 15, 2005.
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When carriers do report the data, FAA does not require that they
include all repair stations performing critical component repairs or
that inspectors validate the information. These efforts fall short of
providing FAA with the information it needs. FAA officials stated they
are still formulating the guidance language, however, it is unclear
whether FAA will require air carriers to report volume data for repair
stations that perform critical component repairs and require inspectors
to validate the data.
Aircraft Manufacturers' Suppliers
In February, we reported \11\ that since 1998 FAA has worked toward
implementing a risk-based oversight system for aviation manufacturers.
However, this system was implemented in FY 2003 and does not take into
account the degree to which manufactures now use suppliers to make
aviation products. FAA based the new system on historical manufacturing
business models, in which manufacturers maintain primary control over
the production of their aircraft rather than use suppliers to design
and manufacture extensive portions of aircraft.
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\11\ OIG Report Number AV-2008-026, ``Assessment of FAA's Risk-
Based System for Overseeing Aircraft Manufacturers' Suppliers,''
February 26, 2008.
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We found weaknesses throughout FAA's oversight system for
manufacturers and their suppliers. First, FAA has not ensured that
manufacturers are providing oversight of their suppliers. Manufacturers
are the first line of defense in ensuring the products used on their
aircraft meet FAA and manufacturers' standards. Yet, during the 24
months preceding our review, manufacturers had not audited 6 of the 21
critical parts suppliers we visited.
Second, FAA does not require inspectors to perform enough audits of
suppliers to determine how well manufacturers' quality assurance
systems are working. FAA's guidance for overseeing manufacturers'
quality assurance systems only requires inspectors to perform, at most,
four supplier audits, regardless of how many suppliers the manufacturer
uses.
Supplier control audits are a primary tool that FAA uses to assess
how well manufacturers' oversight systems are working. Equally
important, these audits function as a second layer of control for
preventing improperly produced parts from entering the market. However,
as shown in the table below, in each of the last 4 years, FAA has
inspected an average of 1 percent of the total suppliers used by the
five manufacturers we reviewed.
At FAA's current surveillance rate, it would take inspectors at
least 98 years to audit every supplier once. This is particularly
troubling because manufacturers are not evaluating these suppliers
frequently or comprehensively.
Third, the systemic deficiencies we identified at the 21 supplier
facilities we visited indicate that manufacturers and FAA need to
strengthen their oversight of these facilities. For example, nearly
half (43 percent) of the suppliers had deficiencies in their tool
calibration and employee training programs. Deficiencies in these areas
could impact the quality of the parts these suppliers produce.
Improving Runway Safety
From 1999 to 2001, runway incursions increased at alarming rates.
To its credit, FAA took decisive action that helped reduce these
incidents--it established regional runway safety offices, and initiated
aggressive educational programs for pilots. However, since 2003, the
number of runway incursions has begun climbing again, reaching a high
of 370 in FY 2007--a 12-percent increase over FY 2006 (see figure 3).
During the last 10 years, our work has showed that a range of
actions are needed to enhance the margin of safety on the Nation's
runways. We have identified four specific areas where FAA and other
aviation users should focus runway safety efforts.
Implementing existing and new FAA systems to alert
controllers and pilots to potential runway incursions.
Making airport-specific infrastructure and procedural
changes, such as improved runway signage and markings.
Reinvigorating FAA's national program for improving runway
safety and identifying and correcting root causes of runway
incursions.
Addressing controller human factors issues, such as fatigue
and attention, through improved training.
Implementing Existing and New FAA Systems To Improve Runway Safety
New technology is considered by many to be a key factor in the mix
of solutions for improving runway safety. However, our work on three
major FAA acquisitions for improving runway safety has shown that there
are significant concerns as to what can be effectively deployed within
the next several years. For example, a key technology for preventing
runway accidents--the Airport Surface Detection Equipment--Model X
(ASDE-X)--may not meet its cost and schedule goals to commission all 35
systems for $549.8 million by 2011.
ASDE-X is a ground surveillance system intended to alert
controllers to potential ground collisions. As of FY 2007, FAA expended
about $314 million (57 percent) and obligated about $378 million (69
percent) of the planned funding. However, FAA only deployed 11 of 35
systems for operational use.
FAA must now deploy the last 24 systems at the more complex
airports with less than half of the planned funds. We reported in
October \12\ that ASDE-X may not achieve all planned safety benefits.
These include maintaining operational capability during inclement
weather (when it is most needed) and alerting controllers to possible
collisions on intersecting runways and taxiways (``hot spots'' for
runway incursions).
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\12\ OIG Report Number AV-2008-004, ``FAA Needs To Improve ASDE-X
Management Controls to Address Cost Growth, Schedule Delays, and Safety
Risks,'' October 31, 2007.
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Another significant technology under development is Runway Status
Lights (RWSL). RWSL technology uses automated, surveillance-driven
lights that work as independent, direct warning systems to alert pilots
in departing or crossing aircraft that the runway is occupied. Lights
illuminate red when it is unsafe to cross or depart from a runway, thus
increasing the crew's situational awareness and decreasing the
potential for runway incursions caused by pilot deviations.
In January, we reported \13\ that RWSL is a viable technology for
reducing runway incursions. At Dallas-Fort Worth International Airport
(DFW), the test site for RWSL, the system met or exceeded all
performance expectations. In addition, all system users we met with
agreed that RWSL work as intended and have no known negative impact on
capacity, communication, or safety.
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\13\ OIG Report Number AV-2008-021, ``FAA's Implementation of
Runway Status Lights,'' January 14, 2008.
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However, the technology is still in the early stages of
implementation, and much work remains for FAA to achieve full
deployment. A key issue is that RWSL require ASDE-X fusion data for its
surveillance capabilities and therefore depends on the successful
deployment of that technology. In addition, RWSL have not been tested
on intersecting runways.
One of the most promising technologies on the horizon is the
Automatic Dependent Surveillance-Broadcast (ADS-B)--a satellite-based
technology that allows aircraft to broadcast their position to other
aircraft and ground systems. When displayed in the cockpit, ADS-B
information can provide a ``second set of eyes'' by including the pilot
in the loop to detect and alleviate hazardous surface situations.
In August 2007, FAA took an important step by awarding a contract
for the development and installation of the ground infrastructure for
ADS-B. However, as we testified in October,\14\ ADS-B ground
infrastructure will not be in place until 2013, and users will not be
required to equip with the needed avionics until 2020. A clear
transition path for moving forward with ADS-B with well-defined costs
and benefits does not yet exist.
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\14\ OIG Testimony Number CC-2007-100, ``Challenges Facing the
Implementation of FAA's Automatic Dependent Surveillance-Broadcast
Program,'' October 17, 2007.
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Making Airport-Specific Infrastructure and Procedural Changes
The uncertain timeline and emerging risks of FAA's runway safety
technologies underscore the need to explore other near-term solutions
to improve runway safety. We found that there are several relatively
low-cost, simple, airport-specific changes that can help reduce the
risk of runway incursions. These include airport infrastructure changes
as well as procedural changes to daily airport operations.
In May 2007, we reported \15\ on runway safety efforts at four
airports that had experienced a surge in runway incursions in 2005 and
2006--Boston, Chicago, Philadelphia, and Los Angeles. We found that
airport operators at all four locations responded to the rise in runway
incursions by improving airport lighting, adding better signage, and
improving runway and taxiway markings. This included upgrading surface-
painted, hold-short surface markings in advance of FAA' s mandatory
date of June 2008.
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\15\ OIG Report Number AV-2007-050, ``Progress Has Been Made in
Reducing Runway Incursions, but Recent Incidents Underscore the Need
for Further Proactive Efforts,'' May 24, 2007.
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Some airports also added unique signage to prevent runway
incursions. For example, at Chicago O'Hare, the airport operator added
above-ground signage near the general aviation ramp instructing general
aviation aircraft to hold and contact the ground controller before
continuing. This will help prevent general aviation pilots from
inadvertently taxiing onto an active runway.
We also found that airport operators and FAA managers made the
following procedural changes to daily operations:
Air Traffic managers adopted tools for tracking controller
performance and increased the minimum time for management to
work in the operational area.
Airport operators tightly controlled the testing of drivers
in the airfield driver certification process and imposed
punitive action for non-compliance of driver rules.
Airport operators and the FAA Runway Safety Office created
maps or brochures to highlight potentially hazardous
intersections (known as hot spots) on the airport movement
area.
Results through FY 2007 at Boston and Philadelphia show a
significant decrease in runway incursions (more than half at both
locations). However, results are not as clear at Los Angeles
International Airport (which is still completing airfield construction)
and Chicago O'Hare (which is still struggling with extremely complex
runway layouts). At Los Angeles, the number of runway incursions
remained steady but at Chicago the number increased.
While the implementation of these actions varied among airports,
they all had the potential to reduce runway incursions system-wide.
However, other than informal networking, there were no formal means for
the various users to share actions that had reduced or prevented runway
incursions at their locations.
Our recommendations included developing an automated means, such as
establishing an intranet site through the Regional Runway Safety
Offices, to share best practices for reducing runway incursions with
all users of the National Airspace System. In response, FAA implemented
a best practices website for runway safety in December 2007.
In addition, in August 2007, FAA convened a task force of pilots,
airport managers, and controllers to address runway safety issues. The
group agreed on a short-term plan to improve runway safety, which
focuses on (1) conducting safety reviews at airports based on runway
incursion and wrong runway departure data, (2) deploying improved
airport signage and markings at the 75 busiest, medium-to large-sized
airports (ahead of the June 2008 mandated deadline), and (3) reviewing
cockpit and air traffic clearance procedures.
In January 2008, FAA reported that the aviation industry has
initiated and completed significant short-term actions to improve
safety at U.S. airports. For example, safety reviews of the top 20
high-risk airports were completed, resulting in more than 100 short-
term initiatives and numerous mid- and long-term initiatives. Also, 71
of the same 75 busiest airports completed enhancements to surface
markings, and airlines committed to providing pilots with simulator
training or other realistic training for taxiing aircraft from the
terminal to the runway.
Reinvigorating FAA's National Program for Improving Runway Safety
From 1998 to 2001, we reported that runway incursions were
increasing at alarming rates. To its credit, FAA took decisive action,
and the total number of runway incursions decreased from a high of 407
in FY 2001 to a low of 323 in FY 2003. During our review at the Boston,
Chicago, Los Angeles, and Philadelphia airports, however, we found that
many important national initiatives for promoting runway safety
(undertaken by FAA as early as 2000) had waned as the number of
incidents declined and FAA met its overall goals for reducing runway
incursions.
For example, FAA established the Runway Safety Office in 2001 to
provide central oversight and accountability for implementing runway
safety initiatives throughout the Agency. However, at the time of our
review, that office had not had a permanent Director for almost 3
years. In addition, the office was reorganized and realigned twice
since FAA established the Air Traffic Organization in February 2004,
and its staff was reduced by half, including the elimination of two
Headquarters Division offices within the Office of Runway Safety.
We also found that FAA no longer prepares its National Plan for
Runway Safety, which defined the Agency's strategy and prioritized
efforts to reduce runway incursions. The last time FAA prepared this
plan was in 2002.
FAA has begun addressing many of our concerns. For example, in
August 2007, FAA hired a permanent director for its Runway Safety
Office and plans to reinstate its National Plan for Runway Safety.
Although this is a good start, sustained commitment along with adequate
resources and executive level attention will be key to achieving
results.
Addressing Controller Human Factors Issues Through Improved Training
Addressing human factors issues, such as fatigue and situational
awareness, is important to improving runway safety. In its
investigation of Comair flight 5191, the NTSB expressed concerns that
the lone controller on duty at the time of the accident had about 2
hours of sleep before his shift. As a result of its investigation at
Lexington, the NTSB added controller fatigue to its ``Most Wanted
List'' in 2007 and made two recommendations to FAA concerning
controller fatigue.
As we testified in February before the House Aviation
Subcommittee,\16\ controller staffing and training will be key watch
items during the next 10 years as FAA begins executing its plans to
hire and train 17,000 new controllers through 2017. Training new
controllers on human factor issues (such as addressing fatigue and
increasing attention) as well as technical aspects of air traffic
control (such as airspace, phraseology, and procedures) will become
increasingly important as FAA begins to address the large influx of new
controllers.
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\16\ OIG Testimony Number CC-2008-043, ``FAA's Fiscal Year 2009
Budget Request: Key Issues Facing the Agency,'' February 7, 2008.
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We also reported in May that FAA needed to focus on controller
human factors issues and training to improve individual, team, and
facility performance. In its last National Plan for Runway Safety, FAA
cited human factors and lack of controller teamwork as significant
contributing factors of runway incursions caused by controller
operational errors. However, we found that FAA had made little progress
in addressing human factors training to help reduce the risk of runway
incursions caused by controllers.
To its credit, FAA has successfully implemented an important
training initiative--increasing the use of training simulators at
towers. Tower simulators can improve overall facility performance by
reducing runway incursions through enhanced initial and proficiency
training. They provide controllers with a virtual replica of the tower
environment, which can be used to train controllers using real-life
scenarios such as day-versus-night operations, varying weather
conditions, different runway configurations, or emergency situations.
Simulators also can be used to model changes in airport
configurations and procedures. For example, Boston Logan used a tower
simulator to help establish necessary safety procedures for a newly
constructed runway. Likewise, the National Aeronautics and Space
Administration used a tower simulator to study alternatives for
improving runway safety at Los Angeles and evaluate the effectiveness
of adding a center-field taxiway between its parallel runways. FAA
recently installed tower simulators at four towers--Chicago O'Hare,
Miami, Ontario, and Phoenix. Results thus far indicate that simulators
are a valuable training tool.
FAA plans to install 12 additional simulators this year (6 at large
airports and 6 at the FAA Academy) and 12 next year (at other
airports). FAA needs to ensure that this initiative remains on track to
capitalize on the significant success this training has demonstrated.
We are reviewing several other issues concerning controller human
factors. At the request of the House Aviation Subcommittee Chairman, we
are reviewing the rate and root causes of controller training failures
(developmental controllers who fail training either at the FAA Academy
or at their assigned facility). At the request of Senator Durbin of
Illinois, we are reviewing factors that could affect controller
fatigue. We are focusing our current efforts at Chicago O'Hare Tower,
Chicago TRACON, and Chicago Center but may review other locations and
FAA's national efforts based on the results of our work at Chicago.
Addressing Attrition Within Two of FAA's Critical Workforces
A key issue that will affect FAA for at least the next 10 years is
addressing attrition in two of its critical safety workforces--air
traffic controllers and aviation safety inspectors. FAA currently is
training more new controllers than it has in the past 15 years. The
percentage of developmental controllers within the controller workforce
has increased from about 15 percent in 2004 to about 25 percent in
2007.
As a result, FAA is facing a fundamental transformation in the
composition of its controller workforce that will require improvements
in its facility training program. A critical piece for addressing
controller attrition is facility training. However, we found that FAA's
facility training program continues to be extremely decentralized and
the efficiency and quality of the training varies extensively from one
location to another. We found similar problems in 2004.
FAA also is facing substantial safety oversight challenges due to
potential attrition in its inspector workforce. FAA has about 4,100
inspectors to oversee a dynamic and rapidly changing industry, which
includes 114 commercial air carriers, almost 5,000 foreign and domestic
repair stations, more than 700,000 active pilots, and more than 1,600
approved manufacturers.
Addressing Controller Attrition Through Improvements in Facility
Training
The long-expected surge in controller attrition has begun. Since
2005, 3,300 controllers have left the Agency. The total rate of
attrition was 23 percent higher than FAA projected; however, FAA has
accelerated its hiring efforts to fill vacancies. Since 2005, FAA has
hired 3,450 new controllers-25 percent more than projected. Still, FAA
faces a major challenge as it must hire and train 17,000 new
controllers through 2017. Figure 4 shows FAA's estimates and actual
numbers for controller attrition and new controller hiring from FY 2005
through FY 2007.
As a result of the high level of controller attrition, FAA is
facing a fundamental transformation in the composition of its
controller workforce. The overall percentage of controllers in training
has grown substantially during the past 3 years. From April 2004 to
December 2007, the overall size of the controller workforce remained
constant; however, during the same period, the number of controllers in
training increased by 1,375, or 62 percent, while the total number of
CPCs, decreased by 1,302. New controllers now represent about 25
percent of the workforce (up from 15 percent in 2004). However, that
percentage can vary extensively by location--from as little as 2
percent (e.g., Boston TRACON) to as much as 50 percent (e.g., Las Vegas
TRACON).
As we testified in February,\17\ a major challenge in addressing
the attrition surge will be to train new controllers to the CPC level
at their assigned locations. Facility training can take up to 3 years
and is the most expensive part of new controller training. Training new
controllers to the CPC level is important for two reasons: (1) only
CPCs are qualified to control traffic at all positions of their
assigned area, and (2) only CPCs certified for at least 6 months (at
their assigned location) can become on-the-job training (OJT)
instructors for other new controllers. FAA must have enough OJT
instructors at all locations if it is to achieve its ambitious hiring
and training plans for the next 10 years and beyond.
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\17\ OIG Testimony CC-2008-043, ``FAA's Fiscal Year 2009 Budget
Request: Key Challenges Facing the Agency,'' February 7, 2008.
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It is important to note that new controllers who have completed
portions of training and have been certified on a position can
independently staff that position. However, controllers are not
qualified CPCs until they have certified on all positions within their
assigned area. In addition, using position-qualified controllers
extensively to staff positions can lengthen the time required for them
to become CPCs since they are not training on other new positions.
We recently completed an audit of FAA's controller facility
training program--our second review of this program since 2004.
Overall, we found that the program continues to be extremely
decentralized and the efficiency and quality of the training varies
from one location to another. We found similar problems in 2004. FAA is
taking actions at the national level to get this important program on
track, but many of FAA's efforts are still in the early stages. To
achieve its goals for the controller workforce, FAA will need to take
the following actions:
Clarify responsibility for oversight and direction of the
facility training program at the national level. Facility
training is primarily the responsibility of the Air Traffic
Organization's Vice President for Terminal Services and Vice
President for En Route and Oceanic Services. However, the Vice
President for Acquisition and Business Services oversees new
controller hiring and the FAA Academy training program, and the
Senior Vice President for Finance oversees the development of
the Controller Workforce Plan. Both have key roles in the
controller training process as well. As a result of these
overlapping responsibilities, we found there is significant
confusion at the facility level.
During our review, facility managers, training managers, and
even Headquarters officials were unable to tell us who or what
office was responsible for facility training. FAA needs to
clarify responsibility for oversight and direction of the
facility training program at the national level and communicate
those roles to facility managers.
Establish realistic standards for the level of developmental
controllers that facilities can accommodate. Given the various
sizes and complexities of FAA' s more than 300 facilities, FAA
needs to identify (by facility) how many developmental
controllers facilities can realistically accommodate. FAA must
consider several factors, such as: (1) the number of available
OJT instructors, (2) available classroom space, (3) the number
of available simulators, (4) all training requirements, and (5)
the number of recently placed new personnel already in
training.
Implement key initiatives proposed in its 2004 Controller
Workforce Plan. FAA has not implemented key initiatives to
improve facility training that it proposed in the 2004
Controller Workforce Plan. These include, ``developing,
implementing, and enforcing a policy that assigns facility
training as a priority second only to operations.'' This was to
be accomplished by ``(1) placing developmental controllers only
at facilities that had available training capacity, (2)
requiring facility managers to suspend training only for
critical operational necessities, and (3) establishing nominal
time-to-certify metrics and holding managers accountable for
achieving those targets.'' However, FAA never issued this
policy.
In addition, FAA has not comprehensively evaluated its facility
training program. In its 2004 Controller Workforce Plan, FAA
stated it would ``conduct a thorough review of facility
training to ensure it begins where the Academy ends. This
review will take into consideration other efficiency gains
identified in this plan and will result in facility training
programs tailored to meet the needs of developmental
controllers of the future.'' FAA intended for this effort to
help reduce the time it takes new controllers to become CPCs.
However, FAA never conducted the evaluation. FAA must follow
through with this evaluation and its Controller Workforce Plan
initiatives.
Addressing Inspector Attrition and Implementing Staffing Models
FAA is also facing substantial safety oversight challenges due to
potential attrition in its inspector workforce. FAA has about 4,100
inspectors to oversee a dynamic and rapidly changing industry, which
includes 114 commercial air carriers, almost 5,000 foreign and domestic
repair stations, more than 700,000 active pilots, and more than 1,600
approved manufacturers. Last year, FAA's hiring efforts kept pace with
retirements, and the Agency ended the year with 133 additional
inspectors compared to FY 2006 levels. However, FAA must continue to
closely oversee this effort since nearly half of the inspector
workforce will be eligible to retire in the next 5 years.
FAA will never have an inspector workforce that is large enough to
oversee all aspects of the industry, so it is important for the Agency
to place inspectors where they are most needed. To maximize its limited
inspector resources, FAA has been working toward risk-based safety
oversight systems for air carriers, repair stations, and manufacturers.
These systems target inspector resources to areas of greatest risk.
However, unless FAA develops a reliable staffing model, it will not be
able to effectively use its inspectors. At the direction of Congress,
the National Research Council completed a study \18\ of FAA's current
methods for allocating inspector resources in September 2006 and
recommended that FAA develop a new staffing model.
---------------------------------------------------------------------------
\18\ ``Staffing Standards for Aviation Safety Inspectors,''
September 20, 2006.
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It has been more than 1 year since the Council study, and FAA is
still in the early stages of developing a new staffing method. FAA has
established an interim target date to assess current staffing methods
and begin identifying the elements of the next generation staffing tool
by September 2008.
FAA recently finalized milestones to develop and implement the new
model and plans to begin using it by October 2009. Making measurable
progress toward a new staffing model is a key watch item, and we will
continue to monitor this important initiative.
That concludes my statement, Mr. Chairman, I would be happy to
address any questions you or other Members of the Subcommittee may
have.
Senator Rockefeller. Thank you very much.
And now Mr. Chealander.
STATEMENT OF HON. STEVEN R. CHEALANDER, MEMBER, NATIONAL
TRANSPORTATION SAFETY BOARD
Mr. Chealander. Thank you and good morning, Chairman
Rockefeller, Ranking Member Hutchison, Chairman Inouye, and
Vice Chairman Stevens. Thank you for allowing me the
opportunity to present testimony on behalf of the National
Transportation Safety Board.
Let me begin by discussing runway safety and, in
particular, runway incursions and excursions because of the
number and potential seriousness of these events.
Improper or misunderstood instructions, human error,
continues to place aircraft vehicles and their passengers in
danger despite ongoing improvements. As an example of human
error, the world's deadliest runway incursion, which remains
the world's deadliest aviation accident, occurred in March
1977, and 583 lives were lost in a collision between two jumbo
jets on a runway at Tenerife in the Canary Islands. Human
error.
Since October 1, 2007, all surface incidents are being
classified as runway incursions. From January 2007 through
March 31st of 2008, 441 runway incursions were reported. More
importantly, since October of 2007, there have been 15 A or B
categorized incursions, which are the most serious. This is
more than double the amount during the same time last year.
In July 2000, the Safety Board made recommendations to
address the issue of providing direct warning to flight crews.
This direct warning is crucial because it gives both flight
crews and controllers increased time to react. Until a system
is in place that provides direct warning to pilots, the
potential for this type of a disaster will continue to be high.
Since 2005, the FAA has been conducting field tests on
Runway Status Lights at the Dallas-Fort Worth and San Diego
airports. Initial test results have been promising and the FAA
is extending these tests to more complex airports such as
Boston, Chicago O'Hare, and Los Angeles International.
The FAA's NPRM on Automatic Dependent Surveillance
Broadcasts, better known as ADS-B, published in 2007 mandates
all aircraft be equipped with ADS-B Out although not until the
year 2020. Moreover, the FAA does not plan to mandate ADS-B In
at all. For ADS-B to provide the maximum safety benefit, the
system should support both ADS-B Out and ADS-B In. ADS-B In
provides surface conflict warnings directly to pilots in the
cockpit while ADS-B Out provides basic aircraft separation
information.
The Safety Board is encouraged by the FAA's progress in
areas such as lighting and improved signage at airports.
However, implementation of other technologies has been slow.
In 2000, the Safety Board recommended that all runway
crossings be authorized only by specific air traffic control
clearance and that controllers issue a takeoff clearance only
after the previous runway has been crossed. Yet, the FAA has
not implemented either procedural change. If those procedures
had been implemented, the Comair accident in Lexington,
Kentucky, which claimed 49 lives, may not have occurred.
The Safety Board also investigated several runway
excursions, including an accident involving a Southwest Boeing
737 that killed one person at Chicago's Midway Airport in 2005.
The Safety Board has been focusing on FAA oversight and
surveillance of operators and aircraft maintenance for over 20
years.
For example, in the Alaska Airlines Flight 261 accident off
the coast of California with 88 fatalities, FAA oversight of
the carrier's maintenance program was an issue.
In the Chalk's Ocean Airways Flight 101 accident in Miami
Florida, with 20 fatalities, FAA oversight of the carrier's
maintenance program was an issue.
Additionally, American Airlines Flight 1420 accident in
Little Rock, Arkansas, which claimed 11 fatalities, is an
example of an issue with operations oversight.
The Safety Board has examined FAA oversight during all of
its accident investigations. For instance, in the past 10
years, the Board has issued 29 recommendations on maintenance
activities alone.
That concludes my testimony. Thank you for the opportunity.
I would be happy to answer any questions you may have.
[The prepared statement of Mr. Chealander follows:]
Prepared Statement of Hon. Steven R. Chealander, Member,
National Transportation Safety Board
Good morning, Chairman Rockefeller and Ranking Member Hutchison.
Thank you for allowing me the opportunity to present testimony on
behalf of the National Transportation Safety Board. I am privileged to
represent an agency that is dedicated to the safety of the traveling
public.
As you know, the Safety Board is charged with investigating
aviation incidents and accidents, determining their probable cause, and
making recommendations to prevent similar accidents from happening
again. The Board is concerned about key safety issues including: runway
incursions, runway excursions, icing conditions, fuel tank inerting,
human fatigue, and maintenance of aircraft.
The world's deadliest runway incursion accident, which remains the
world's deadliest aviation accident, occurred in March 1977 when two
passenger jumbo jets collided on a runway at Tenerife, Canary Islands,
causing the deaths of 583 passengers and crew. The deadliest U.S.
runway incursion accident involving two aircraft was a collision
between a USAir 737 and a Skywest Metroliner commuter airplane at Los
Angeles International Airport (LAX) in February 1991, which killed 34
people. Another accident, involving a Comair Bombardier CL600 that
departed the wrong runway on August 27, 2006, killed 49 people in
Lexington, Kentucky. The Safety Board has also investigated several
other runway excursions including the accident involving a Southwest
Boeing 737 that killed one person at Chicago's Midway Airport.
Runway Incursions
On October 1, 2007, the Federal Aviation Administration (FAA)
adopted the International Civil Aviation Organization's definition of
runway incursion. Prior to that date, the FAA classified events that
did not result in a loss of required separation as ``surface
incidents,'' not incursions. Incursions required a loss of separation
with another aircraft, person, object, or vehicle. Since October 1,
however, all surface incidents are now classified as runway incursions
and are categorized based on the severity of the incident. Category A
and B incursions represent the highest likelihood of a collision. From
January 2007 through March 31, 2008, 441 runway incursions were
reported, with 15 of those classified as a category A or B. That's more
than twice as many as were reported during the same time last year (7).
Between May and October 2007, the Safety Board investigated seven
serious runway incursions involving 792 people onboard those airplanes.
Most notably, in May 2007, there was a runway incursion that occurred
about 1:30 in the afternoon at San Francisco International Airport
involving a Republic Airlines Embraer 170 and a Skywest Embraer 120
Brazilia. These two aircraft, carrying 92 people, nearly collided in
the intersection of runways 1 left (L) and 28 right (R). The tower
controller forgot about Skywest when he cleared Republic for takeoff
from an intersecting runway. Skywest came to a stop in the runway
intersection and Republic lifted off and overflew Skywest by about 35
feet. Another incident occurred on July 11, 2007 at about 2:30 in the
afternoon when a United Airbus A320 and a Delta Airlines Boeing 757
almost collided in the intersection of runway 9L and taxiway M at the
Fort Lauderdale-Hollywood Airport, Florida. Delta was inbound for
landing on runway 9L and United was taxiing for departure on the same
runway. The United crew missed a turn, and was heading toward the
runway when the tower controllers told United to stop and Delta to go
around. Although Delta touched down briefly, the crew was able to
initiate a go-around and a collision was averted by less than 100 feet.
Alert controllers and quick actions by the crews saved 307 people from
a catastrophic accident. Incursions occur because both pilots and
controllers make mistakes. Improper or misunderstood instructions
continue to place aircraft, vehicles, and their passengers in danger--
despite improved signage, more visible painted runway markings, ongoing
safety briefings and seminars for controllers and pilots, and
informational brochures. The reason is simple and complex--human error.
Pilots may misunderstand a clearance or read it back incorrectly and
controllers fail to catch the error. Pilots may take a wrong turn when
they are taxiing. Controllers may clear an aircraft to take off or land
on a runway already occupied by a vehicle or another aircraft.
There isn't any one single solution that will eliminate the problem
of runway incursions. In July 2000, the Safety Board made
recommendations to attack the issue in a variety of ways, including
procedural changes, educational efforts, and technology improvements
that provide a direct warning to the flight crews. This direct warning
is crucial because it gives both controllers and those operating the
aircraft increased time to react. Information needs to be provided
directly to the flight crews as expeditiously as possible to prevent
runway accidents. The issue is one of reaction time. Safety Board
investigations have found that AMASS/ASDE-X are not adequate to prevent
serious runway collisions, because too much time is lost routing
valuable information through air traffic control. After an alert, the
controller must determine the nature of the problem, determine the
location, identify the aircraft involved, and determine what action to
take. Only after all of these determinations have been made can
appropriate warnings or instructions be issued. The flight crew must
then respond to the situation and take action. Simulations of AMASS
performance using data from actual incursions show that alerts may
occur as little as 8 to 11 seconds before a potential collision. In
recent incidents, AMASS did not alert controllers in time to be
effective, and the situations were instead resolved by flight crew-
initiated actions. An example of this was the San Francisco accident
previously mentioned. Until there is a system in place to control
ground movements of all aircraft with direct warning to pilots, the
potential for this type of disaster will continue to be high.
Since 2005, the FAA has been conducting field tests of Runway
Status Lights at the Dallas/Fort Worth International Airport and San
Diego International Airport since 2006. Red lights activated on the
runway when an aircraft was taking off, landing, or crossing an active
runway giving information directly to the pilots. Initial test results
have been promising and the FAA is extending those tests to more
complex airports such as Boston, Chicago O'Hare and Los Angeles
International Airports. The FAA is also testing final approach runway
occupancy signals that alert pilots on final approach when the runway
is occupied. It is also reviewing a flight deck-based direct warning
system. The Safety Board has provided favorable assessments of that
technology.
Although the Board has been encouraged by the recent progress, it
has been over 7 years since these recommendations were issued. Yet it
has been only in the past few years that the FAA has started evaluating
technologies that provide direct warnings to the cockpit. Further,
while these technologies may offer added safety, they are many years
away from possible national implementation.
Additionally, since 2007, the FAA has stated that ADS-B (Automatic
Dependent Surveillance-Broadcast) would mitigate the number and
severity of runway incursions. On September 9, 2005, the FAA officially
committed to establishing ADS-B as the basis for air traffic control in
the future. On October 5, 2007, the FAA published a Notice of Proposed
Rulemaking (NPRM) that proposed performance requirements for certain
avionics equipment on aircraft to facilitate the use of ADS-B.
According to the NPRM, ADS-B will be available nationwide in 2013 for
aircraft surveillance by FAA and Department of Defense air traffic
controllers. ADS-B will be very beneficial for expanding surveillance
coverage to areas of the United States that are not covered now, such
as the Gulf of Mexico, Hawaii, and Alaska. However, in order for ADS-B
to provide maximum safety benefits, the system should support both ADS-
B Out and ADS-B In. ADS-B Out provides basic aircraft information
(location, altitude, etc.) to air traffic controllers in order to
provide traffic separation. ADS-B In would permit users to use
additional services such as obtaining datalinked weather and traffic
information, and would also provide a means of transmitting surface
conflict warnings directly to pilots via the ADS-B In communications
link. However, the NPRM states that aircraft are not required to be
equipped with ADS-B Out until 2020 and the FAA will not mandate ADS-B
In at this time because, according to the NPRM, it ``has not been
identified as a requirement for maintaining the safety and efficiency
of National Airspace System (NAS) operations.'' The NPRM further states
that operators may equip their aircraft with ADS-B In ``if they so
choose.''
The Safety Board is disappointed that this NPRM does not require
ADS-B In which would be instrumental in providing additional safety
information that would prevent incidents such as runway incursions. All
of the runway incursion prevention technology being developed and
tested by the FAA that would give a direct warning to the cockpit, such
as Runway Status Lights and the final approach occupancy signal, and
ADS-B are years from being installed and they will not be installed at
all airports with passenger service. The Safety Board believes that the
ability of ADS-B In to support data sharing between aircraft and
controllers would be a major contributor to improved situational
awareness and would reduce the likelihood of both airborne and surface
conflicts.
Actions Remaining
The FAA has made progress with lighting and improved signage at
airports, but some basic improvements in air traffic control procedures
are needed. In July 2000, the Safety Board recommended that all runway
crossings be authorized only by specific air traffic control clearance
and that controllers issue a takeoff clearance only after the previous
runway has been crossed. Both of those recommendations are contained in
the Manual on the Prevention of Runway Incursions prepared by the
International Civil Aviation Authority and is the guidance material
used internationally for implementing national or local runway safety
programs. Yet, the FAA has not implemented either procedural change. If
those procedures had been implemented, the Comair accident in
Lexington, Kentucky may not have occurred.
The Safety Board supports the use of ADS-B and believes that ADS-B
Out will provide a safety benefit in the NAS in areas without
sufficient radar coverage. However, the adoption of ADS-B In, direct
delivery of warnings to aircraft pilots via datalink, and recommended
procedural changes will increase the level of safety during ground
operations and should be expeditiously incorporated in the FAA's
development planning.
Runway Excursions
Recent accidents, such as the December 2005 Southwest Airlines
runway excursion at Midway Airport, indicated that the Safety Board
should broaden its runway safety efforts to include runway excursions.
Over the last 10 years, 73 accidents involving turbine-engined aircraft
were reported resulting in 15 fatalities. Runway excursions only need
to be reported to the Safety Board if there was substantial damage to
the airplane, serious injury to a person, or if an emergency evacuation
was required, so there are most likely additional excursions during
this period that we are not aware of.
Landing distance calculations are critical to flight safety,
especially when runway conditions limit braking effectiveness. As a
result of the Southwest Airlines accident, the Safety Board issued an
urgent recommendation on January 27, 2006, asking the FAA to prohibit
operators from using reverse thrust credit in landing performance
calculations to ensure adequate landing safety margins on contaminated
runways. The FAA responded that it would issue an Operations
Specification that would establish mandatory actions by aircraft
operators and meet the intent of the recommendation; however, it
subsequently decided to issue only a Safety Alert For Operators (SAFO).
SAFOs are not regulatory and compliance is therefore voluntary.
On October 4, 2007, the Safety Board superceded the previous urgent
recommendation, issuing a new recommendation asking that the FAA
require crews to make a landing distance assessment with an adequate
safety margin for every landing. To date the FAA has not made this a
requirement.
In the U.S. during the last 2 years, there were five runway
excursion accidents involving turbine-powered aircraft, resulting in
one fatality. However, these events involved 247 other crewmembers,
passengers, or people on the ground who happened to be in the area when
the excursions occurred. The NAS cannot continue to depend on the last
minute alertness of pilots and controllers, whose actions have helped
avoid several runway incidents that could have been catastrophic. We
need the extra protection of additional procedures and advanced
technology to compensate for human mistakes.
Action Remaining
Require operators to conduct arrival landing distance
assessments before every landing based on existing performance
data, actual conditions, and incorporating a minimum safety
margin of fifteen percent.
Reduce Dangers to Aircraft Flying in Icing Conditions
The 1994, in-flight icing encounter and subsequent loss of control
and crash of a commuter airliner in Roselawn, Indiana, which claimed 68
lives, prompted the Safety Board to examine the issue of airframe
structural icing and conclude that the icing certification process has
been inadequate because the process has not required manufacturers to
demonstrate the airplane's flight handling and stall characteristics
under a realistic range of adverse ice accretion/flight-handling
conditions. The FAA did not have a systematic and proactive approach to
the certification and operational issues of turbine-engine-driven
transport-category airplane icing.
The consequences of operating an airplane in icing conditions
without first having thoroughly demonstrated adequate handling/
controllability characteristics in those conditions are sufficiently
severe that they warrant a thorough certification test program,
including application of revised standards to airplanes currently
certificated for flight in icing conditions.
As a result of the Roselawn accident, the Safety Board called on
the FAA to revise the icing criteria and icing testing requirements
necessary for an airplane design to be approved within the United
States, and the operational requirements that specify under what icing
conditions it is permissible to operate an aircraft.
On July 25, 2007, the FAA issued a final rule titled ``Airplane
Performance and Handling Qualities in Icing Conditions,'' which became
effective October 9, 2007. On September 10, 2007, the FAA issued
Advisory Circular (AC) 25-25, ``Performance and Handling
Characteristics in the Icing Conditions Specified in Part 25, Appendix
C.'' The AC provides detailed guidance on acceptable means of
compliance with the new requirements. These actions were responsive to
some aspects of the recommendations from the Roselawn accident. The FAA
still needs to take the following actions:
Revise Part 121, applicable to airplanes with takeoff
weights less than 60,000 pounds, to address when to activate
the ice protection system and when the flight crew should exit
icing conditions.
Develop Part 25 rules that include requirements to
demonstrate that an airplane can safely operate in certain
super-cooled large drop (SLD) conditions for an unrestricted
time or can detect SLD and enable the flight crew to exit icing
conditions; and
Development of similar Part 23 rules after completing the
Part 25 rulemaking.
The ARAC is still working on regulations concerning SLD and mixed-
phase icing for both Part 25 and Part 23. The Safety Board has learned
of FAA activities in response to recommendations concerning icing
issued as a result of the February 16, 2005, crash of a Cessna Citation
560 during approach to landing in icing conditions at Pueblo, Colorado.
This accident occurred in SLD conditions, and FAA and Cessna flight
testing in response to the investigation used procedures and tests
suggested by the ARAC to analyze airplane handling characteristics in
SLD conditions. This suggests that the FAA may be near developing and
issuing regulations concerning SLD. However, the FAA has not provided
any projected dates for development and issuance of an NPRM and final
rule. The pace of the FAA's activities in response to these
recommendations remains unacceptably slow, despite recent encouraging
action.
Actions Remaining
Complete efforts to revise icing certification criteria,
testing requirements, and restrictions on operations in icing
conditions; and
Evaluate all aircraft certified for flight in icing
conditions using the new criteria and standards.
Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on Transport-category
Aircraft
Center wing fuel tank explosions have resulted in 346 fatalities.
Operating transport-category airplanes with flammable fuel/air vapors
in fuel tanks presents an avoidable risk of explosion. A fuel tank
design and certification philosophy that relies solely on the
elimination of all ignition sources, while accepting the existence of
fuel tank flammability, is fundamentally flawed because experience has
demonstrated that all possible ignition sources cannot be predicted and
reliably eliminated. As a result of the TWA Flight 800 accident that
occurred in July 1996, the Safety Board asked the FAA to develop and
implement both long-term and short-term solutions to the fuel tank
issue. Previously, fuel tank explosions occurred somewhere in the world
approximately once every 52 months, but two explosions in the last 3
years have changed the average for the worse. In the 10 years since the
TWA flight 800 accident, there have been three additional fuel tank
explosions, illustrating the continuing need for reforms in this area.
In response to the long-term solution preventing flammable fuel/air
vapors in fuel tanks the FAA commissioned the ARAC to evaluate design
modifications, such as inerting, that would satisfy this
recommendation. In its July 1998 final report, the ARAC concluded that
inerting would achieve this goal, but at a cost of over $20 billion.
The ARAC also concluded that inerting systems would be very difficult
to retrofit into existing airplanes and recommended that the FAA
continue to investigate a more cost-effective approach to reducing
explosive vapors. A 2001 follow up study also concluded that the
benefit of inerting could not be reasonably balanced by its cost. In
May 2002, in contrast to the ARAC's reports, the FAA developed a
prototype inerting system that required no moving parts, weighed less
than 200 pounds, and could be retrofitted into existing airplanes at a
fraction of the industry-estimated cost: the cost of this prototype
system was only $100,000. The system has been flight tested by the FAA,
NASA, Boeing, and Airbus, and the results indicate that fuel tank
inerting is both practical and effective.
Although 11 years have passed since this recommendation was issued,
the FAA's recent actions indicate positive movement, particularly in
the development of a practical fuel tank inerting system. Boeing is
making a flammability reduction system a basic feature in the design of
the new 787 Dreamliner aircraft. Boeing has also designed a
flammability reduction system and delivered these systems on production
models of the 747 and 737 NG. Although the first B-737 equipped with a
flammability reduction system was delivered on December 8, 2005, to
Southwest Airlines, this system is an option, and many 737's currently
being delivered are not equipped with this system. The next design to
receive a flammability reduction system will be the B-777.
The FAA has developed a final rule to do some, but not all, of what
the Safety Board has recommended. The proposed final rule is somewhat
controversial and received close scrutiny from OST and OMB. The latest
word is that OMB's review of the final rule will be completed by May
2008.
Action Remaining
Complete rulemaking efforts to preclude the operation of
transport-category airplanes with flammable fuel/air vapors in
the fuel tank on all aircraft.
Cockpit and Flight Data Recorders/Require Cockpit Video Recorders
Flight recorders have proven themselves invaluable in providing
crucial information during accident and incident investigations. Last
month, the FAA issued a final rule, titled ``Revisions to Cockpit Voice
Recorder and Digital flight Data Recorder Regulations.'' The Board was
pleased to see that all larger passenger airliners will be required to
carry 2-hour cockpit voice recorders (CVRs), greatly expanding the
current 30-minute requirement. But the rule stopped short of what the
Board has recommended by not requiring that older 30-minute CVRs be
replaced on existing commuter and corporate jet aircraft. The FAA did
require that newly manufactured commuter and corporate jets come
equipped with 2-hour CVRs.
The Board had asked that airliners be retrofitted with cockpit
voice recorders that had an emergency 10-minute power supply in case of
an electrical interruption, such as occurred on ValuJet Flight 592 in
1996 and Swiss Air Flight 111 in 1999. The FAA rule will require that
newly manufactured airliners be so equipped, but declined to require
retrofits again as recommended by the Board. The Board also called for
certain configurations of microphones and dedicated channels in
airliner cockpits, and for dual combination recorders, one in the front
and one in the back of the plane, however those items are not addressed
in the new rule. The FAA also did not address the Board's
recommendations concerning cockpit video recorders.
The new rule calls for increased flight control position sampling
rates on flight recorders, which should improve the quality of data
available to investigators. Improvements in flight recorders has been
on the Board's list of Most Wanted Safety Improvements since 1999.
Reduce Accidents and Incidents Caused by Human Fatigue
The Safety Board has long been concerned about the issue of
operator fatigue in transportation and has stressed its concerns in
investigation reports issued throughout the 1970s and 1980s. In 1989,
the Board issued three recommendations to the Secretary of
Transportation calling for research, education, and revisions to
existing regulations. These recommendations were added to the Board's
Most Wanted list in 1990, and the issue of fatigue has remained on the
Most Wanted list since then. The Safety Board's 1999 safety study of
DOT efforts to address operator fatigue continued to show that this
problem was widespread. Operating a vehicle without the operator's
having adequate rest, in any mode of transportation, presents an
unnecessary risk to the traveling public. The laws, rules, and
regulations governing this aspect of transportation safety are archaic
in many cases and are not adequate to address the problem.
Flight Crews
In December 1995, the FAA issued an NPRM to update the flight and
duty regulations for airline pilots; however, in the intervening 12
years, the regulations have not been revised. The FAA has attempted on
three occasions to reach consensus with the industry on a proposed rule
but has not succeeded. FAA's ARAC upon reviewing Part 135 regulations
has recently made some recommendations to simplify and improve the duty
time regulations for flight crews covered by Part 135. The FAA recently
advised the Safety Board that it is developing an NPRM that
incorporates the ARAC's recommendations; the NPRM will include a
fatigue risk management system that provides an alternative to
prescriptive limitations.
The Safety Board recommended 14 years ago that the FAA close a
loophole in the regulations regarding hours of duty for flight crews
that allowed crews to be on duty flying for much longer periods of time
than allowed under Part 121 or Part 135. The 1995 NPRM proposed
revisions that were responsive, however, those revisions resulted in
considerable controversy and the FAA withdrew the NPRM. The Safety
Board's concern that flight crew fatigue is a significant aviation
safety issue continues today, yet little or no action has been taken by
the FAA and they have not indicated any firm plans to take the
recommended action.
Maintenance Personnel
In 1999, the FAA issued a report entitled Study of Fatigue Factors
Affecting Human Performance in Aviation Maintenance. The FAA completed
the first phase of the expanded study and issued a report in April 2000
entitled Evaluation of Aviation Maintenance Working Environments,
Fatigue, and Maintenance Errors/Accidents. The expanded study looked at
multiple and combined environmental factors of temperature, noise,
light, vibration, and sleep, which are known to accelerate fatigue
onset, as well as the effects of lifestyle habits on fatigue and human
performance. The study was designed to collect data in the aviation
maintenance work environment on known factors that affect human fatigue
and performance. The data were intended for use in predicting
situations that are conducive to fatigue, accidents, incidents and
errors.
The FAA's findings suggest that fatigue is an issue in this
workforce. Data from ``mini-logger monitors'' that recorded data from
the selected parameters of light, noise levels, and temperature;
activity monitors that monitored physical activity, sleep, and sleep
quality; and the answers to background questions that employees were
asked clearly indicate that sleep durations are inadequate to prevent
fatigue. For most aviation maintenance technician specialties, 30-40
percent of respondents reported sleep durations of less than 6 hours,
and 25 percent of respondents reported feeling fatigued or exhausted.
The DOT stated that the findings of its studies indicate that the
extreme complexity of the issue of maintenance crew fatigue and duty
time do not present appropriate material for regulatory activity, and
education and training in fatigue management are the most appropriate
actions for the FAA to sponsor and foster. The FAA has consequently
conducted education and training activities on fatigue management for
aircraft maintenance personnel. The Safety Board reviewed Advisory
Circular (AC) 120-72, ``Maintenance Resource Management (MRM)
Training,'' which seems to be the primary focus of the FAA's education
and training initiatives related to fatigue among aviation maintenance
crews. We found little in AC 120-72 that provides guidance on human
fatigue in maintenance crews other than generalized warnings that
attention to fatigue is important and should be considered in MRM
Training. AC 120-72 contains little guidance as to how an employer
should design a program to ensure that maintenance crews are not
fatigued. In addition, the website referenced in the reports to
Congress (http://hfskyway.faa.gov) is in fact nothing more than a
single page with a very general description of the FAA's aviation
maintenance human factors research program. It contains no useful
information to educate and train someone in the aviation community on
the issues of fatigue management in aircraft maintenance personnel.
The Safety Board disagrees that regulating hours of service for
aviation maintenance crews is not appropriate. In addition, the Board's
reviews of the FAA's education activities related to reducing fatigue
among maintenance crews shows them to be limited and of questionable
value.
Air Traffic Controllers
In 2007, the Safety Board issued recommendations to the FAA and the
National Air Traffic Controllers Association regarding air traffic
controller fatigue. The Safety Board had investigated four incidents
that provided clear and compelling evidence that controllers are
sometimes operating in a state of fatigue because of their work
schedules and poorly managed utilization of rest periods between shifts
and that fatigue has contributed to controller errors. Controller
fatigue decreases aviation safety. FAA policies and controllers' off-
duty habits can contribute to the problem. Although the FAA and other
organizations have conducted a great deal of research on this issue
resulting in an improved scientific understanding of the causes of
fatigue, its effects on controller performance, and strategies for
reducing controller fatigue, the FAA has been slow to change
controller-scheduling practices.
The FAA has convened a working group to develop shift rotation and
scheduling guidelines, and it is our understanding that last month the
National Air Traffic Controllers Association (NATCA) provided
information on fatigue and scheduling practices. The FAA plans to
develop and implement a fatigue awareness and countermeasures training
program to be used by all FAA Air Traffic Organization operational
service units. NATCA has informed the FAA and the Safety Board of its
eagerness to participate in this group, and indicated its commitment to
developing workable scheduling practices that minimize controller
impairment due to fatigue.
Action Remaining
Issue regulations that establish scientifically based duty
time limitations for air carrier maintenance personnel and
flightcrews.
Develop a fatigue awareness and countermeasures training
program for controllers and those who schedule them for duty.
Maintenance Oversight
In the course of Safety Board investigations--particularly those
involving air carrier operations--Board investigators routinely examine
issues related to regulatory oversight; policy and procedures;
certification; and inspection and enforcement. Safety Board
investigation reports typically include a characterization of
regulatory policies and oversight as they relate to the circumstances
of the accident or incident investigated. In some cases, deficiencies
are identified in FAA regulation or oversight. In other cases, Safety
Board investigations have identified local deficiencies in the actions
of personnel responsible for enacting FAA policy. In those cases when
the identified deficiencies were determined to have contributed to the
circumstances in an accident or incident, the Safety Board has cited
the FAA or FAA personnel as part of the probable cause of the accident.
Therefore, a summary of the Safety Board's historic assessment of FAA
oversight requires a review of the Board's findings of probable cause
as well as the discussions of FAA policy and effectiveness in the text
of Board reports.
The Safety Board records its findings of probable cause for
aviation investigations in its aviation accident and incident database.
Database records include the Board's probable cause statement in its
original narrative form as well as a categorically coding of the causal
findings. Attached is a summary of records from the Safety Board's
aviation accident database in which the FAA or FAA personnel have been
cited with regard to oversight functions. [not printed] Included in the
summary are cases from 1983 to the present in which the Board cited FAA
oversight or functions associated with oversight of operators and
aircraft maintenance. Excluded from this attachment are cases in which
FAA functions not directly related to oversight, such as air traffic
services.
That concludes my testimony and I would be happy to answer any
questions you may have.
Senator Rockefeller. Thank you.
Mr. Brantley?
STATEMENT OF TOM BRANTLEY, PRESIDENT, PROFESSIONAL AVIATION
SAFETY SPECIALISTS, AFL-CIO
Mr. Brantley. Good morning, Chairman Rockefeller, Senator
Hutchison, and members of the Subcommittee, and thank you for
inviting PASS to testify today on FAA's aviation safety
program.
The recent incident involving Southwest Airlines has drawn
attention to the FAA's current inability to provide adequate
oversight of the airlines. The slew of aircraft groundings
indicate that there are problems within the system that are not
being addressed. PASS is extremely concerned that the agency
has become so focused on working in partnership with the
airlines that it has allowed its safety mission to become a
lower priority, in many cases ignoring warnings from its own
workforce. Because of the agency's internal pressure to
collaborate with industry, inspectors are being forced to
change inspection data in FAA databases, reprimanded or removed
from oversight responsibility of a carrier, and encouraged not
to pursue enforcement actions.
PASS has also learned of cases in which FAA managers have
allowed airlines to misuse FAA safety programs. The Voluntary
Disclosure Reporting Program, VDRP, encourages airlines to
self-disclose violations to avoid facing penalties. Inspectors
report that the airlines are being allowed to self-disclose
after an inspector has discovered a problem. In some cases,
inspectors are being ordered by managers to hold off on an
action to allow the airline to self-disclose. While self-
disclosure can work, the deterrent is eliminated when the
program is abused.
PASS concurs with many of the IG's recent recommendations
regarding the program, including that the FAA implement a
secondary review of self-disclosures before they are accepted.
The customer service initiative, CSI, is another FAA
program that is being misused. CSI gives the airlines the right
to ask for a review of an inspector's decision. Again, the idea
is valid, but the FAA is permitting air carriers to use the CSI
to remove an inspector simply for doing his or her job.
Guidance for the CSI actually directs the agency to treat
the airlines as their customer. In PASS's view, the FAA should
be focused on protecting aviation safety and treating the
flying public as its customer rather than satisfying the
aviation industry.
PASS recommends that this program be suspended until there
can be an independent review of the program to ensure that it
can be used properly and it can achieve its intended results.
With fewer inspectors out in the field, the FAA is touting
ATOS as an effective way to prioritize the workload of safety
inspectors based on risk. Yet, it is clear from the evidence
over the last few months that ATOS data, the majority of which
is provided by the airlines, cannot be relied upon without
physical verification. Inspectors have informed PASS that the
fundamental flaw of ATOS is that they are not performing enough
hands-on surveillance. In fact, where inspectors used to spend
most of their time in the field, they now tell us they are
spending more than 70 percent of their time at their desks.
The FAA's recent actions to improve the inspection program
do little to address the concerns of aviation safety
inspectors. It is clear to PASS that if those charged with
inspecting the safety of the air carrier industry are not
allowed to thoroughly examine and fully report potential safety
issues, the FAA will fail in its mission of maintaining and
enhancing aviation safety. It is time this became clear to the
agency, and it is time for the FAA to once again make safety
its top priority.
I feel strongly that the FAA must stop trying to portray
the current crisis as an isolated incident and admit that a
systemic problem exists. The FAA must stop relying on the
industry to police itself and resume its oversight
responsibilities. Partnership is a fantastic way of doing
business as long as the FAA does not lose sight of its
responsibilities. I think they can work with the industry. It
does not have to be adversarial, but at the end of the day, the
buck has to stop with the FAA. And right now, they are not even
seeing the buck.
That concludes my comments, and I look forward to any
questions you may have.
[The prepared statement of Mr. Brantley follows:]
Prepared Statement of Tom Brantley, President,
Professional Aviation Safety Specialists, AFL-CIO
Chairman Rockefeller, Senator Hutchison and members of the
Subcommittee, thank you for inviting PASS to testify on Federal
Aviation Administration (FAA) aviation safety oversight. The
Professional Aviation Safety Specialists, AFL-CIO (PASS) represents
11,000 FAA employees, including approximately 2,900 Flight Standards
field aviation safety inspectors located in 110 field offices in the
United States as well as three international offices in Germany, the
United Kingdom and Singapore. FAA safety inspectors are responsible for
certification, education, oversight, surveillance and enforcement of
the entire aviation system, including air operator and air carrier
certificates, repair station certificates, aircraft airworthiness,
pilots, mechanics, flight instructors and designees.
A recent high-profile incident in which Southwest Airlines was
allowed to continue flying several planes despite being in violation of
an FAA Airworthiness Directive (AD) has drawn significant attention to
the FAA's ability to provide aviation safety oversight. The fact that
FAA employees had to seek help outside the agency in order to get these
safety concerns addressed is an unfortunate indication of the overall
culture at the agency. PASS and the FAA aviation safety inspector
workforce we represent have serious concerns regarding the FAA's
ability to fully and properly oversee aviation safety. Through the
following testimony, PASS will outline significant challenges
encountered by the inspector workforce, including the FAA's over
reliance on a computer-based system, the excessively close relationship
between the FAA and airlines, misuse of FAA ``partnership programs,''
oversight of outsourced maintenance, oversight of foreign repair
stations and the critical need for increased inspector staffing.
Air Transportation Oversight System (ATOS)
The Air Transportation Oversight System (ATOS) was developed in
1998 as a ``system safety'' approach to oversight of the air carrier
industry aimed at ensuring airlines comply with FAA safety requirements
to control risk and prevent accidents. The creation of ATOS was a
direct result of the 1996 ValuJet accident, in which it was discovered
that outsourced maintenance was a causal factor. In theory, ATOS allows
potential problems to be identified before they result in an incident
or accident. The FAA's guidance on ATOS requires that a surveillance
plan be implemented for each airline and standardizes the inspection
and certification processes through automation tools.
While prioritizing workload based on levels of risk and attempting
to manage that workload through automated tasks are valid concepts,
there are several problems with ATOS that prevent the agency from
benefiting from the system. Of primary concern is the fact that ATOS is
limiting a vital aspect of the inspection process: visual, hands-on
inspections actually performed by an FAA inspector. PASS believes that
the FAA is relying too heavily on a data-driven system, due in part to
the diminishing number of safety inspectors. In other words, by
transitioning to ATOS without an adequate number of inspectors, the FAA
is increasing its reliance on limited data rather than a combination of
visual inspections and statistical analysis to catch safety problems.
Yet, FAA analysts have shared with PASS that they do not believe that
there is enough statistical data to properly determine risk.
Throughout its implementation, several industry groups and
government bodies have expressed concern about ATOS. In 2002 and 2005,
the Department of Transportation Inspector General (IG) identified
system-wide problems with ATOS. Among the issues discovered included
lack of inspector training on the system, incomplete inspections in
recognized risk areas, inadequate data and not placing inspectors where
they were most needed. The IG recommended that the FAA strengthen
national oversight and accountability of ATOS. According to the IG, the
FAA has yet to fully address these recommendations.\1\
---------------------------------------------------------------------------
\1\ Department of Transportation Inspector General, Actions Needed
to Strengthen FAA's Safety Oversight and Use of Partnership Programs,
CC-2008-046 (Washington, D.C.: April 3, 2008), pp. 3-4.
---------------------------------------------------------------------------
According to inspectors, prior to ATOS, they developed their own
yearly surveillance plan with the ability to keep it fluid in order to
address daily concerns or changes as they developed. The inspector
spent most of his or her time at the airline or maintenance facility,
meaning more surveillance was done on the actual operations and
maintenance performed. Today, inspectors tell us that the fundamental
flaw of ATOS is that they are not performing enough hands-on
surveillance. Without actual visual inspections, inspectors are not
able to validate the data provided by the airline and generate new data
to input into the system. Moreover, when inspectors perform on-site
visits, their presence alone serves as a deterrent. Unfortunately, the
agency has restructured ATOS so there are fewer inspectors in the field
and even eliminated the majority of remotely sited inspectors
nationwide. Therefore, despite the increasing use of regional carriers
and so much work being outsourced globally, the FAA appears focused on
keeping its inspectors in a few central locations rather than where the
actual work is taking place.
In the wake of Southwest Airlines' noncompliance disclosure, the
effectiveness of ATOS was called into question once again. Southwest
Airlines is an ATOS carrier and has been since the inception of ATOS in
1998. How effective is the FAA's ATOS process in identifying and
managing risk if Southwest Airlines was able to become so lax in its AD
compliance? In fact, ATOS inspectors are supposed to examine airlines'
systems every 5 years to ensure compliance, yet Southwest's AD system
had not been examined since 1999.\2\ PASS believes that one of the main
reasons ATOS is not working as intended is because it has not been
properly resourced and supported by the FAA. It is a mistake for the
FAA to rely on incomplete data, the majority of which is provided by
the airlines, and limited visual inspections to determine risk.
---------------------------------------------------------------------------
\2\ Id., p. 13.
---------------------------------------------------------------------------
With attention focused on AD compliance, the FAA issued Notice
N8900.36 on March 13, 2008, directing a two-phased audit of Part 121
air carrier compliance with ADs in order to reassure the flying public
that the Southwest incident was not a system-wide issue. In phase 1 of
the audit, which was due March 28, inspectors sampled 10 ADs for each
of the air carriers' fleets. Phase 2 of the audit, which is due June
30, will sample additional ADs to total 10 percent of the ADs
applicable to the air carriers' fleets. While the original notice
instructed inspectors to perform a visual inspection of the aircraft
along with verification of records, the FAA released a broadcast
message that FAA inspectors should only perform a records check due to
the two-week time constraint for completion of Phase 1. In other words,
the aircraft and/or its components were not required to be inspected.
On April 2, the FAA released results from the first phase of the audits
claiming a 99 percent rate of airline compliance with ADs.
However, without FAA surveillance of an aircraft, the aircraft's
physical AD compliance status is unknown despite what the records may
indicate. While the FAA has hailed the first results of the audit as an
indication that the overall program is working, PASS has serious
concerns as to the validity of any results collected through this
directive and whether a records check on so small a sampling of
aircraft data will render meaningful results or assurance of
compliance. Furthermore, PASS has learned that many inspectors were
told to perform ``easy'' checks during this audit--items that would not
require a considerable amount of time or result in many problems. One
inspector told PASS that the airline he was responsible for checking
was actually warned of which ADs would be checked a full 5 days before
the FAA reviewed them.
The IG recommendation for increased national oversight of ATOS,
including a process to track field office inspections to ensure that
they are conducted in a timely manner,\3\ is an important step forward
in addressing some of the major issues that prevent the agency from
benefiting from the system. However, without enough people--FAA
inspectors who are trained to see and hear things not quantifiable
through any database--any adjustments to the process will have little
or no impact.
---------------------------------------------------------------------------
\3\ Id., p. 16.
---------------------------------------------------------------------------
FAA Culture Impedes Work of Safety Inspectors
The culture at the FAA has devolved into one in which the employees
are criticized for their actions, questioned on their expert opinions
and made to feel as if they are the only ones fighting for the safety
of the system. As stated earlier, the creation of ATOS was the FAA's
answer to providing reassurance in the wake of the ValuJet accident.
National Transportation Safety Board (NTSB) hearings on the accident
reveal that at least one employee expressed repeated concerns as to the
safety of ValuJet prior to the accident, going so far as to file a
report suggesting the FAA intensify its surveillance of the airline by
increasing the number of inspectors assigned to the carrier. However,
that report was ignored and not passed along to higher levels of
management. During the hearing, it was indicated that the environment
at the FAA was one in which the comments and observations of
subordinates were regularly dismissed by those at the top. The lack of
change in the culture at the FAA is striking. Although ATOS may have
been conceived with the best intentions, it obviously does not address
the underlying problems that continue to plague the agency.
``Cozy'' Relationships Between FAA Management and Airlines
A 1996 act of Congress eliminated a portion of the FAA's ``dual
mandate'' that directed the agency to promote air travel.\4\ Although
legislation describing the FAA's mandate now instructs the agency to
focus on maintaining and enhancing safety, there remains pressure from
FAA management to promote the aviation industry even if it is at the
sacrifice of safety enforcement. In fact, PASS has learned of numerous
instances in which, due to collaboration between the FAA and industry,
FAA safety inspectors were prevented from moving forward with
enforcement actions after identifying a violation of the Federal
Aviation Regulations. As a result, the role of inspector as safety
enforcer is becoming increasingly overshadowed and inspectors are being
pressured by FAA management not to pursue enforcement actions or to
severely censor their evaluations.
---------------------------------------------------------------------------
\4\ Public Law 104-264, Section 401: Elimination of Dual Mandate.
---------------------------------------------------------------------------
There are many examples in which FAA management has ``looked the
other way'' rather than seriously contemplating the safety inspector's
professional opinion and taking immediate steps to ensure that the
airline was in compliance with FAA regulations. One recent high-profile
example in which safety violations were detected at an airline
illustrates the FAA's cultural flaw all too clearly. In September 2007,
the IG released a report on an incident involving a safety inspector
for Northwest Airlines who, after identifying safety problems with the
airline, was prevented from further access to the carrier and
reassigned to administrative duties. After a thorough investigation,
the IG determined that many of the inspector's findings were legitimate
and that the FAA appeared to focus on ``discounting the validity of the
complaints rather than determining whether there were conditions . . .
that needed correction.'' \5\ The IG warned that a ``potential negative
consequence of FAA's handling of this safety recommendation is that
other inspectors may be discouraged from bringing safety issues to
FAA's attention.'' \6\ PASS fully concurs with the IG's assessment. In
fact, many safety inspectors with whom we spoke were hesitant even to
discuss similar situations with the union in preparation for this
testimony for fear that their managers would find out and put them
under investigation or otherwise ``make work a nightmare.''
---------------------------------------------------------------------------
\5\ Department of Transportation Inspector General, Actions Taken
to Address Allegations of Unsafe Maintenance Practices at Northwest
Airlines, AV-2007-080 (Washington, D.C.: September 28, 2007), p. 7.
\6\ Id.
---------------------------------------------------------------------------
Furthermore, PASS has learned of instances in which FAA management
has urged or actually required inspectors to alter their information in
FAA databases in order to diminish the seriousness of the inspectors'
findings. Recently, two grievances were filed by inspectors involving
incidents in which inspectors working at the Northwest Airlines
certificate management office (CMO) were forced to change information
they had entered into the ATOS database by their frontline managers.
According to FAA policy, when there is a difference of opinion
concerning critical assessment data captured in an FAA database, all
information is supposed to be elevated to the principal inspector so
that he or she has the necessary data in order to assess the safety
risk. In one instance, however, management demanded a more generic
version of the data that did not reflect as negatively on the airline
to replace the inspector's actual findings. In another case, an
inspector, after documenting observations of noncompliance, was told to
change responses in the ATOS database. When the inspector refused,
believing that this would significantly affect the quality of the
safety information, the inspector was admonished. A recent change to
FAA policy will allow FAA managers access to the system and permit them
to alter the data without forcing the inspector to make the changes.
Management will be required to identify the author of the change and
provide the reporting inspector with a copy of the change. Although
this will certainly limit the demand placed on inspectors to conform to
management pressure, this process still has the potential to impact the
safety of the system.
Consider the following additional examples in which the
disturbingly close relationship between FAA management and industry is
highlighted:
In 2003, an inspector assigned to Continental Airlines
discovered that over 4,000 life vests had not been overhauled
by a certificated repair station in accordance with the
component maintenance manual. The inspector's supervisor did
not want to have the airline replace the life vests and,
according to the inspector, went so far as to accuse the
inspector of wanting to bankrupt the carrier. FAA management
allowed the airline to continue operating with these ``un-
airworthy'' life vests for several weeks. Only after the
persistent efforts of the inspector did a higher level of
management insist the life vests be replaced immediately.
In October 2007, a safety inspector assigned to American
Eagle in Fort Worth uncovered training and operational issues
the inspector believed should be addressed by the agency. The
inspector wrote 11 letters on issues ranging from handbook
compliance to regulatory compliance and sent them to the
principal inspector assigned to the American Eagle CMO
operations unit, who then sent them on to the unit supervisor.
In November 2007 and again in January 2008, the inspector asked
the unit supervisor about the status of the letters. On both
occasions, the unit supervisor, who is a former employee of the
carrier, responded that sending all the letters at once would
overwhelm the carrier. After details regarding upcoming
hearings were released, the inspector was informed that the
unit supervisor had told the principal inspector to send the
letters to the carrier.
In 2007, inspectors assigned to the Hawaiian Airlines
certificate were advised that they could no longer perform
inspections on aircraft in service when the flight turnaround
time is only an hour and a half. When a plane is in service and
sitting at the gate on the ``ramp,'' it is considered an
excellent time to inspect the carrier to validate the airline's
assertion that the aircraft is ready for passenger-carrying
service, especially since most of these aircraft will be flying
over water for extended periods. An e-mail from management
emphasized that the airline had expressed concerns due to
delays caused by these inspections and that ``on-time
performance is a high priority item for Hawaiian.'' Inspectors
have been directed not to conduct detailed inspections of an
aircraft during ``quick'' turnaround in order for the
inspectors to ``be less apt to cause a disruption.'' The e-mail
specifically states that this change in procedure is to enhance
the working relationship between the FAA and the airline.
Moreover, even if an enforcement action initiated by an FAA safety
inspector makes it through all the procedural steps and results in a
civil penalty, a process that can take up to several years, these fines
or penalties are often dramatically reduced. A 2005 report by the
Government Accountability Office (GAO) stated that from FY 1993 through
2003, there was a ``52 percent reduction in the civil monetary
penalties assessed from a total of $334 million to $162 million.'' \7\
Inspectors have told PASS, and the GAO report has confirmed, that the
lessening of penalties for present violations has severely reduced the
prevention of future violations. In other words, if punishment for
violating safety regulations is not appropriately strict, penalizing an
airline will have little or no impact on future actions.
---------------------------------------------------------------------------
\7\ Government Accountability Office, Aviation Safety: FAA's Safety
Oversight System Is Effective but Could Benefit from Better Evaluation
of Its Programs' Performance, GAO-06-266T (Washington, D.C.: November
17, 2005), p. 12.
---------------------------------------------------------------------------
One case involving an FAA safety inspector working for the United
Airlines CMO illustrates this prevalent practice of reducing the amount
of civil penalties assessed on an airline found to be in violation. In
2003, the inspector discovered a significant problem with improper
accomplishment of work under an FAA AD on the United Boeing 777
aircraft. The AD required that ``each backup generator must be serviced
by different individuals before any subsequent flight.'' The inspector
found that the air carrier had been systematically performing dual
servicing contrary to the AD for years. As a result, an EIR was filed.
The EIR sanctioning guidelines provided for a recommended civil penalty
of $500,000, but the office manager would not endorse the EIR with that
proposed amount. The office manager eventually approved the EIR with a
proposed civil penalty of $195,000. The informal hearing regarding the
case was held in December 2007, and the proposed sanction after the
hearing was $32,000. The final amount appears to be a civil penalty of
$28,000. In addition, while gathering records for the EIR, the
inspector discovered falsification of records. Despite the efforts of
the inspector, there was never any consequence to the falsification
issue.
Customer Service Initiative (CSI)
In 2003, FAA Aviation Safety Associate Administrator Nick Sabatini
unveiled his Customer Service Initiative (CSI) program in order to
allow certificate holders to ``request reconsideration of a decision
made by an Aviation Safety office.'' \8\ The guidance on the initiative
reads similar to what one may expect to encounter in any service-based
industry where the emphasis is on satisfying the customer. In PASS's
view, the FAA should be focused on protecting aviation safety and
treating the flying public as the most important customer rather than
satisfying the aviation industry. The CSI allows airlines to ask for
review on any inspector's decision made in the regulatory or
certification process. However, the FAA is permitting air carriers to
use the CSI to make customer complaints and remove an inspector simply
for doing his or her job. In essence, the CSI program finds the
inspector guilty without a trial, granting the airlines an almost
effortless way to clean the slate, as well as sending a disturbing
message to any other inspector assigned to the carrier that if they
attempt to hold the carrier accountable, they may be removed from the
assignment or face other repercussions.
---------------------------------------------------------------------------
\8\ Federal Aviation Administration. Customer Service Appeals &
Petitions [updated August 3, 2005; cited February 2008]. Available from
www.faa.gov/about/office_org/field_offices/fsdo/cs_initiative.
---------------------------------------------------------------------------
PASS is aware of many incidents in which FAA management has allowed
an air carrier to exploit the CSI process after an inspector attempted
to hold the airline accountable. In some cases, air carriers have even
requested that their certificate be transferred to another Flight
Standards District Office (FSDO). Consider the following examples:
In 2005, an inspector working at the Northwest Airlines CMO
in Minnesota detected a problem with the airline's use of
temporary workers who were not properly trained and familiar
with the airline's maintenance operation. The inspector
repeatedly related concerns that the airline's use of temporary
workers who were not competent or properly trained could
jeopardize the continued operation of the airline. In response
to these findings, the airline contacted the FAA manager at the
CMO and accused the inspector of harassment. Without conducting
a proper investigation, the FAA removed the inspector from the
certificate. When the agency refused to address the system
issues regarding the use of temporary maintenance workers, the
inspector was forced to file a safety recommendation. This
safety recommendation was ignored, compelling the inspector to
elevate the issue to Congress and the Inspector General due to
serious safety concerns regarding the operation of the airline.
In 2005, a major helicopter company performing an external
lift operation in the FAA field office district of Fort Worth,
Texas, was found in noncompliance with the company's FAA-
approved altitude restrictions and congested area limitations.
The reporting inspector had proposed severe sanctions against
the pilot and operator, and a letter was sent to the operator
detailing the proposed civil penalties. The operator complained
about the sanctions and the enforcement actions were dismissed.
The FAA responded by prohibiting inspectors in Fort Worth from
performing any future surveillance on the operator when it
operates in their district.
Due to the repeated misuse of the CSI program, PASS recommends that
the program be suspended until there can be an independent review of
the program in order to ensure that it is being used properly and
achieving intended results.
Voluntary Disclosure Reporting Program (VDRP)
FAA management has allowed the culture at the agency to degenerate
into one in which satisfying airlines has priority over aviation
safety. In fact, FAA management is allowing airlines to use FAA safety
programs to avoid enforcement action. The misuse of these partnership
programs not only reduces the essential aviation safety inspector role
to a mere nuisance, diminishing their credibility with the airline they
are charged with overseeing, it forces inspectors to work in an
environment where their expert warnings are often ignored or severely
downgraded--a dangerously negligent approach to aviation safety.
The Voluntary Disclosure Reporting Program (VDRP) allows
certificate holders operating under Title 14 of the Code of Federal
Regulations to disclose voluntarily to the FAA apparent violations of
certain regulations. As a result of airlines self-disclosing a
violation and presenting a plan for a ``comprehensive fix'' of the
problem, entities will receive a letter of correction instead of a
civil penalty. According to the FAA, this policy is intended to
``encourage compliance with FAA regulations, foster safe operating
practices, and promote the development of internal evaluation
programs.'' \9\ However, in order for the VDRP to operate successfully,
several steps must be rigorously enforced by the FAA, which is often
not the case.
---------------------------------------------------------------------------
\9\ FAA Order 8900.1--Flight Standards Information Management
System (FSIMS), Volume 11: Flight Standards Programs, Chapter 1:
Voluntary Disclosure Reporting Program.
---------------------------------------------------------------------------
At a minimum, the FAA should enforce its requirement that the air
carrier ``promptly'' disclose the violation upon its own detection and
immediately terminate the improper conduct. According to the order,
``In evaluating whether an apparent violation is covered by this
policy, the responsible inspector will ensure . . . [the entity] has
notified the FAA of the apparent violation immediately after detecting
it before the agency has learned of it by other means'' \10\ (emphasis
added). Furthermore, aside from specific exceptions, FAA policy states
that the FAA ``will not forgo legal enforcement action if [the entity]
informs the FAA of the apparent violation during, or in anticipation
of, an FAA investigation/inspection or in association with an accident
or incident.'' \11\
---------------------------------------------------------------------------
\10\ Id.
\11\ Id.
---------------------------------------------------------------------------
The policy makes it clear that once an FAA safety inspector finds a
safety violation, that discovery should result in an enforcement
action--the airline is not supposed to be given a chance to self-
disclose at that point. If an inspector finds an apparent violation, it
should be considered a significant event and should be treated
accordingly. The important and safety-critical work of FAA safety
inspectors must be taken seriously and their findings must be given
proper attention and merit.
Regardless of the explicit directions in the FAA policy, the
intense focus of FAA managers on maintaining a positive relationship
with the airlines is resulting in serious abuse of the VDRP. The IG has
expressed belief that the FAA ``relies too heavily on self-disclosures
and promotes a pattern of excessive leniency at the expense of
effective oversight and appropriate enforcement.'' \12\ PASS has
learned of many cases that validate this concern in which inspectors
find safety violations but are being directed by their front-line
managers to hold off on enforcement to allow the airline to self-
disclose the item. For example, in 2006, an FAA safety inspector
assigned to conduct oversight of a major air carrier in the Southern
region discovered problems when reviewing modifications made to a
Boeing 737.\13\ The inspector discovered that the problems applied to
several aircraft and promptly notified the principal inspector and
operator. When following up on the incident the next week, the
inspector discovered that the airline had been allowed to self-disclose
the problem despite the FAA safety inspector discovering the problem
first. According to inspectors in the field, this abuse of the self-
disclosure process occurs frequently, negating the purpose of the
program and raising the chance that safety risks will not be captured
appropriately.
---------------------------------------------------------------------------
\12\ Department of Transportation Inspector General, Actions Needed
to Strengthen FAA's Safety Oversight and Use of Partnership Programs,
CC-2008-046 (Washington, D.C.: April 3, 2008), p. 3.
\13\ Due to fear of retaliation, the inspector would not permit
PASS to disclose the identity of the air carrier.
---------------------------------------------------------------------------
Furthermore, the VDRP guidance does not penalize an airline for
self-disclosing the same item repeatedly as long as it is determined
that a ``comprehensive fix was satisfactorily completed and followed.''
\14\ While it is possible that a comprehensive fix was not successful,
thus causing a repeat occurrence, this is something that should be
determined prior to the case being considered closed. Allowing
unlimited disclosure of the same issue further undermines the
credibility of the program. In fact, the IG stated that ``a partnership
program that does not ensure carriers correct underlying problems is
less like to achieve safety benefits.'' Airlines are businesses with a
focus on profit and, while safety is no doubt a priority, there must be
government surveillance and accountability to ensure that profit does
not overshadow the safe operation of the carrier.
---------------------------------------------------------------------------
\14\ FAA Order 8900.1--Flight Standards Information Management
System (FSIMS), Volume 11: Flight Standards Programs, Chapter 1:
Voluntary Disclosure Reporting Program.
---------------------------------------------------------------------------
PASS concurs with the IG's assessment that the FAA must implement a
secondary review of self-disclosures before they are accepted and that
guidance for the VDRP instruct the inspector to fully review the
carrier's proposed solution for the reported problem and document that
review prior to accepting the self-disclosure.\15\ In addition, PASS is
concerned that the VDRP database is not being monitored on a local,
regional or national level to identify trends that may impact several
airlines. If this analysis is not being performed, PASS suggests that
the FAA take action to ensure that the VDRP database is examined on an
ongoing basis in order to identify and address widespread risks as well
as determine whether the program is achieving the desired results.
---------------------------------------------------------------------------
\15\ Department of Transportation Inspector General, Actions Needed
to Strengthen FAA's Safety Oversight and Use of Partnership Programs,
CC-2008-046 (Washington, D.C.: April 3, 2008), p. 21.
---------------------------------------------------------------------------
Oversight of Foreign Repair Stations
Another problem on which this committee has focused attention is
airlines increasing their reliance on outsourced maintenance work
performed at facilities within this country and abroad. Whereas much of
this work was once done at the air carrier's facility, according to the
IG, air carriers' use of outsourced repair stations has grown from 37
percent of air carriers' maintenance costs in 1996 to 62 percent in
2005, or nearly $3.4 billion of the $5.5 billion spent on maintenance.
During the first three quarters of 2006, the amount of outsourced
maintenance had already increased to 64 percent.\16\
---------------------------------------------------------------------------
\16\ Department of Transportation Inspector General, Aviation
Safety: FAA's Oversight of Outsourced Maintenance Facilities, CC-2007-
035 (Washington, D.C.: March 29, 2007), p. 1.
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A large portion of this work is being performed at facilities in
foreign locations, and many inspectors say that they are not confident
with the level of oversight of foreign repair stations and that serious
safety issues are not being addressed. The regulations governing
foreign repair stations have also been called into question. For
example, as opposed to domestic airline or repair station employees,
workers at contract foreign repair stations are not required to pass
drug and alcohol tests. There also continues to be major concerns
regarding security at these facilities, with many of the repair
stations lacking any security standards. If a foreign repair station
wants to work on U.S.-registered aircraft or any aircraft that operate
in this country, those repair stations should be required to meet the
same safety standards as domestic repair stations.
Another concern is that the FAA continues to expand the use of
bilateral agreements with foreign countries to oversee repair of U.S.
carriers. The Bilateral Aviation Safety Agreement (BASA) with
Maintenance Implementation Procedures (MIPs) allows foreign authorities
to provide oversight of the work performed at repair facilities without
any involvement from FAA inspectors. This eliminates the need for the
inspector to travel to the repair station at all and entrusts
responsibility entirely to a foreign entity. According to the IG,
however, foreign authorities do not provide the FAA with sufficient
information on what was inspected, the problems discovered and how
these problems were addressed. The IG has recently stated that despite
some additional efforts, the concern remains that the ``FAA is still
not regularly visiting the facilities in the countries where agreements
exist with other aviation authorities.'' \17\ The IG cited an example
in which FAA inspectors for one air carrier had not visited a major
foreign engine repair facility even though the repair station had
performed maintenance on 39 (74 percent) of the 53 engines repaired for
the air carrier. Furthermore, FAA inspectors had not conducted any spot
inspections of this facility in 5 years.\18\
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\17\ Id., p. 9.
\18\ Id.
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In order to ensure that the work performed at foreign repair
stations meets FAA and air carrier standards, PASS believes that all
certificated foreign repair stations should be inspected at least twice
a year by an FAA inspector and all workers working on U.S. aircraft
should be drug and alcohol tested. In addition, the increasing use of
foreign repair stations has been drawing even more attention to the
inspector staffing problem. Clearly, the inspector workforce must be
expanded in order to meet the demands required by work performed on
U.S. aircraft overseas.
Use of Non-Certificated Repair Facilities
With airlines increasing their use of outsourced maintenance work,
there has been a significant increase in the use of non-certificated
repair stations. ``Non-certificated'' means that the repair facility
does not possess a certificate issued by the FAA to operate under
Federal Aviation Regulation Part 145 and is therefore not subject to
direct FAA oversight. A certificated repair station meets the standards
as outlined in the Federal Aviation Regulation and is therefore subject
to direct FAA oversight to ensure that it continues to meet those same
standards. The differences in regulatory requirements and standards at
the two facilities are extremely troubling. For example, in an FAA-
certificated repair station, it is required that there be designated
supervisors and inspectors and a training program. These items are not
required at non-certificated repair facilities.
Effective oversight of non-certificated repair facilities gained
attention in the aftermath of the January 2003 Air Midwest crash in
Charlotte, N.C. The National Transportation Safety Board determined
that incorrect rigging of the elevator system by a contractor
contributed to the accident and pointed to ``lack of oversight'' by Air
Midwest and the FAA. \19\ The airline contracted out the work to an
FAA-certificated repair station, which then subcontracted to a non-
certificated repair facility. Under Federal regulations, the airline is
ultimately responsible for ensuring that the work is performed in
accordance with FAA standards and requirements.
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\19\ National Transportation Safety Board, Loss of Pitch Control
During Takeoff, Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D,
N233YV, Charlotte, North Carolina, January 8, 2003, Aircraft Accident
Report NTSB/AAR-04/01 (Washington, D.C.: 2004), p. x.
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According to the IG, the FAA does not know how many non-
certificated maintenance facilities air carriers currently use, but the
IG identified ``over 1,400 non-certificated repair facilities
performing maintenance and more than 100 of these facilities were
located in foreign countries.'' \20\ The IG also discovered that there
are no limitations to the amount of maintenance work non-certificated
facilities can provide, and that these facilities are performing far
more work than minor services, including much of the same type of work
FAA-certificated repair stations perform, such as repairing parts used
to measure airspeed, removing and replacing jet engines, and replacing
flight control motors. Some of these non-certificated facilities are
even performing critical preventative maintenance.
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\20\ Department of Transportation Inspector General, Aviation
Safety: FAA's Oversight of Outsourced Maintenance Facilities, CC-2007-
035 (Washington, D.C.: March 29, 2007), p. 13.
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Despite the fact that these facilities are performing safety-
critical work, FAA oversight is practically nonexistent. In other
words, these facilities are performing work pivotal to aviation safety
with no guarantee that it is being done in line with FAA and air
carrier standards. It is obvious that there must be changes made
regarding air carriers' use of non-certificated repair facilities. As
such, PASS believes that all air carrier maintenance work (substantial,
regularly scheduled or required inspections items) should only be
performed by an FAA-certificated repair station.
FAA Must Ensure Adequate Inspector Staffing
PASS is extremely concerned about staffing of the FAA safety
inspector workforce. Whereas decades ago, FAA safety inspectors were
regularly on location performing visual inspections, the agency has
undergone dramatic changes and inspectors now report spending more than
70 percent of their time at their desks. The FAA has shifted its focus
to a risk-based, data-driven system due to the decreasing number of FAA
aviation safety inspectors. With the increased outsourcing of
maintenance work in this country and abroad, growing number of aging
aircraft, the emergence of new trends in aviation (such as very light
jets, unmanned aircraft and regional carriers) and the expansion of the
FAA's designee programs--all of which require additional inspector
oversight--it is imperative that there are enough inspectors in place
to monitor the safety of the system.
Making this situation even worse is the fact that nearly half of
the inspector workforce will be eligible to retire in the next 5 years
and many areas are already severely understaffed. Considering the
recent Southwest incident, it is even more critical that the FAA have
enough inspectors to ensure proper identification of airline safety
violations and adequate follow-up. Unfortunately, in its FY 2009 budget
request, the FAA has not requested any funding to hire additional
Flight Standards aviation safety inspectors. Since it is critical that
there are enough inspectors in place to adequately oversee the growing
industry and ensure the safety of the aviation system, sufficient funds
must be authorized to hire more inspectors.
Conclusion and Recommendations
Following the Southwest Airlines incident, the FAA, claiming that
it was now ``wide awake,'' released a series of improvements to the
agency's inspection program. The highlight of these improvements is the
creation of the Safety Issues Reporting System (SIRS) to provide
employees an ``additional mechanism to raise safety concerns if they
feel they are not receiving the necessary airing or response from
supervisory and management personnel.'' \21\ This hotline is in
addition to hotlines already in existence that were used by FAA
inspectors in the Southwest Airlines incident to no avail. Inspectors
have told PASS that these hotlines serve no real purpose other than to
bring negative attention to the inspector using the hotline. In fact,
one inspector informed PASS that after not receiving an appropriate
response from management, the inspector elevated concerns through one
of these hotlines. The responsibility for responding to the hotline
report was shifted through layers of management until it was directed
back to the very same managers about whom the inspector had complained
in the first place. The inspector, who did not conceal his identity
when using the hotline, revealed that the problems never were
adequately addressed.
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\21\ Federal Aviation Administration, ``FAA Announces Improvements
to Inspection Program,'' April 2, 2008.
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Clearly, another hotline is not a solution to the pervasive
problems at the FAA. The IG has stated that the FAA needs to make
``immediate and comprehensive changes to its oversight of air
carriers.'' \22\ While a hotline may be immediate, it is in no way
comprehensive. Another hotline is nothing more than lip-service to a
field of aviation experts attempting to raise aviation safety issues
that require immediate attention. It may indeed be necessary to create
another avenue through which inspectors can express concerns, but this
plan cannot be successful if it is another FAA project. PASS believes
that any such program must be independent of the FAA if it is to
succeed.
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\22\ Department of Transportation Inspector General, Actions Needed
to Strengthen FAA's Safety Oversight and Use of Partnership Programs,
CC-2008-046 (Washington, D.C.: April 3, 2008), p. 16.
---------------------------------------------------------------------------
In addition, there is no doubt that the relationship between the
FAA and the airline industry needs to change to ensure safety issues
are given appropriate attention. PASS agrees with the concept of
rotating managers in order to prevent these types of ``cozy''
relationships from developing. Those with the ultimate responsibility
for oversight of FAA safety inspectors and the carrier should be the
group that is rotated among facilities. As such, PASS recommends that a
plan be executed to rotate all first- and second-level managers on a
regular basis. This rotation will help to discourage management from
becoming too closely connected with the airlines. While this rotation
may be a good start, PASS also concurs with the U.S. Office of Special
Counsel in that since ``the culture of complacence and cover up goes
very high in management circles'' at the FAA, there needs to be ``a
serious discipline and shakeup of the FAA in order to send the proper
message inside what appears to be a very insular organization . . . .''
\23\
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\23\ U.S. Office of Special Counsel, Statement of the Honorable
Scott J. Bloch, Special Counsel, U.S. Office of Special Counsel
(Washington, D.C.: April 3, 2008), pp. 6-7.
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According to the FAA's website, aviation safety inspectors are the
``FAA's on-site detectives.'' \24\ While this statement was once true,
the FAA has become an agency where a limited inspector workforce facing
a constantly increasing workload is prevented from pursuing safety
concerns by a management culture focused on pleasing the industry. The
FAA's customers are the flying pubic, not the airlines, and its most
critical role is to protect the safety of these customers. Safety is
always the primary focus of the FAA safety inspector workforce--their
contributions and the safety of the aviation system should never be
anything but the agency's top priority as well.
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\24\ Federal Aviation Administration. Aviation Safety Inspectors
[updated January 4, 2007; cited February 2008]. Available from
www.faa.gov/about/office_org/headquarters_offices/ahr/jobs
_careers/occupations/av_safety_insp.
Senator Rockefeller. Thank you.
Mr. Barimo?
STATEMENT OF BASIL J. BARIMO, VICE PRESIDENT,
OPERATIONS AND SAFETY, AIR TRANSPORT
ASSOCIATION OF AMERICA, INC.
Mr. Barimo. Good morning, Mr. Chairman, Senator Hutchison,
members of the Committee. This morning's hearing is important
and timely and it provides us with the opportunity to take
stock of commercial aviation safety in the United States, and
more specifically, it provides us the opportunity to review how
we got here and to discuss how best to improve that remarkable
safety record. Let me highlight a few basic considerations.
First, the bedrock principle in aviation is safety first.
Congress has said in the Federal aviation law that assigning,
maintaining, and enhancing safety and security are the highest
priorities in air commerce. That Congressional mandate says it
all, and we are committed to doing our part to achieving it.
Second, we did not get to where we are today by being
lucky. We have worked very hard to achieve our safety record,
which last year saw no fatal accidents in air carrier accidents
in the United States. While we recognize clearly that FAA is
the regulator and airlines are the regulated entity, we also
recognize with equal clarity that aviation safety is a
collaborative undertaking.
Third, you never rest on your laurels in this business. The
safety record of the Nation's airlines is so impressive because
of the unrelenting commitment of everyone involved, Congress,
the FAA, the NTSB, manufacturers, airports, maintenance
organizations, the employees and their unions, and airlines, to
improving civil aviation safety. That commitment has not
flagged.
I would like now to discuss where things stand in three key
areas that the Subcommittee has identified: regulatory
oversight, maintenance, and runway safety.
The FAA's responsibility to regulate airlines to achieve
the highest degree of safety, which Congress has mandated, has
not diminished, nor has the airlines' responsibility to fulfill
that mandate diminished. Both are immutable.
What has changed, though, are the tools that are available
and, I would emphasize, necessary to meet those
responsibilities. Instead of being reactive and establishing
safety goals based on the most recent accident or incident, the
industry and FAA have learned to use the wealth of data from
all stakeholders to guide the safety agenda so that not only
existing, but potential risks are identified and solutions to
them developed in the most effective way. FAA's ATOS system, we
heard described earlier, embodies this principle, and we
believe that the concept of ATOS is sound, although as the
Inspector General has pointed out, some refinements are needed.
This analytical and more predictive approach has paid
tremendous dividends. It is the key to future safety
improvements. Commercial aviation safety is a much more
forward-looking endeavor today than in the past. Data in
amounts and detail unimaginable a decade ago and collaborative
risk analyses have become indispensable. Make no mistake. That
does not mean that FAA inspectors should not be kicking the
tires and touching metal. It means, however, that the historic
means of regulatory oversight simply are not enough today.
Airline maintenance issues have been front page news for
the past few weeks, including today. Airline maintenance
programs are carefully designed, comprehensive, and
continuously refined. Today's headlines have not changed any of
that. The maintenance system being scrutinized today has
delivered unprecedented levels of mechanical reliability, which
in turn contribute to overall safety. The chart in my written
statement illustrates the exceptional performance of the Boeing
fleet, and I will note that the Airbus fleet is comparable. The
chart shows that regardless of where maintenance is done, it is
being done and done well.
But it is a complicated business and we are not perfect. As
we have seen recently, tracking hundreds of thousands of
individual maintenance tasks is challenging. Even though a
recent FAA audit of AD compliance revealed a compliance rate of
better than 99 percent, airlines are committed to further
improving an already robust system. And this recent experience
underscores airlines will ground aircraft when there is any
doubt about a maintenance issue.
Runway safety remains a high priority for the industry, but
there is no single fix when it comes to eliminating runway
incursions. The solution is a layered one that integrates
technological advances, improved procedures, taxi and runway
improvements, better understanding of human factors in
performance. ADS-B mentioned earlier will ultimately provide
much better situational awareness for flight crews whether in
the air or on the ground.
In the interim, we are pleased that FAA, working with
airport operators, is deploying new systems like ASDE-X and
AMASS and Runway Status Lights and adding perimeter taxiways,
and all that, combined with heightened flight crew awareness
and training, will certainly help reduce collision risks. We
recognize, though, that this is an ongoing effort.
In summary, we realize how unsettling the news about
maintenance and regulatory oversight practices has been lately.
There is no getting away from that. Whatever shortcomings may
ultimately be identified in these episodes, the unchangeable
reality is that airline maintenance and operation practices
have produced the safest period of flying that our industry has
ever experienced. In the coming weeks and months, we should
prudently evaluate suggested changes to that system. Change can
be very good, but change for its own sake rarely is. That is
particularly so when it involves the safety of our customers
and our crews.
That concludes my statement. I am happy to answer your
questions.
[The prepared statement of Mr. Barimo follows:]
Prepared Statement of Basil J. Barimo, Vice President, Operations and
Safety, Air Transport Association of America, Inc.
Introduction
The Air Transport Association of America, Inc. (ATA), the trade
association of the principal U.S. passenger and cargo airlines,\1\
appreciates the opportunity to submit these comments for the record on
the state of aviation safety in the U.S. airline industry. ATA member
airlines have a combined fleet of more than 4,400 airplanes and account
for more than 90 percent of domestic passenger and cargo traffic
carried annually by U.S. airlines.
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\1\ ABX Air; AirTran Airways; Alaska Airlines; American Airlines;
ASTAR Air Cargo; Atlas Air; Continental Airlines; Delta Air Lines;
Evergreen International Airlines; Federal Express Corp.; Hawaiian
Airlines; JetBlue Airways; Midwest Airlines; Northwest Airlines;
Southwest Airlines; United Airlines; UPS Airlines and US Airways.
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ATA was founded in 1936 by fledgling U.S. airlines for two
fundamental reasons: to improve and promote safety within the industry
and to advocate for a legal and regulatory environment that would allow
the U.S. commercial airline industry to grow and prosper. What was true
then is true today: Safety is the foundation of this industry. U.S.
airlines will thrive only if the industry in fact is safe and only if
the public recognizes and believes it is safe. For this reason, our
members take their safety responsibilities very seriously. ``Safety
first'' is more than just a catchphrase--it is the core principle of
this industry.
Airlines Fuel Our Nation's Economy
The U.S. airline industry is not simply an important sector of our
national economy; its services fuel our entire economy. Air
transportation is an indispensable element of America's infrastructure
and our Nation's economic well-being. Individuals, businesses and
communities depend on the national air transportation system. U.S.
airlines transport more than 2.1 million passengers on a typical day
and directly employ over one-half million persons to do so; they
provide just-in-time cargo services; they are the backbone of the
travel and tourism industry; and airlines link communities throughout
our Nation and to the world.
Moreover, the airline industry is the foundation of the commercial
aviation sector, which is comprised of airlines, airports,
manufacturers and associated vendors. According to the Federal Aviation
Administration (FAA), U.S. commercial aviation ultimately drives $1.1
trillion in U.S. economic activity and nearly 10 million U.S. jobs. By
any measure, the U.S. airline industry is a valuable national asset and
its continued economic health should be a matter of national concern.
Safety Above All Else
The challenges facing the U.S. airline industry are widely known.
Once lucrative international markets are softening, jet fuel prices are
at an all-time high with no relief in sight and, by all accounts, the
United States has entered an economic recession. Since Christmas Eve,
five airlines have fallen victim to these challenging conditions. Yet
despite entering this new era of volatility, airline safety has
remained rock solid.
In 2007, Part 121 carriers transported 750 million passengers more
than eight billion miles and logged 19 million flight hours on 11.4
million flights. According to the NTSB, 2007 saw no passenger
fatalities or major accidents. The trend continues in 2008 and without
question, scheduled air service is incredibly safe and working hard to
be even safer.
A Performance-Based, Data-Driven Approach
While there are many reasons for the industry's excellent safety
record, in our opinion two key developments stand out as having a
significant positive impact. First, we have progressed from a
prescriptive, conduct-based regulatory philosophy that focuses on what
to do and how to do it, to one that looks to set performance standards
first and the manner of achieving the desired performance second. This
has shifted the focus to where it should be--on the safety objective,
allowing carriers and the FAA to better define and implement
appropriate procedures and requirements. Second, instead of being
reactive and establishing safety goals based on the most recent
accident or incident, the industry has learned to use the wealth of
hard data accumulated by all stakeholders--FAA, NTSB, manufacturers and
air carriers--to drive the safety agenda so that the most serious risks
are identified and solutions developed in an orderly, efficient and
effective manner. This data-driven, risk-assessment approach to safety
has paid tremendous dividends already. It is the key to future safety
improvements and continued accident prevention.
Voluntary Programs Are Raising the Bar
FAA and airline safety programs reflect and implement the
regulatory philosophy and data-driven approach to safety previously
described. In particular, the development of voluntary programs that
encourage the reporting of operational data that would otherwise be
lost has expanded the data set and enhanced the value of the analytical
products. Working with the FAA and other stakeholders, U.S. airlines
have developed flight operational quality-assurance programs--known as
FOQA programs,\2\ aviation safety action programs,\3\ voluntary
disclosure programs \4\ and line operations safety audit programs.\5\
These programs have provided valuable data that have yielded insights
into the precursors of accidents. FAA and the airlines have used this
information to jointly identify and effectively mitigate risks that
might otherwise have resulted in accidents. This view is shared not
only by the airlines and FAA, but by independent safety experts
worldwide including Flight Safety Foundation President and CEO William
R. Voss. In a March 2008 statement, Mr. Voss states:
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\2\ FOQA programs involve the collection and analysis of data
recorded in flight to improve the safety of flight operations, air
traffic control procedures, and airport and aircraft design and
maintenance.
\3\ ASAP involves collection and analysis of safety concerns
reported by employees.
\4\ VDRP allows a certificate holder to disclose a case of
noncompliance without facing a civil penalty, provided the entity
promptly and comprehensively corrects the noncompliance.
\5\ LOSA involves the collection of safety data through in-flight
observations of flight crews by specialists; Airlines use this
information to assess the effectiveness of their training programs.
``The commercial aviation system in the United States is the
safest in the world, and both the FAA and industry should be
justifiably proud of their record. As in any safety management
system, there is always room for continuous improvement, but we
cannot allow isolated breakdowns, which the FAA and industry
are moving swiftly to address, to ruin partnership programs
that have demonstrably contributed to aviation's sterling
safety record. Nor can we afford to dry up the free flow of
information that allows professionals to identify problems
before they become safety threats. We cannot create a wall
between the FAA and the airlines that will stop the flow of
information and set aviation safety back 20 years.'' \6\
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\6\ Flight Safety Foundation Press Release dated March 3, 2008.
In fact, the DOT Inspector General recently testified as to the
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value of voluntary programs, stating that:
``Such programs (Voluntary Disclosure Reporting Program and
Aviation Safety Action Program), if properly implemented, can
add value by identifying issues that might not otherwise come
to light . . . We support the concept of self-disclosure
programs and recognize the challenge they present to FAA--
carefully balancing a collaborative relationship with effective
oversight and appropriate enforcement actions.'' \7\
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\7\ Statement of the Honorable Calvin L. Scovel III, Inspector
General, U.S. Department of Transportation before the House Committee
on Transportation and Infrastructure, April 3, 2008.
In addition to data-driven programs, aviation safety can be viewed
as the cumulative outcome of numerous other activities by the FAA,
NTSB, airlines and their employees, and airframe and engine
manufacturers. The most obvious of these is the approval and
surveillance by the FAA of air carrier training programs. Training
programs for flight and cabin crews are critical to safe operations.
Airlines employ a rigorous selection and training process that includes
comprehensive initial and recurrent training. Most major airlines today
utilize the Advanced Qualification Program, which enables each airline
to tailor its curriculum to its unique operating environment and
thereby maximize crew-member proficiency. We believe these and other
similar programs will produce further improvements in aviation safety.
One of the most important programs affecting safety has been the
joint industry-government Commercial Aviation Safety Team (CAST). CAST
was established in 1997 to develop a comprehensive strategy to identify
and prioritize risks based on past accidents and then develop solutions
to reduce commercial aviation fatalities in the United States. Using a
data-driven process, the CAST initiative identifies accident precursors
and contributing factors to ensure that resources are applied to
improve safety where needed most and where most effective. Over time,
CAST has successfully addressed several types of accidents, such as
controlled flight into terrain, approach and landing accidents, runway
incursions, maintenance management, icing and uncontained engine
failures. As of 2007, 39 different safety enhancements had been
accomplished, and 26 were underway. Through these 65 enhancements, the
industry is approaching its goal of reducing the fatality risk by 80
percent.
But CAST doesn't stop there. While the original CAST approach
looked back at accidents to better understand them and prevent future
accidents, the next generation of CAST efforts will look forward to
future risks. Compiling a wide range of safety indicators, CAST will
identify risks to aviation safety before they result in accidents. The
key to our success will be our ability to confidentially aggregate
sensitive, industry-wide safety data and mine it for trends. The
Aviation Safety Information Analysis and Sharing (ASIAS) system \8\ was
launched in October 2007 to enable the exchange and analysis of safety
data on a national level. We will continue to support the ASIAS system
and look forward to the benefits it offers.
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\8\ The Federal Aviation Administration (FAA) developed the
Aviation Safety Information Analysis and Sharing (ASIAS) system to
enable users to perform integrated queries across multiple databases,
search an extensive warehouse of safety data, and display pertinent
elements in an array of useful formats.
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As noted, the CAST strategy is first and foremost data driven. It
relies on comprehensive analysis of past accidents/incidents to
identify accident precursors and then develop specific safety
enhancements to address those precursors and related contributing
factors. But the CAST process does not stop there. It is a fully
integrated process that includes airlines, manufacturers, maintenance
providers, commercial pilots, National Aeronautics and Space
Administration (NASA) and other stakeholders, so that once the
solutions have been identified, the affected parties implement the
safety enhancements and track their implementation for effectiveness.
Ultimately, the knowledge gained is used to continually improve not
only the U.S. aviation system, but aviation safety worldwide. Canadian
and European authorities also participate in CAST.
Current Safety Issues
Current safety issues being addressed by our industry include
runway safety, maintenance, fuel tank flammability, FAA oversight, air
traffic controller staffing, operational errors and the safety of our
employees.
Runway Safety.\9\ Several high-profile events over the last 2 years
have drawn attention to the issue of runway incursions, but runway
safety has always been a high priority for the industry. For decades,
airlines have recognized the challenges they face on the airport
surface and have invested significant resources to ensure the safety of
their passengers and crews. Unfortunately, there is no silver bullet
when it comes to eliminating runway incursions. The solution is a
layered one that integrates technological advances, better signage and
markings, robust flight crew and ATC procedures and a better
understanding of human factors and performance. ADS-B, a fundamental
component of NextGen, will ultimately enable better situational
awareness for flight crews, allowing them to see all traffic around
them whether in the air or on the ground. Combining this real-time,
highly accurate positional information with moving map displays will
yield real safety benefits. In the interim, we are pleased that FAA is
deploying several new systems designed to reduce the risk of runway
incursions at our busiest airports. Enhanced automated surveillance
tools like AMASS and ASDE-X, Runway Status Lights, perimeter taxiways,
and EMAS, combined with heightened flight-crew awareness, streamlined
taxi procedures and refined training, will help to reduce collision
risk. We look forward to working with the FAA and airports to implement
these new safety improvements.
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\9\ ATA testified on February 13, 2008, before the House Aviation
Subcommittee on the issue of runway safety. Written testimony included
details about the causes of runway incursions as well as specific
actions taken and underway to reduce the risk of runway incursions. The
testimony is available at www.airlines.org.
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In addition to runway incursions, the industry is focused intently
on reducing the risk of runway excursions. ATA members, as well as
pilot associations and the airport community, are actively
participating in the recently formed Takeoff and Landing Distance
Aviation Rulemaking Committee. The ARC will review current practices
for determining runway distance needed under various conditions and
revise the regulatory guidance accordingly.
Maintenance. The recent FAA announcement of a large civil penalty
against Southwest Airlines and the subsequent audit of Airworthiness
Directive compliance has attracted significant attention to the subject
of airline maintenance. Despite the isolated shortcomings highlighted,
it is important to note that the U.S. commercial airline fleet is
maintained to impeccable standards, which are reflected in mechanical
reliability performance. As shown in the chart below for Boeing models
(and noting that Airbus models perform comparably), airline maintenance
programs are yielding unprecedented levels of mechanical reliability
which, in turn, contribute to overall safety performance.
Effective and efficient maintenance programs play a central role in
making air travel safe. Maintenance is a 24/7 function that requires
careful organization, tight control, diligent oversight and robust
quality assurance. Airlines have developed comprehensive--although not
perfect--oversight systems to ensure that aircraft are maintained
properly in accordance with FAA regulations and manufacturers'
standards. As we have seen recently, tracking the accomplishment of
hundreds of thousands of individual maintenance tasks is challenging.
Even though a recent FAA audit of AD compliance revealed a compliance
rate better than 99 percent, airlines are committed to further
enhancements that will further improve an already robust system.
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\10\ Data reflects technical delays greater than 15 minutes for
Boeing 717, 737, 747, 757, 767, 777, MD11, MD80 and DC 10 models.
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Beyond the scope and frequency of individual maintenance tasks is
the contentious issue of who actually performs maintenance tasks and
where those tasks are performed. Contract maintenance continues to be
scrutinized with critics alleging that the practice is unsafe, yet the
industry's safety record tells a different story. Repair stations
(third-party maintenance providers certificated under Part 145) have
and will continue to play a vital role in air carrier operations and
enable U.S. airlines to compete effectively worldwide.
Fuel Tank Flammability. After the tragic loss of TWA Flight 800 in
1996, FAA initiated a multiyear research and development effort to
address flammable vapors in fuel tanks. The effort produced a design
that would reduce the amount of time that vapors are in a flammable
state. The FAA proposed a regulation that would incorporate this new
concept for commercial airliners, or other methods for preventing or
mitigating fuel vapor explosions. The reduction concept does not
diminish the need to eliminate ignition sources that could ignite the
vapors. To prevent ignition sources, the FAA adopted sweeping
regulations requiring improved design standards for fuel tank systems,
reviews of existing systems with respect to the new standards, system
modifications, specific operational procedures, and more exacting
maintenance procedures. Industry continues to coordinate with the FAA
and manufacturers as a stakeholder in developing these upgrades, which
FAA has, since 1996, mandated through issuance of 170 Airworthiness
Directives. Further, two ATA member airlines independently developed
and gained FAA approval for a modification that may prove to be the
single most progressive ignition-prevention measure developed to date.
For both economic and safety reasons, airlines have, when practical,
reduced their use of auxiliary power units while on the ground--a
measure that can provide relatively modest reductions in the amount of
time that vapors are flammable. Our studies indicate that a retrofit of
currently available flammability reduction systems cannot be justified
under government guidelines for rulemaking, and that actions taken to
prevent ignition sources exceed FAA standards and are the most
effective approach to mitigating fuel tank explosion risk.
FAA Oversight. FAA Inspectors work where `the rubber meets the
road' and are the central component of the FAA safety oversight system.
They enforce regulations and standards concerning civil aviation
safety, including the airworthiness of aircraft, the competence of
personnel, and safety aspects of aviation facilities, equipment and
procedures. The way in which they fulfill their mission continues to
evolve with changes in oversight philosophy. FAA's risk-based Air
Transport Oversight System (ATOS) leverages air carriers' internal
oversight programs and advanced data-collection tools to create
customized surveillance plans. Instead of searching randomly for
deficiencies, FAA can efficiently identify and target potential areas
of risk and work with the carrier to mitigate that risk. Make no
mistake, ATOS does not preclude the need for FAA to conduct regular
surveillance of air carrier operations. It is, however, one of many
tools available to FAA and endorsed by the DOT Inspector General \11\
to ensure that the operations of certificate holders conform to Federal
regulations.
---------------------------------------------------------------------------
\11\ ``We have always supported the concept of risk-based oversight
as the only way FAA will be able to effectively oversee a large and
rapidly changing aviation industry.'' Statement of the Honorable Calvin
L. Scovel III, Inspector General, U.S. Department of Transportation
before the House Committee on Transportation and Infrastructure, April
3, 2008.
---------------------------------------------------------------------------
While ATOS remains a valuable component of FAA's oversight effort,
airlines do not rely on ATOS to keep them safe. Airlines are
responsible for ensuring that they operate safely and cannot delegate
that responsibility.
Air Traffic Controller Staffing. Air traffic controllers make
today's world-class aviation system work. They struggle to move growing
numbers of aircraft through our Nation's airspace without the benefits
of state-of-the-art technologies. Forecasted demand from a broad range
of users will exceed the capability of our system despite the best
efforts of our skilled controller staff. Unfortunately, today's system
is not scalable--adding more towers, TRACONs, or centers full of
controllers will not work. We must provide today's controllers with
tools that enable them to safely increase the number of aircraft that
they manage at a given time.
Operational Errors. Creating a safety culture that embraces
voluntary reporting of safety information while effectively managing
individual performance is challenging. The Air Traffic Safety Action
Program (ATSAP), FAA's version of the ASAPs used so effectively within
airlines, is a step in the right direction. We are optimistic that the
ATSAP will generate valuable insight into the challenges air traffic
controllers face and ultimately contribute to the safety and efficiency
of the ATC system.
Operational errors have long been a contentious issue for
controllers and FAA management. A minimum separation limit for
aircraft, coupled with punishment for even slight violations provides a
disincentive for controllers to optimally space aircraft. On the
contrary, controllers are incentivized to add a buffer to ensure that
the limit is not violated. This wastes valuable airspace and reduces
airport throughput. We are encouraged that FAA is changing their
approach to aircraft separation by adopting the concept of proximity
events. The proximity event approach establishes a window within which
the controller keeps the aircraft. This approach gives the controller
an optimal separation target along with a buffer ahead and behind the
aircraft to absorb fluctuations in airspeed. We believe that this
approach ensures continued safe separation of aircraft, optimizes
airspace usage and will reduce the risk of operational errors.
Employee Safety. Airlines continuously strive to make the work
environment safer and more comfortable for employees, regardless of
whether that environment is on the ground or in the air. Flight crews
as well as passengers benefit from advancements in technology, such as
the hospital-grade HEPA air filters and ozone converters now installed
on most long-range aircraft, which improve cabin air quality. Better
data about cosmic radiation provided by the FAA CARI-6 computer program
allows flight crews to monitor their cumulative exposure to radiation
and make changes where necessary to protect their health. A close
partnership with the Centers for Disease Control and Prevention (CDC)
has ensured that airlines can pass along to employees up-to-the-minute
information on disease outbreaks and precautionary measures.
Ramp employees face a myriad of threats as they load, service and
move aircraft. ATA members collect and analyze detailed data related to
employee injuries, as well as aircraft and equipment damage. This data-
based approach enables carriers to identify risks and take specific
actions to mitigate those risks. ATA collaborates with other key
stakeholders to lead industry-wide changes, such as publishing safety
guidelines/best practices, redesigning ground support equipment to make
it more user friendly, incorporating advancements in personal-
protection technologies, and establishing safety protocols for ramp
personnel.
Conclusion
Notwithstanding the challenging environment in which airlines
operate, the U.S. airline industry has experienced the safest period in
its history. While hearings like this allow us to proudly reflect on
this accomplishment, we understand that we cannot become complacent and
rest on our accomplishments. Aviation safety demands constant
vigilance, review and improvement. For this reason, we will continue to
work with the FAA, the NTSB and the many parties with a stake in the
continued safety of our industry. ``Safety first'' will continue to be
our core principle.
Senator Rockefeller. Thank you very much.
We do have 10 minutes left. So, Kay Bailey Hutchison and I
have decided that we are going to give our opening statements,
which will be brief. We will then have our votes, and we will
come back loaded for bear.
First of all, it was very interesting for me to hear the
difference between the panelists. Everything is just wonderful
from FAA's point of view. I have to point out that I assume
that your testimony was vetted by OMB before you gave it.
Mr. Sabatini. Yes, sir, it is.
Senator Rockefeller. So that means that you are not
speaking what you may think, but you are speaking what the
administration wants you to say. I say that not to embarrass
you or humiliate you, but simply to say this is what always
goes on and it is important that people understand that.
Mr. Sabatini. Well, if I may, Mr. Chairman, I believe what
I said.
Senator Rockefeller. Yes, I am sure.
I also want to say that it is frustrating to me that during
this time in which things, I think, have been spiraling
downwards--I agree very much with you, Mr. Scovel and Mr.
Chealander--that there remains this terrible tension between
FAA and its unions. Neither side can put out enough press
releases in order to downgrade the other more. Now, I have
worked with lots of government agencies, but I have never seen
anything close to this. One of our witnesses today has an
upcoming contract, and yet, I cannot remember seeing that
witness in my office, or in my staff's office or his
predecessors in my office talking about some of the problems
which he spoke about. This is not a way of functioning. If you
want to deal with the Commerce Committee and the Aviation
Subcommittee, you have got to do it straight up.
So I think the Federal Aviation Administration's lax
oversight of Southwest Airlines is terrible--and, as you
indicated, now we have American Airlines and others laying off
employees, canceling flights day after day after day. It is
almost like we stopped reading the headlines except that it is
a horrible situation. It is a perfectly dreadful situation. I
think it is our job today to find out if these are just
isolated incidents, as some at the FAA and Southwest contend,
or part of a large, systemic problem facing both the agency and
the industry.
When it comes to safety of the air traveling public, the
American people put their trust in you all. In recent weeks, I
think that trust has been put to a severe test. I know it has
in my case, with the disturbing reports surrounding the lack of
FAA oversight with Southwest, all of these cancellations that
are taking place by American and others, and the revelations
involving the FAA's Southwest Regional office.
Almost nightly there are news stories of major commercial
airlines grounding hundreds of flights for maintenance
inspections. All of a sudden, hundreds of flights. I do not
know how you measure the damage caused to people with the
inconvenience of you doing your work a little bit earlier so
that this does not happen. But I know that you would come out
on the losing side of that balance.
Bottom line. Each passing day brings more questions and no
answers. Despite the growing questions surrounding FAA's
oversight of the airline industry--and excuse me for saying
this, it is not meant to be political, it was probably true in
the previous administration--the White House and the Department
of Transportation remain unbelievably and inexplicably silent.
Silent. They just leave it up to you to take the blame. The
administration should be assembling a task force to investigate
this issue. It should have done so weeks ago and make
recommendations for improving aviation safety. But they do not
seem to be interested.
The FAA has taken some steps to rebuild the public's
confidence in the Agency's core mission of maintaining the
safety of the Nation's aviation system, and moving forward, the
FAA needs to take a real good look at itself. The FAA is an
agency spiraling downward and I think is losing the confidence
of the American people and the Congress. So I think you have to
take a look at yourself, and you have to figure out your
external relationships with commercial air carriers and how
that contributed to the current situation.
Many, including myself, have long criticized the Agency for
being too close to the industry it regulates, a point that Mr.
Brantley made. It started in 1996 with the privatization of the
Agency. Congress grudgingly accepted provisions that would
allow the FAA to operate more like a business in the hope that
it would cost less to compete and to operate.
Well, the FAA is not a business. It is a government agency.
The FAA does not provide commercial services. It provides
public goods, which are air traffic control, aircraft
certification, and safety oversight. We pay taxes for these
services. You are not private. You are the result of our
taxpayers' funds and, hopefully, our oversight.
Clearly, it is time to start thinking about FAA
differently. Toward that end, we need the FAA to operate as a
most efficient and effective government agency. It is a subtle
distinction but one that I think is incredibly and deeply
important. Bringing about institutional change is never easy,
but when you have crises or near crises facing us it is
necessary. Mr. Sabatini talked about how everything was getting
better on incursions. Then you should look at the last 6
months, and you would find that incursion rates are headed
right back up. So I do not have confidence in your analysis
that everything is going well and you are striving for even
higher achievements. I do not buy that for 1 second.
The air traveling public wants solutions. They want to be
reassured that our Nation's aviation system is still the safest
in the world. No doubt, many of the witnesses will remind the
Committee that there has not been a fatal airline accident in
almost 2 years. This argument makes me mad because you have
mentioned an over 99 percent rate. We are working hard toward
that last 1 percent. No. You have got to get a 100 percent
right. You have got to be 100 percent right every single day.
And you say this is statistically the safest time to fly. Well,
let us hope it stays that way.
I have very serious concerns that there are an increasing
number of safety challenges facing the FAA and the industry
that, if left unaddressed, could lead to catastrophic
accidents. Mr. Chealander mentioned this. For instance, the
number of serious runway incursions remains unacceptably high,
and they are trending in a troubling direction, i.e.,
downwards. We have all read and seen stories of near misses at
our Nation's airports. Let us be honest. Had it not been for
the quick thinking and actions of a few air traffic controllers
and pilots, our Nation would have had one, if not several,
major incidents claiming hundreds and hundreds of lives.
So 99 percent does not impress me. Only 100 percent
impresses me, and that is all you should be talking about.
I do not mean to be dramatic. I am being long. I will,
therefore, conclude my statement and turn to Kay Bailey
Hutchison.
STATEMENT OF HON. KAY BAILEY HUTCHISON,
U.S. SENATOR FROM TEXAS
Senator Hutchison. Thank you, Mr. Chairman.
Let me say that I do think that things could be worse than
they are right now. I do think things are bad. But worse would
be if we had had a terrible accident and that is how all of
this came to light. I am glad that it was not a terrible
accident, but nevertheless, it has all come to light and I
think it means all of us have to work together to make sure
that the oversight is proper.
I am looking at the cancellations of flights. I have
certainly talked to the airlines that are canceling these
flights. And I know they are doing it out of an abundance of
caution and safety should be first. Nevertheless, the
inconvenience to passengers has to be addressed very, very
promptly, and when the safety inspections are made and it is
safe, the airlines need to do everything in their power to help
the passengers who have been stranded. And I have imparted that
to them.
So I think we are now looking at a couple of things. First
of all, this is the Committee that has the capability to pass
the FAA reauthorization bill. There are some very important
parts of that bill that we need to have put in place. There are
very tough negotiations not yet able to be had because there
are such disagreements between the House and Senate, some
disagreements between the Senate and the Senate, but mostly the
House and the Senate.
I know Senator Rockefeller and I have met with the Acting
Administrator and with the Secretary of Transportation
together. We are both committed to going forward on that bill.
But we are not going to move forward on the bill if it is going
to do more harm than good, and some of the House provisions in
our opinion would make it worse than it is now to just extend
it. So we will be grappling with that issue.
When I was on the NTSB, the mission of the FAA was almost
at cross purposes in some ways because it was the promotion of
aviation as well as safety. That is no longer the case. Today
it is a very clear mission of the FAA, and that is safety.
I do not disagree with the concept of the voluntary coming
forward approach rather than the sort of crime and punishment
approach because I think in some ways it has worked well.
However, it will only work well if there is a real safeguard in
the system so that if there is a lessening of the companies'
vigilance on safety, that that would be captured very quickly
and we would be able to address it within the system, meaning
the FAA would be able to address it within the system.
So I think what I would be looking for from the FAA is that
safeguard because I think having the collaborative culture has,
in the main, been a good thing, and I think most companies
realize that safety is in their best interest as well as in the
public's best interest. So I think everyone has the same goal,
but when you have a problem that we have seen happen just in
the last few months come to light, then it is not just letting
people come forward and be whistleblowers more readily--that is
good--but we need something that catches it in the system
earlier than that so that you would be able to detect if there
was not a proper oversight.
So I think that what I am going to ask and what I would
like to hear from you is how you think we can address this
issue. Mr. Brantley brought it out. I think everyone on the
panel has acknowledged that we need to do more to assure that
the system works, but let us look at the ways we can do it and
see what the FAA is going to propose and move forward together.
That would be my goal.
So I thank all of you for coming, and I will look forward
to having questions to see if we can do what is Congress'
responsibility and then what the FAA proposes to do to police
itself.
Thank you.
[The prepared statement of Senator Hutchison follows:]
Prepared Statement of Hon. Kay Bailey Hutchison, U.S. Senator from
Texas
Chairman Rockefeller, thank you for convening the hearing this
morning. I would also like to welcome our panel. As a former Vice Chair
of the NTSB, I intimately understand the crucial mission the FAA has in
overseeing the Nation's airlines and aviation system. Aviation safety,
and the public trust that goes with it, is the bedrock of our national
aviation policy and we simply cannot allow for any degradation of
service to the flying public.
As we will hear from the FAA, the U.S. commercial aviation industry
is experiencing the safest period in history. I commend the FAA and the
air carriers for an excellent accident safety record, but there is
still much room for improvement. Fortunately, the recent incidents have
involved oversight issues, not accidents or the loss of life. Everyone
here today knows the stakes, and the loss of even one life is too many.
There is always room for improvement in aviation safety, and the FAA
needs to take that message seriously.
The collaborative safety system between the FAA and the air
carriers has been effective; however, it is time for that system to
evolve into the next generation of the Air Transportation Oversight
System (ATOS). The FAA must make an earnest assessment and review of
the safety foundation it has made and make some dramatic improvements
no matter how difficult they may be.
This Subcommittee understands there is a fine line between
voluntary disclosure of safety violations and the effective use of
traditional regulatory enforcement. I think the Subcommittee also
understands the movement away from a simple ``blame and punishment''
culture to a no penalty collaborative culture has allowed for
significant strides in aviation safety. However, the FAA needs to be
vigilant and take quick and corrective action whenever necessary, and
the agency needs to strengthen its current regulatory role and
processes.
Whether they are cultural, policy, or procedural changes, the FAA
needs to be open to change and progress. I am increasingly concerned
that the FAA will not learn from this situation and will maintain a
``bunker mentality'' instead of making the safety changes necessary to
improve the system. I believe the FAA needs to heed the recommendations
made by the Inspector General and work with the IG to revamp and
improve FAA safety policies.
Finally, the recent incidents that occurred between the FAA and the
noncompliant air carriers were an absolute failure on both the FAA and
air carriers' part. Those directly responsible should be held
accountable; such poor decisions by critical employees are not
acceptable in today's safety culture. The recent incidents are an
aviation safety wake-up call and everyone involved should use this
opportunity to improve the operation of the aviation safety system.
Thank you, Mr. Chairman; I look forward to the testimony and to
working with you on these important issues.
Senator Rockefeller. Thank you, Senator Hutchison.
I think it would be wise if we went down and voted because
by the time we get down there, it will be time. Let us come
back, and then as I said, members will be given 7 or 8 minutes
for questioning as opposed to 5, and they can include parts of
their statements in their questioning if they so choose. So we
stand in recess.
Senator Stevens. Senator, I cannot come back. I would like
to make a comment, if that is all right.
Senator Rockefeller. Yes, please.
STATEMENT OF HON. TED STEVENS,
U.S. SENATOR FROM ALASKA
Senator Stevens. I am a pilot and I have been a pilot for a
long time. I think one of the things that the Inspector General
and those who are checking these systems ought to examine is
the updating of the diagnostic systems. For instance, I was
just reminded of the number of times that we have gotten onto
an airplane and oncoming pilots check the systems. The
diagnostic system shows there is a light on, and everybody sits
and waits for that to be checked. Why should that not be the
job of the people who just left the airplane? The last pilot
operating a plane ought to go through the systems and certify
that there are no lights and no reason to have any maintenance.
Second, it does seem to me that what we need to do is
develop the concept that one of my friends told me about, and
that is that we have this paradigm now in the United States
that we manufacture to perfection. Motors are built to be 100
percent perfect, and that is what the Chairman wants. But the
way you check it is with diagnostic systems.
You mentioned the Alaska Airline catastrophe off of
California. I had friends on that plane. I went out to check
that myself. The jackscrew was the responsible item, and that
did not have a diagnostic system on it. There was no way for
the pilot to tell that that was fouling up. In normal
operation, it could foul up.
Now, I do think what we ought to do in terms of this
concept of the ongoing interest in the operation of our
airlines is to assure that we do have the diagnostic systems
that maintain the requirement for 100 percent perfection.
We are all talking about inspections. Very plainly--and I
apologize for it--I do not think that the inspections are what
we ought to be concerned with. I think we ought to be concerned
with the diagnostic systems being in place and everyone
knowing, before they get on that airplane, that the systems
show that the operation is perfect. It does seem to me we ought
to catch up with technology and rely on technology a great deal
more than we do today in this maintenance system.
Thank you, Mr. Chairman.
[The prepared statement of Senator Stevens follows:]
Prepared Statement of Hon. Ted Stevens, U.S. Senator from Alaska
Good morning, my thanks to Senators Rockefeller and Hutchison for
holding today's hearing on aviation safety. Given the recent high
profile maintenance incidents and the continued economic woes of the
airline industry, it has never been more crucial that our aviation
safety system is operating at its highest level.
The U.S. aviation safety system is a complex and redundant system
that includes layers of coordination between many stakeholders
including the FAA, air carriers, manufacturers, pilots, inspectors and
controllers, amongst others. When the ``safety first'' culture breaks
down, as in the Southwest Airlines incident, it is not acceptable.
The FAA and all the aviation stakeholders involved have a
professional and moral responsibility to maintain the utmost level of
aviation safety. In Alaska, the aviation community has worked hard to
create an ever improving culture of safety. As I have told this
committee many times, Alaska is dependent on aviation more than any
other state. With the vast spectrum and sheer amount of commercial,
cargo, combi, and general aviation in our state, it has been a
challenge to continually improve our accident rates.
Through programs like Capstone, Alaska has been able to make
dramatic strides in the area of aviation safety. The FAA and Alaska
aviation industry stakeholders have set a long-term goal of equipping
Alaska-based aircraft and installing ADS-B ground infrastructure to
cover 90 percent of the operations in our state. By working
collaboratively to reach that goal, the FAA estimates there will be a
33 percent reduction in fatal accidents over the next 27 years.
In addition, because Alaska has 6 times the number of pilots per
capita compared to the Lower 48 and 14 times the number of aircraft,
the aviation community initiated the medallion foundation. Medallion is
a voluntary program for air carriers and pilots in Alaska that
establishes safety standards that exceed regulatory requirements that
help the Alaska aviation community detect safety trends or needs before
actual accidents occur.
The benefits of Capstone and Medallion would not have been realized
without the collaboration between the Alaska aviation stakeholders and
the FAA. The FAA can learn a valuable national lesson from the Alaska
example.
While the process of change is almost always difficult for both the
FAA and the stakeholders involved, the safety benefits far outweigh the
angst it took to get them. The FAA needs to take a renewed look at the
way it implements its aviation safety partnership programs. FAA needs
to thoroughly review the recommendations of the DOT IG and take quick
corrective action to address the problems.
Mr. Chairman, at this time, I also have a copy of prepared written
testimony from the Alaska Air Carriers Association that I would like to
submit for the formal record. I ask that it be included as part of
today's hearing [published in the Appendix of this hearing record].
Thank you, I look forward to the testimony.
Senator Rockefeller. Thank you, Senator Stevens.
Senator Inouye has some comments.
STATEMENT OF HON. DANIEL K. INOUYE,
U.S. SENATOR FROM HAWAII
The Chairman. I thank you very much.
Perfection may be impossible to achieve, but I agree with
Chairman Rockefeller that it should be our goal, even knowing
that perfection cannot be reached.
Having said that, my first flight on an aircraft was in
1944 in Italy. It was a thrilling experience. Since then I have
done much flying. Two weeks ago, I received a certificate from
one of the major airlines congratulating me on 3 million miles
flying. And I suppose if you add the other airlines that I have
flown on, together with military aircraft, it must have
exceeded 4 million miles, close to 5 million.
The only problem that I remember, during all these hours of
flying, was landing in Honolulu from Los Angeles on two
engines. Two engines were put to rest and we landed on two. It
was a perfect landing. No one got hurt.
I want to say that I have concluded that the safest way of
traveling is by air. I think it is much safer than going from a
residence to the shopping center or traveling to and from work.
But having said that, I would hope that we will be able to
do what the Chairman suggested and strive for better
statistics, not 1 in 15 million flights, but maybe 1 in 50
million flights.
So with that, I would like to thank all of you for having
done your best to give us safe travel. I have other concerns
which I will ask when my time comes around.
I do not know why, but I suppose it is culture and
tradition that we frown upon snitches and whistleblowers. But
in this day and age, whistleblowers play a very important role,
and I hope you take them seriously.
Thank you very much.
[The prepared statement of Senator Inouye follows:]
Prepared Statement of Hon. Daniel K. Inouye, U.S. Senator from Hawaii
The traveling public has been very fortunate that despite the
recent publicized lapses in safety inspections and maintenance, we are
currently experiencing the safest period in the history of aviation.
Safety is the paramount consideration upon which our commercial
aviation system was built. It should be the highest priority for air
carriers and the core value for pilots. This single-minded focus on
safety has served the U.S. aviation industry well. And it must always
serve as the primary guide for all the decisions made by the FAA.
Unfortunately, the aviation industry's safety reputation has been
recently tarnished. Last year, this Committee's hearing on the FAA's
oversight of repair stations raised significant questions about whether
the agency has the ability and the resources necessary to keep track of
the complex, global operations of many air carriers.
Equally disturbing are the recent revelations that airlines have
not complied with a number of Airworthiness Directives. Over the past 2
days, American Airlines was forced to cancel approximately 2,100
flights in order to re-inspect wiring on their MD-80 aircraft. As a
result of the incidents reported over the last few months, I have
serious concerns about the FAA's ability to maintain a vigilant safety
oversight program.
It is my hope that this hearing will provide us with a better
understanding of how these recent lapses in safety occurred and what
the FAA is doing about it. The Congress will not tolerate poor
oversight of the safety of air travelers.
As we proceed with the reauthorization of the FAA, we must ensure
that Congress provides the agency with the resources necessary for
effective oversight of our commercial aviation system. We must also
consider what additional authorities may be necessary for the FAA to
ensure that safety remains the hallmark of the U.S. aviation system.
At the same time, the FAA must vigorously ensure that commercial
air carriers are complying with their safety mandate in a thorough and
timely manner.
The traveling public may be assured that this Committee will
continue to monitor the FAA's and the aviation industry's efforts to
improve on its safety record.
Senator Stevens. Mr. Chairman, we could do a lot if we just
got that renewal of our aviation bill, the FAA bill out. I
think some of the changes that are mandated in that bill would
be very helpful in this discussion.
The Chairman. Yes, sir.
Senator Rockefeller. We stand in recess.
[Recess.]
Senator Rockefeller. Members are returning. We had three
different votes, which is a lot of time, and we apologize.
I am going to go ahead with my questioning. I will start
with Mr. Chealander. I made the comment in my opening statement
that I believe that the U.S. aviation system may be operating
on borrowed time before another major accident. Do you share
that view?
Mr. Chealander. I will say that, as we pointed out in our
testimony, the runway incursion issue is one of our hottest and
major topics. I was asked a question just a day or so ago that
goes along with your question, Senator, and that is, where do I
expect the next major accident or incident to happen. And I
believe it is in that area.
We are working very hard on that. I would not say that we
are all standing around waiting for the next shoe to drop, but
we are working very hard on, as was pointed out earlier, the
layers of safety and protection that we can recommend be put in
place to stop those runway incursions from being a catastrophic
accident. So runway incursion I believe is the direction that
we are looking at the hardest to try to prevent an accident
from happening.
Senator Rockefeller. A question for Mr. Sabatini. You know,
American Airlines canceled 1,000 yesterday, 900 today. I do not
know what all the other scores are because I did not really
have a chance to read the newspapers. But it is catastrophic
economically, and it is an embarrassment to the Nation. I
cannot imagine what people in Indonesia or Japan are thinking
about this. Some people would say I do not care. I do care
because it is who we are as a Nation, and it does not strike me
as impressive right now.
American Airlines recently grounded its fleet of MD-80
aircraft for a second time. Other carriers have done the same
thing to make sure they were in full compliance with FAA
regulations. This has, obviously, caused a volcanic disruption
which, in and of itself, is unthinkably uncouth.
If the FAA had conducted more regular and frequent
compliance audits on the industry, would you have caught these
problems earlier, and had you caught them, would there have
been less disruption for consumers?
Mr. Sabatini. Mr. Chairman, that of course, would be a
speculation on my part, what would have happened.
But I can tell you, Mr. Chairman, that this is a system
where I have 3,800 FAA inspectors and there are hundreds of
thousands of safety professionals in the industry who have the
primary responsibility of the compliance. Our oversight system
is one of assuring compliance. We have put in place the ATOS
system, which is far more robust in identifying these areas. We
identified them as areas of risk. And we are at a point in time
talking about----
Senator Rockefeller. You are not answering my question. You
do understand that. I did not ask you about what you are doing
to prevent this from happening. I am asking if you had done a
better job before, would some of these cancellations have been
forestalled?
Mr. Sabatini.--if this had been identified at another point
in time, I believe the outcome would have been the same. The
carrier was not in compliance with an Airworthiness Directive.
We brought that to their attention, and they made the right
decision. They put those aircraft on the ground until they
could demonstrate compliance.
Senator Rockefeller. Yes, they did, but the fault did not
all lie with them. I would just say that for the moment.
Let me go on as you defend the FAA. You have stated that
Southwest improprieties and safety violations, including
missing structural inspections on 46 jets, resulted from a
``failure on the part of the leadership at the regional
level.'' That makes me want to ask a couple questions.
What responsibility do you bear? What responsibility does
the senior leadership of the FAA bear for letting this
situation spiral out of control? Is this one of those things
like Abu Ghraib where you sort of get rid of the people way
down low, but nobody up top ever has to be accountable? What
responsibility do you bear for this?
Mr. Sabatini. I am ultimately responsible for the safety
organization, sir, and I am taking all the action that I need
to take to address what we have learned. That was a failure, as
I have said, on the part of people, people who failed to
discharge their duties as they are required to on both the FAA
side and on the air carrier side.
Senator Rockefeller. So you are responsible, but you do not
have to take responsibility. You do not have to be accountable.
You are responsible, you do not have to be accountable.
Mr. Sabatini. I am accountable, sir.
Senator Rockefeller. Well, if you are accountable, you
should have been howling in my office and Kay Bailey
Hutchison's office some time ago. It just gets into that whole
syndrome of where punishment should occur. If you want to
punish somebody, you punish individuals at a lower level and
always refer to a regional problem. It is never your fault. It
is a regional problem. Well, the regional problem is, in fact,
FAA headquarters because you control the region. So I am not
satisfied by your answer, but I will go ahead.
What responsibility do you and the senior leadership of the
FAA bear for letting this situation spiral out of control?
Mr. Sabatini. I am not sure exactly what it is that you
want me to say, Mr. Chairman. I am accountable and I am
responsible, and I take my responsibilities very seriously. I
have been a safety professional my entire adult life. I have
been in public service and have been dedicated to public
service and I accept that responsibility. And I want you to
know that I take what has happened very, very seriously. I am
not a theorist about safety. I have started in this
organization as an inspector. I know the business from the
bottom up and I take what happened very, very seriously, sir.
And I do hold myself accountable.
Senator Rockefeller. Sometimes when people have been in
office for a very long time and they have worked very hard to
work their way up through the bureaucratic ranks so they can
get to be in a position as high as you, they have to make
certain compromises. I am not saying that you have, but I am,
nevertheless, putting that out there.
Why did other senior leadership in Washington not step in
and address the severe management problems at the Southwest
Region office?
Mr. Sabatini. We did, immediately upon it coming to our
attention. When we became aware of what was going on and the
gravity of what was taking place, we took the action that we
could take.
Senator Rockefeller. Well, Mr. Stuckey was the head of the
regional Flight Standards office who supervised government
inspectors assigned to Southwest. He works for the FAA, for
you. You have removed him from all safety oversight
responsibilities and transferred him who knows where. Yet, he
remains on the FAA's payroll. Now that may be because you have
due process in terms of terminating employees. So I also assume
that once this process is completed, he will no longer be an
FAA employee. Am I correct?
Mr. Sabatini. Well, let me make a statement, sir, that does
not prejudice any future outcome. We are looking into this and
investigating it thoroughly. I would not want to prejudice a
future outcome. As you well know, in civil service, everyone
has rights, and we have got to honor those rights.
Senator Rockefeller. It sounds very much like the
Department of Defense where nobody at the top ever gets fired.
No three stars, no four stars, just people lower down.
My follow up question, then I will stop. Will the FAA act
against any other senior managers in headquarters office? And
if not, why not? You are accountable. You are responsible.
Mr. Sabatini. I will say again, sir, that we will examine
everything surrounding this circumstance and we will take
whatever action needs to be taken.
Senator Rockefeller. Yes. I have been told to move on.
Senator Hutchison?
Senator Hutchison. I want to clarify with Mr. Sabatini that
the regional administrator of the FAA who was responsible for
the incident with Southwest Airlines has been removed. Is that
correct?
Mr. Sabatini. He has been relieved of the duties he had in
the Flight Standards Division, which would be the ranking
senior person in the Flight Standards Division in the Southwest
Region.
Senator Hutchison. Correct. And there would be nothing that
you could do that would overcome your legal requirements to
give that person all of the due process that the law requires,
which is why you could not say he has been fired or would be
fired at this time. Is that correct?
Mr. Sabatini. That is correct.
Senator Hutchison. Let me ask you this because I think,
from what I have learned, that the issue is being addressed
after the fact with what happened between Southwest and the
FAA. However, I do want to ask you to be more specific--and
others on the panel may come in on this--about what would be
the trigger in the procedures that would allow this to come
forward much earlier than it did with the Southwest case?
Mr. Sabatini. Well, Senator Hutchison, you made a very
important comment in your opening statement. We are here today
not post-accident, but at a point in time where the system is
incredibly safe. And I also said it is that tiny little
percentage that keeps me awake at night continuing to look for
remaining risks.
This is an opportunity that has been brought to our
attention and which was a failure and requires attention. What
we have realized about what happened at Southwest is that
people who have a safety concern did not have a direct
mechanism to elevate it to people like myself.
I am putting in place a system where it is going to be
documented with a control number. Any safety professional
working at any level in our organization can feel free, without
fear of repercussion, to come forward and document what it is
that they want to have discussed, entitled to resolution, and
if not resolution, then it continues to be elevated all the way
up to me. It will be subject to a review and we will hold
people accountable that this process works. It will be
finalized by the end of April, and it will guarantee that
people in a safety culture like ours will be encouraged to come
forward to express their concerns. We have an organization of
very experienced people who have safety backgrounds and have
differences of opinion. We need to be sure that we resolve
those differences of opinion in a constructive manner because
we want to better serve the public.
Senator Hutchison. I want to bring up one other point, and
then I want to ask anyone else on the panel who would wish to
speak on this. At this point, is it correct that a person who
works for a company cannot go into the FAA system and oversee
or be in the process of overseeing that same company for a
period of 2 years? Is that correct?
Mr. Sabatini. That is true.
Senator Hutchison. Do you think that there should be a
complete ban on that capability, or do you think there should
be a different number of years beyond which a person could then
go back and work with the company from which they came and are
now on the other side of the safety inspection process?
Mr. Sabatini. We are going to initiate a rulemaking project
which will address that, Senator. We are going to basically
have a rule that will prevent a person who would be a former
FAA person to be hired by an air carrier and then have direct
interface with the FAA. We are looking for a 2-year moratorium
before that person can have interaction with the FAA if they
have been a former FAA employee.
Senator Hutchison. But are you looking at keeping 2 years
as the time?
Mr. Sabatini. Well, currently people that we employ who
come from the industry have a 2-year moratorium before they can
have any direct oversight responsibility of a previous
employer. We are going to basically just have a mirror image of
that when someone leaves the FAA.
Senator Hutchison. And you think 2 years is the right
amount of years?
Mr. Sabatini. I believe it is. I think history has shown
that that seems to be an adequate period of time.
Senator Hutchison. I would like to have any other views on
that. Mr. Brantley or Mr. Chealander?
Mr. Brantley. Senator, yes. We do believe that having the
same cooling-off period going both ways would be appropriate,
and something in the 2- to 3-year time-frame would be adequate,
yes.
Senator Hutchison. And do you think that a complete ban
would be not reasonable, not realistic?
Mr. Brantley. By complete, are you referring to no
timeframe, just----
Senator Hutchison. Just that a person who comes either way,
industry to FAA or FAA to industry, that it would not be the
same company ever. Is that not realistic?
Mr. Brantley.--to be honest, I had not considered that, but
that is certainly a possibility. It is not as if there are not
plenty of other companies to work for or to do oversight on. So
I would consider that and get back to you.
Senator Hutchison. We would have to think it through, I
know, but I just wondered if there are enough professionals
capable of going either way. But I think we ought to look at--
if you are going to do a rulemaking at 2 years, I think we
should certainly look at comments on whether that is the
realistic time.
Mr. Chealander, did you have anything to add to that?
Mr. Chealander. Only that in my own instance, which is
about all I can draw on because from the NTSB's purview, we do
not investigate accidents and find whether a moratorium on
employment was an issue or not, nor do we any data to identify
that. But in my situation, for instance, coming from private
industry, an airline in specific, and coming to the Federal
Government and the NTSB, I had to sign an ethics agreement that
recused me from that airline for ethical reasons. So I can just
only cite the example of myself and use that in the thinking as
to whether or not that is a good idea.
Senator Hutchison. Thank you very much.
Thank you, Mr. Chairman.
Senator Rockefeller. Thank you, Senator Hutchison.
Senator Lautenberg actually came in. So, Senator, you are
up.
STATEMENT OF HON. FRANK R. LAUTENBERG,
U.S. SENATOR FROM NEW JERSEY
Senator Lautenberg. Thanks very much, Mr. Chairman. I would
like to proceed first with my opening statement. As I
understand it, we will have the questions included in the same
timeframe. So I thank you, Mr. Chairman.
Since we are now discussing some things that I have talked
about on a continuing basis, I appreciate the fact that we have
got a chance to review some of the specifics. Some of them are
so current that it is hard to believe that, though the reasons
for the problems were obvious, so little was done at the FAA.
Every day more than 2 million men, women, and children
board planes across America with a trust and an expectation
that those airplanes in our aviation system are safe.
And Mr. Sabatini, I refer to some part of your testimony.
You said a total 1,451 commercial operations were conducted by
Southwest Airlines in violation of the law, putting thousands
of people at risk. And I want to keep that in mind as we go
further because that issue does not square with the activities
of FAA and with the safety inspectors.
The Bush administration's FAA has abused trust by putting
people's time and their safety at unnecessary risk. Now, some
may argue, as you said, that this has been one of the safest
periods in aviation history. Thank goodness it has happened,
but it has happened in spite of FAA policies, not because of
them.
Far too often we have had to rely on quick actions of
pilots, air traffic controllers, other professionals, even
people who are working for the airlines on the ground to keep
our families safe. We also had the benefit of some improved
technology over these last years, some of it fairly small in
terms of increments, but nevertheless important, and we have to
continue that.
But we have seen record flight delays, increases in near
collisions on our runways, understaffing of controllers and
safety inspectors.
And the FAA has mismanaged the redesign of the New Jersey-
New York airspace, and that has led to planes flying in the
wrong direction over a highly congested region, creating
potential safety problems.
Recently we have seen disturbing reports about safety
inspection failures, letting planes filled with passengers take
off with cracks in their hulls. These failures were not
isolated to just a few planes, as now we all know. In fact, one
airline alone missed hull inspections on 47 different
airplanes.
Similar inspection failures have caused five of our
country's largest airlines to cancel thousands of flights, most
recently American Airlines, with over 2,000 flights canceled.
The pattern is not only disturbing, but obviously, it is
unacceptable. There are several pending investigations of these
failures, including ones by the Inspector General, the FBI, and
Congress. And I look forward to hearing their findings and to
acting upon them.
Mr. Chairman, I regret to say that this is a management
failure at the highest level of the FAA, but instead of
providing innovative leadership and changing the way the agency
does business, President Bush is opting for more of the same.
And he has nominated Robert Sturgell, FAA's second in command
for the past 5 years, to take over at the agency. Now, I do not
get that, I must tell you. Mr. Sturgell has to be held
accountable, not promoted.
And these recent problems also make it clear that we must
pass a reauthorization bill for the FAA pretty soon. Chairman
Rockefeller has worked hard on this subcommittee and the full
Commerce Committee to accomplish this goal, and I applaud your
efforts. And I am going to do my part to get that bill passed,
which I hope will include runway safety legislation that I have
proposed for some time now, and will soon introduce.
I thank you, Mr. Chairman, for the opportunity to move
along with this.
Since 2003, Mr. Sabatini, the FAA's customer service
initiative has let airlines blow the whistle on who they think
are bad inspectors, but it took until last week for the FAA to
create a way for its own inspectors to blow the whistle on bad
airlines. Why has the FAA been putting the concerns of the
airlines ahead of the concerns of your own safety inspectors? I
do not get it. Please tell me why.
Mr. Sabatini. Mr. Chairman, our primary motivation here is
the safety of the public. We absolutely know that the public is
our customer.
And I believe there is a misunderstanding about the
customer service initiative. I will be very happy to change the
name of this initiative, but it was primarily designed, sir, so
that we could have consistency. What was known about our
organization is that you could have one decision made on the
East Coast, for example, and on the very same regulation, a
different decision made on the West Coast. And we need to be
consistent and standardized. And that is the purpose of that
initiative, that any decision made anywhere in our organization
by the FAA needs to be consistently applied everywhere
throughout the system. It was not intended nor ever designed to
allow people to complain to have inspectors removed from their
areas of responsibility.
Senator Lautenberg. Well, it certainly has not encouraged
people to blow the whistle, people who have no funded interest
in these things.
Mr. Brantley, do you have a comment to add on this?
Mr. Brantley. Yes, thank you, Senator. I think regardless
of the intent when it was developed, the customer service
initiative has become a bit of a weapon rather than a tool for
inspectors. And I would be hard-pressed to imagine how any kind
of good is coming out of it at this point because people do not
trust it, the inspectors that should be able to rely on it to
help them.
I think one big thing not to overlook--and I think you
alluded to it, Mr. Chairman--there is a culture, a philosophy
within the FAA right now that encourages this type of activity.
And until that changes, all the programs, all the hotlines in
the world will not make a bit of difference. People right now
feel they do not have the right to speak out, and if they do,
they will be targeted. And adding another hotline will not help
that.
Senator Lautenberg. Thanks, Mr. Chairman.
Senator Rockefeller. Thank you, Senator Lautenberg.
Senator Klobuchar?
Senator Klobuchar. Are we going every other one? I am glad
to go. I just wondered if it was Senator Snowe's turn.
Senator Rockefeller. Do you want to fight?
[Laughter.]
Senator Klobuchar. No. I think in the proper order that
perhaps she would go.
Senator Rockefeller. Were you here first?
Senator Snowe. Yes.
Senator Klobuchar. Yes.
Senator Rockefeller. Then Senator Snowe. The Chairman made
a mistake.
STATEMENT OF HON. OLYMPIA J. SNOWE,
U.S. SENATOR FROM MAINE
Senator Snowe. I thank the Senator. See, there are
senatorial courtesies. Thank you, Mr. Chairman.
I want to thank you all for being here.
This is, obviously, a crucial hearing with respect to
aviation safety, without question. I think we are all stunned
by, I think, the breath-taking lapses in leadership in
enforcing safety standards within the FAA.
We have had this debate within this committee, I well
remember, 10 years ago after the crash of ValuJet. We debated
and I was championing the initiative about eliminating the dual
mandate within the FAA charter to promote the aviation
industry, but at the same time, it had the responsibility for
being dedicated to upholding safety standards. And it seemed to
be conflicting and contradictory missions and responsibilities,
and I wanted them to transferred to other offices in the
Department of Transportation so that the FAA could singularly
focus on the question of safety.
And I see a systemic breakdown here, as I think has already
been illustrated in Mr. Scovel's, Mr. Chealander's, Mr.
Brantley's testimony. I know, Mr. Sabatini, you indicated in
your remarks that this is an isolated incident, but I certainly
do not see it that way.
I think at the heart of the problem is the culture at FAA,
and hearing here today not only that--the whole idea on
Southwest and then it is Northwest--I mean, the breadth of the
problem and the dimensions of the problem and the fact that
inspectors were fearful bringing to superiors' attention, and
when they did, they feared penalties. They had to resort to
whistleblower protections in order to do their jobs. I mean,
that is unconscionable.
So there is a breakdown. There is a breakdown within FAA,
and the sooner that you and all the leadership at FAA recognize
that, the better off we will be and, more importantly, the
passengers who are flying across this country by the millions.
I mean, that is what we have to deal with now because it is
clear that passenger safety was put at risk. I mean, when 46
Southwest Airline aircraft were flying even in spite of failing
inspections and even was encouraged to fly by a supervisor, I
think it is an indication of the depth of the problem within
FAA. It is not an isolated incident.
And in looking at the Inspector General's testimony and
report, it seems to me it speaks volumes about the actions that
need to be taken to reverse the situation within FAA. I would
like to hear from you today that you are going to embrace those
recommendations and going to reverse the situation within FAA
because if it is a collaborative, cozy relationship which, by
all indications, it appears to be and that safety was placed
secondary to all other issues, whether or not to allow airlines
to avoid penalties through the self-disclosure mechanism,
whether or not to rely on self-disclosure, knowing full well
that the FAA inspectors were not conducting those inspections.
When more than 70 percent, I think Mr. Brantley indicated, were
sitting at their desks rather than conducting the inspections,
we truly have a major problem.
And I think more than anything else, in order to rectify a
problem, you have got to recognize it, acknowledge it,
understand it, and do something about it. And I hope that in
this hearing and the other hearings that you are a part of,
that you will express that because if you do not, then we are
going to continue to have the problems that are pervading FAA
today. And that is just the beginning.
I mean, we not only have a lack of inspectors, but we are
also deficient in air traffic controllers. I know that has
happened in Maine, but it is throughout the country. Many of
them are going to be retiring and they are retiring in
unprecedented numbers, and many of the trainees are being
rushed through a program without understanding the
comprehensive dimensions of the air traffic control system. If
you have a lack of inspectors, which has basically been the
backdrop for the safety regime within the FAA, and now that we
are learning all that we are currently, clearly this is a
crisis.
So I would like to have you explain to me exactly how FAA
is going to go about redressing these issues and accepting the
Inspector General's recommendations. What steps are going to be
specifically taken in order to address that? Because clearly,
it is a cultural problem. Before it was promoting the aviation
industry and also doing the dual responsibility of upholding
safety standards.
Now it is the customer service initiative that, obviously,
is complicating matters here. It is one thing to have a working
relationship with the aviation industry, but you can never lose
sight of your primary mission and what the intent and purpose
is of the FAA and what your responsibilities are designed to do
and to uphold, given what is at stake.
So what do you intend to do within your position at FAA to
embrace the Inspector General's report and all the other
recommendations that have been made here today with respect to
what has happened within the FAA?
Mr. Sabatini. Thank you, Senator.
I would first like to say that my organization is the
largest it has ever been, thanks to the help of the Congress in
getting us to the size of an organization that we are today.
Over the past 3 years, we have added over 400 people, about 430
people, to the FAA inspector ranks.
And I will tell you that what we see in terms of real
evidence of what failed, it happened in the Southwest Region.
Please do not take that to mean that I am discounting that it
could potentially be happening elsewhere. No one today has
provided me the objective evidence to, in fact, say it has.
But having said that, I can assure you that I am addressing
this from a systems perspective. I am going to put in place, as
I mentioned earlier, a process. Some may not like it in terms
of referring to it as just another hotline. It is not. I will
hold myself and every person in the management chain of command
accountable to assure that we have an atmosphere where
inspectors, safety professionals can come forward and air their
differences and have it resolved. And I will have a process in
place that will assure regular review of these situations that
arise. They will have control numbers and they will be known to
me.
I will also put in place, as I have mentioned, actually
requesting a project for rulemaking, and that is, requiring
that inspectors who are hired by an air carrier cannot have
direct interaction with the FAA for a 2-year period.
And we are going to change how a voluntary safety
disclosure can be given to the FAA. We are going to require
that only people who are officials, high level officials, in
the airline can be the persons who can come forward to the FAA
and submit a self-disclosure that has not been previously known
to the FAA. And on the FAA side, we are going to require that
only an office manager can accept that. And those will be
subjected to review.
As far as Airworthiness Directives, which, as you well
know, are very technical and complex engineering documents,
what we have learned here is that there are technical
interpretations, but you have got to be fully compliant. You
cannot just be a little bit compliant. And that is basically
what you are seeing here with carriers canceling some flights.
They must be in compliance.
So we are going to review that entire process and have
greater involvement so that we do not face this kind of a
situation again.
Senator Snowe. May I ask, Mr. Scovel? Because I think this
is a critical issue as to whether or not you feel that FAA is
on track to adopt many of the recommendations that you have
made and many of the issues that you have disclosed within your
report because this wink and a nod by inspectors and
supervisors within the FAA is clearly disturbing when it comes
to what the potential down side would have been for placing
people in life-threatening situations.
Mr. Scovel. Thank you, Senator. I appreciate that you have
clearly read our testimony and endorsed our recommendations.
They were very carefully planned as a ``road map'' for FAA to
improve safety oversight. We believe the Agency can do so, but
it requires will, and we have seen on too many occasions, as
you just put it, a wink and a nod from FAA instead of a
demonstration of true will.
My testimony references a couple of our reports that
examined the ATOS system and its nationwide implementation. In
2002, we reported that CMOs were inconsistently applying the
ATOS system across the country. We recommended that FAA provide
stronger national oversight and implementation and we were
assured in 2002 that the newly appointed Flight Standards
Division Director would undertake that responsibility. It did
not happen.
In 2005, we again examined the ATOS system and found that
26 percent of key inspections were not conducted and that half
of those were in risk areas. Our recommendation was the same as
in 2002: FAA needs to provide national oversight and should not
push it down to the region or decentralize it to autonomous
CMO's. Instead, FAA should bring it up to the national level
and exercise some control. That recommendation from 2005
remains open.
Had FAA implemented our recommendations from 2002 and 2005,
it is possible that we would not be here today because
Southwest's AD compliance program would have been included in a
robust national oversight program to help FAA follow its own
procedures with regard to ATOS.
Senator Snowe. Thank you, Mr. Chairman, and thank you.
Senator Rockefeller. Thank you, Senator Snowe.
Senator Klobuchar?
STATEMENT OF HON. AMY KLOBUCHAR,
U.S. SENATOR FROM MINNESOTA
Senator Klobuchar. Thank you, Mr. Chairman.
This hearing comes at a critical time for the FAA with the
recent GAO report that revealed that air travelers really do
face a high risk of catastrophic collision on U.S. airport
runways. It highlighted the malfunctioning technology. It
highlighted the issues with the FAA, as well as overworked air
traffic controllers.
On top of the study, in recent weeks we have learned of
aircraft skidding off of runways and crossed wire sections and
pieces of airplanes falling off in mid-air.
Most recently we learned of the Southwest issue with nearly
50 planes in need of required inspections for fuselage cracks.
And just yesterday, American Airlines grounded 1,000
planes, and today they have canceled more than 900 additional
planes. All of this in order to double back and conduct
inspections that should have been done as a matter of routine.
The disclosure of these safety lapses and the thousands of
flight cancellations--you just turn on any news program today
and you see the people stranded there--leads to questions about
the current inspection policy.
Now, as I understand it, this voluntary inspection policy
has some merit, but it was designed to go hand in hand with
rigorous enforcement. Unfortunately, in recent weeks we have
heard, as Mr. Scovel described it, of an overly collaborative
or, some might say, cozy relationship between the inspectors
and those that they are supposed to enforce the law against.
And to some inspectors' views, the FAA considered these
airlines to be their customers. And I think one underlying
principle that has to be clear here is the American public is
the customer and not the airlines.
So with that in mind, one of the things I wanted to know
from you, Mr. Sabatini, is do you think it is time for some
soul-searching like we had after some of the crashes in the
mid-1990s to make some changes?
Mr. Sabatini. The safety model is always subject to review,
and it is an ongoing 24/7/365 activity not just by the FAA but
the other safety professionals in the industry. And I want to
make it clear we know that the public is our customer and that
safety of that flying public is what we are addressing each and
every day.
And if you take a look at what happened since 1997, we have
significantly reduced the accident rate to where we are today.
And again, that is not to rest on our laurels. It is just that
you have to know history to understand where you are going into
the future, and the safety model is a very good model. Can it
be improved? It absolutely can. I take this as an opportunity
to learn more, and we are taking steps.
And I would like to address what the Inspector General
said. He has proposed certain initiatives to undertake. We are
undertaking most of those, and I would also like to, for the
record, say that we have made a change in one of those
recommendations that were brought to our attention in 2002 and
2005.
Senator Klobuchar. But I think Mr. Scovel's point was--I do
not want to put words in his mouth--that some of these
recommendations were made before. They were not followed. I
guess I would ask Mr. Scovel. You heard what Mr. Sabatini said.
I went through all of your recommendations. One was that there
should be a cooling-off period. Do you think that his proposal
addresses that?
Mr. Scovel. It will. Of course, we will need to examine the
details. We think it is the key one because, again, it comes
straight from the Southwest incident, in which an FAA inspector
went to work for the airline he used to oversee in September
2006. Shortly after that, there were AD overflights or
violations reported to FAA under the Voluntary Disclosure
Reporting Program.
Senator Klobuchar. And how about this idea that you rotate
where the inspectors are? Do you think Mr. Sabatini has
addressed this?
Mr. Scovel. We intend to work that out.
Senator Klobuchar. So he has not addressed that yet.
Mr. Scovel. We have discussed it. In fact, he and I have
talked on the telephone at least twice in the last week since
our appearance together over on the House side. We understand
that there are union concerns and contract concerns with FAA
when it comes to their inspectors.
Senator Klobuchar. One of the things that I have heard
about is this gaming of the inspection process. For instance,
the FAA may tell the airline on Monday they are going to
inspect it on Wednesday, and the airline then discloses its
safety problems on Tuesday. And the airline then avoids the
penalty under the Voluntary Disclosure Reporting Program.
Do you see this as a problem? I guess I would like both of
you to address that.
Mr. Scovel. I can say that there is certainly the
appearance of that at Southwest. We have not been able to
determine that exact sequence. Customarily, I know that.
Senator Klobuchar. But if it was occurring, would you see
that as a problem?
Mr. Scovel. Absolutely.
Senator Klobuchar. Mr. Sabatini?
Mr. Sabatini. If that was occurring, I would absolutely
agree with the Inspector General. That is a problem. But the
guidance is very clear, and we are going to reinforce that
guidance that that is absolutely unacceptable.
Senator Klobuchar. Another issue that has come up is that
under the Voluntary Disclosure Reporting Program, airlines are
not penalized for self-disclosing the same item repeatedly as
long as it is determined that a comprehensive fix was
satisfactorily completed and followed.
To what extent do the airlines repeatedly disclose the same
safety problem under the Voluntary Disclosure Reporting
Program? In other words, does this allowance for the disclosure
of repeated safety problems without penalty effectively
encourage airlines to address the underlying safety problem?
Mr. Scovel, first.
Mr. Scovel. Yes, that certainly is a problem, as
highlighted by the events at Southwest. We have not had an
opportunity to examine the rest of the industry. We are
anticipating a request from the House Transportation and
Infrastructure Committee to do exactly that.
In taking Southwest as a case study, however, we had eight
violations of four ADs since December of 2006. Had there been
comprehensive fixes to the entire AD compliance system within
Southwest, there may not have been future AD violations
including the one in March that brings us here today.
Senator Klobuchar. Mr. Sabatini?
Mr. Sabatini. Let me say that what happened in Southwest
causes me to be outraged. I am absolutely outraged.
Senator Klobuchar. But do you see it as an individual
problem, or do you see it as systemic when you know that
American Airlines has now grounded almost 2,000 flights? Is it
not more than just one incident, but a systemic problem with
the way the system is working?
Mr. Sabatini. Well, the issue with American is not a
voluntary disclosure. That was a finding by our own inspectors.
But I would agree this is not what was intended, and I do not
have any evidence that it is happening on a widespread basis.
But having said that, we are going to take steps to make
certain that that does not become a widespread circumstance.
Senator Klobuchar. Thank you very much.
Senator Rockefeller. I should be calling on Senator
McCaskill, but I have to leave and Chairman Klobuchar will be
running the deal.
Senator Klobuchar. Now I am in real trouble.
That is what I get for getting here late.
Senator Rockefeller. Three points to make.
The NTSB has 400 open recommendations that the FAA has not
acted on. Comment?
Mr. Sabatini. I will have to review that data, Mr.
Chairman.
Senator Rockefeller. Yes, I think you will.
Second, you sort of credited yourself with getting more
money into the FAA system. You did not do that. We did that.
The President never requested it. The Congress injected that
money. Keep that clear in your mind.
Mr. Sabatini. I believe I acknowledged that.
Senator Rockefeller. No. I do not think you did. Well, so
be it. It is for the record. We did that.
That is the whole pattern--I could ask you how many times
has Mary Peters gone to the President of the United States to
protest certain things. Why was there not any Presidential
interest in all of this that is going on, except as exercised
through the FAA, which some of us seem to be a little bit
skeptical about?
Third, this will seem like a self-serving point, and I
therefore apologize. I believe that in big organizations--I
believe this violently in the Department of Defense, and I am
beginning to believe it in the FAA--that sometimes you have got
to fire people to make a point. And I am going to give you two
examples.
I was a Governor for 8 years in West Virginia and I had a
very good head of a department. He was doing a wonderful job.
And he did something which was probably not criminal, but he
went out hunting in Wyoming with a group of people who
represented groups over which he had oversight jurisdiction and
control. I fired him. I fired him in Wyoming. And nothing like
that ever happened again.
Second, I was president of a college for almost 4 years, a
really good college. It was a private college in West Virginia.
But everybody was afraid to dismiss students that were
nonperforming or had sort of racial preconceptions that were
not helpful to the nature of the institution. And I very
quietly over a period of time did homework with my team, and 1
day we dismissed 60 students, which was I think about 5 percent
of the student body. The next day everybody was at their work
stations teaching math, learning English, learning everything
else at 200 percent of the intensity of the day before. They
were relieved because somebody had put down a marker. I just
want to leave that thought.
I yield now to, well, the chairman, Senator Klobuchar.
Senator Klobuchar [presiding]. Senator McCaskill?
STATEMENT OF HON. CLAIRE McCASKILL,
U.S. SENATOR FROM MISSOURI
Senator McCaskill. I have two areas I want to cover. One is
to follow up on what the Chairman talked about in terms of
accountability, and the second is foreign repair stations.
The head of the Office of Special Counsel, who represents
Federal whistleblowers, has given a very damning indictment of
the FAA in terms of accountability. And I want to read for the
record what the Office of Special Counsel testified to in a
hearing in the House. ``FAA lied''--no sugar coating here.
``FAA lied to OSC and the Inspector General in the 2004-2005
investigation, and during this new one, they disregard the
seriousness of the charges that operational error numbers were
lowered by covering them up and blaming the pilots instead. The
more things change, the more they stay the same in FAA.''
Also, the Special Counsel said, ``The culture of
complacence and coverup goes very high in management circles.''
A serious discipline and shakeup of the FAA, in order to send a
proper message inside what appears to be a very insular
organization.
Now, I have got to tell you that is an amazing testimony.
That is amazing testimony, that the Office of Special Counsel
has said that FAA lied. And what I would like someone to say to
me today is that someone is going to be fired for lying to the
OSC and to the Inspector General. Will anyone be fired for
lying, or do you disagree that someone lied?
Mr. Sabatini. Well, the Special Counsel has not brought any
information to me personally about anyone lying. Certainly if
someone lied, we would take the appropriate action.
Senator McCaskill. Well, this testimony was given on April
3rd. Now if I were in your position, Mr. Sabatini, and somebody
with this job came in front of the House and said this about my
agency, I would be asking them who lied. Have you asked them
who lied?
Mr. Scovel. Senator, if I may shed some light on that
question. The head of Special Counsel, when he was testifying,
was referring first to an investigation conducted by my office.
We were referred to the case by the Secretary on a referral to
her from the Office of Special Counsel. It had to do with
operational errors at the Dallas-Fort Worth TRACON.
Subsequent to that, there has been a renewal of problems
within the same facility. We are now completing our
investigation on that. I do not know that Mr. Sabatini has
knowledge of the findings of our current investigation, and
because it is ongoing I am unable at this point, to comment on
the record.
Senator McCaskill. I think you understand my concern, Mr.
Scovel, that we would have someone in this position say to
Congress that someone is lying in the investigation and
immediately--I mean, this is pretty--that does not happen very
often.
Mr. Scovel. It certainly does not.
Senator McCaskill. And for someone to make that statement,
especially someone in this job, I think is something that
everyone should react to. You talk about the red lights
flashing and the sirens at full bore, it seems to me this is
the moment that there needs to be a sense of urgency about
accountability. And I wanted to begin with that.
Let me ask you, Mr. Sabatini, can someone explain to me why
certification of a repair facility is a valuable thing?
Mr. Sabatini. Well, for many reasons. One, it requires that
for people who apply for a repair station authorization,
certification demonstrates that they have the competence and
the qualifications, the facilities, the housing, et cetera to
perform the work that they are going to perform.
Senator McCaskill. And I am assuming the government incurs
expenses in terms of the certification process and the
oversight of the certification process.
Mr. Sabatini. Yes, we do.
Senator McCaskill. But yet, we do not require people to use
FAA certified facilities.
Mr. Sabatini. Well, an air carrier is going to either
perform the work itself or it can require or engage with
another facility like a repair station that is authorized to
perform that work.
Senator McCaskill. But not certified.
Mr. Sabatini. An air carrier must deal with a certificated
entity to have maintenance performed on its aircraft.
Senator McCaskill. Well, you are aware of all the reports
that have been done about foreign repair stations and the lack
of certification thereof and the problems associated with those
foreign repair stations, I assume.
Mr. Sabatini. Well, yes, I am.
Senator McCaskill. So what I am trying to get at is if
certification is important and if the American taxpayers are
spending money to get facilities certified, what is the point
if you do not need to? I mean, why do it? Why do we not just do
away with certification of repair facilities unless we are
going to require the same standards of all the repair
facilities?
Mr. Sabatini. Well, certification is required for many
reasons, one of which I stated. If an air carrier is traveling
abroad--and certainly aircraft are global by their very
nature--we have a requirement that any air carrier can only
have repairs done or maintenance performed on its aircraft by
an authorized repair station.
If I may, what I think you are addressing is downstream,
can a repair station contract out with an entity that is not
necessarily certified by the FAA? And the answer to that is
yes. However, that repair station or that air carrier that
might have work outsourced to one of those entities, must
assure that that work is done under the quality control system
of the repair station or the air carrier. And we hold the
repair station and the air carrier accountable to that.
Senator McCaskill. Well, my understanding is--and correct
me if I am wrong--that most major airlines in this country are
having work done at foreign repair stations and that there is
no requirement that those foreign repair stations be certified
and that reports have indicated that although one person is
required to be on site and know what needs to be done, a lot of
the checking is being done by phone, that there is never an FAA
inspector on site.
I am just trying to figure out how many people are lined up
wanting to be certified that we have not certified. Are there a
number of foreign repair stations that have requested
certification that we have not certified?
Mr. Sabatini. Yes, there are. I do not have that number
readily available, but I can tell you that there are applicants
at different locations where we have FAA inspectors in-country
in foreign locations that have a pending list.
Senator McCaskill. OK. This is the second hearing where I
have requested how many pending requests for certification does
the FAA currently have, and your agency got this question
yesterday. Your agency got it at a previous hearing.
Should it worry me that nobody can give me the number of
facilities that want to be certified that are waiting to be
certified and cannot be certified? Should that concern me that
nobody can come up with that number?
Mr. Sabatini. Well, I can get you that number, Senator.
Senator McCaskill. OK. I hope you can. I am a little
skeptical at this point because I have been talking about this
for a while now, and I have not yet got any sense of urgency
from the FAA that you are concerned.
As you know, they found a member of Al Qaeda working at a
repair facility in Singapore. As you know, they had access
issues that were cited both by IG's and GAO about access to
facilities in terms of gaps in fencing, a lack of background
checks. Then you have got the whole additional problem that the
outsourcing of labor to foreign repair stations, those that are
certified--the costs of that are being borne by the taxpayer.
So I do not begrudge companies for a lower labor cost by
going outside of the country, but I do begrudge taxpayers
underwriting it. And I have asked for those numbers repeatedly.
How much are taxpayers paying to help these companies have
their airplanes worked on in other countries? If you can assist
me in getting that information, I would be greatly
appreciative.
Mr. Sabatini. Well, Senator, I am actively engaged in
addressing that question you raised last time, and I can tell
you that we are actively reviewing how we assess foreign
applicants for certification. So I will be able to give you
that information--just give me a little bit more time, but I
can assure you, Senator, we are actively engaged in looking at
that.
Senator McCaskill. I think we need to keep a central list,
do you not?
Mr. Sabatini. A pending list?
Senator McCaskill. Yes. I mean, should you not be able to
say how many people want to be certified that we have not
certified? This is not a hard question.
Mr. Sabatini. Well, you know, I will go back about 10 years
when we started into basically certifying foreign repair
stations. We were told by the Congress not to certify any more
repair stations than we can properly surveil.
So an example from the pending list is an applicant who is
not a threat to safety. It is an applicant who is waiting to be
certified as a repair station. So the pending list does exist.
I do not believe we could ever eliminate that pending list. We
simply do not have the numbers of people----
Senator McCaskill. That is what I thought. So it is a
matter of resources. It is a matter that we do not have enough
inspectors to actually send to all these certified facilities.
Mr. Sabatini.--well, we have them today in Singapore, in
Frankfurt, in London, and we have a small group in Beijing, and
we are adding people there. We have added 10 people in
Frankfurt and 6 people in Singapore and 2 in Beijing. And I
would tell you, you could give me a 1,000 people. There will
always be a pending list, and we will not allow--an inspector
to be responsible for any particular group or number of
certificates than they can properly and adequately surveil.
Senator McCaskill. I think that is a great position to
take, and I appreciate it. I think it is the right position.
But I am very confused that no harm, no foul if you use a non-
certified facility. So it is like we are saying we do not have
enough people to really look at all these facilities, but that
is OK. You can go to one that is not certified. It seems to me
that is kind of counterproductive.
Mr. Sabatini. Well, for clarity, those people who are on
the pending list are not performing any repair station
activity. That would be contrary to our rules, and we would not
permit that. For example, a repair station or an air carrier
can go to an entity that specializes in plating of blades or
welding, which does not necessarily require FAA certification.
But that air carrier or that repair station is responsible for
assuring that the work that is done is done in accordance with
the standard for which we apply and hold that entity, the air
carrier or the repair station, responsible and accountable for.
They bear that responsibility.
Senator McCaskill. I think that is great for the
subcontracting specialists, but we have facilities that are
doing all kinds of repairs that are not certified where we are
not certain of the background checks, the access issues, and
all of those. And those are the ones I am concerned about, Mr.
Sabatini.
Mr. Sabatini. Well, I can tell you that we have put in
place a requirement that the air carrier make available to an
FAA inspector, upon request, those entities that they are doing
business with, so that we know who they are and can determine
whether they are performing the work in accordance with that
carrier's procedures. And with regard to repair stations, any
work that they extend to others outside the repair station,
they must demonstrate to us through the repair station that we
have access to those uncertificated entities.
Senator McCaskill. And I appreciate that. I think you
realize this is a problem and I think you are trying to deal
with it. I think that the cow got out of the barn on foreign
repair, and I think we have got some work to do in terms of
credibility at this point. And I appreciate whatever
information you can get to me as quickly as possible so we can
begin to look at whether or not there is, indeed, a problem
here that the American flying public needs to be concerned
about.
Mr. Sabatini. We will do that, Senator.
Senator McCaskill. Thank you very much.
Senator Klobuchar. Thank you, Senator McCaskill.
Mr. Sabatini, when I ended my last questions, we were
talking about the cozy relationship. In my time here now--I
have been in the Senate for a year and a half, I have noticed
that a lot of the issues that can arise--and you cannot always
tag it on them--are due to regulators who have other interests
and then they go and they work at the place that they were
supposed to regulate. We have some issues with the Surface
Transportation Board, the number of people working at
railroads. We saw it in the Consumer Product Safety Commission
in terms of a different problem with industry paying for trips
while the regulation of these industries lagged.
I just wondered if you had statistics and data on the
number or percentage of FDA inspectors who later take jobs with
the airlines.
Mr. Sabatini. FDA?
Senator Klobuchar. FAA. I misspoke. If you have numbers or
statistics on the number of FAA inspectors who then go on to
work at the airlines.
Mr. Sabatini. Not readily at hand, but I will certainly get
that information to----
Senator Klobuchar. If you could get those for me for, say,
the last 10 years, that would be very helpful.
Mr. Sabatini.--I will, assuming those records exist. I will
do my very best.
[The information referred to follows:]
U.S. Department of Transportation
Federal Aviation Administration
Washington, DC, July 11, 2008
Hon. Amy Klobuchar,
Member,
Commerce, Science, and Transportation Committee,
U.S. Senate,
Washington, DC.
Dear Senator Klobuchar:
At a hearing held on April 10, you asked if the Federal Aviation
Administration (FAA) keeps records of whether aviation safety
inspectors go to work for airlines after leaving the FAA. At the time
of the hearing, I did not know the answer to your question.
I want to confirm that the FAA does not have records on where
aviation safety inspectors, or any former employees, are employed after
they leave the FAA. For those employees who have post-employment
restrictions, they are informed of those restrictions before they leave
the FAA and are expected to comply.
At this time, aviation safety inspectors do not have any post-
employment restrictions. We have initiated a rulemaking project to
propose that inspectors be prohibited from working with the FAA on
behalf of an airline for a period of 2 years after they leave the FAA.
This proposal would permit inspectors to be employed by an airline, but
would not allow them to represent the airline. to the FAA for 2 years.
Sincerely,
Nicholas A. Sabatini,
Associate Administrator for Aviation Safety.
Senator Klobuchar. Mr. Chealander, you have been nicely
quiet. I thought maybe you would like a few questions over
there. I was thinking of what you had said when you cited some
of these past disasters or where things went wrong where it
showed that there was a record of a lack of inspections. Was
that right?
Mr. Chealander. Yes, that is correct. We have been looking
at maintenance oversight or oversight by the FAA for 25 years
and making recommendations there.
Senator Klobuchar. Yes, and a lot of it is based on lack of
inspections, that if the inspections had occurred----
Mr. Chealander. Correct.
Senator Klobuchar.--and as I was sitting here listening to
all this, I was thinking of my former life when I was a
prosecutor, the murder rate would be low and everyone would be
celebrating this great record, but then you would always see
signs that problems were ahead when you saw an increase in drug
dealing or an increase in property crimes. And then, sure
enough, you would see the murder rate creep up shortly after
that.
As you listened to everything that the other witnesses have
talked about in terms of these problems and Mr. Scovel's
recommendations, could you talk about your reaction to all of
this and if we just rest on our laurels and say, hey, we have
not had a crash for 2 years? Or if you see the fact that we now
have thousands of passengers that are grounded at these
airports, the flights were not inspected, and you have pieces
of airplanes falling off, and near collisions on runways, if
that leads for you to have more concerns about what could
ensue.
Mr. Chealander. I will give it a shot. There are a lot of
issues involved with what you just said.
We have a different perspective at the NTSB than the IG has
when they do audits and investigations from their perspective.
We are an after-the-fact agency. We come in after the disaster
happens. We investigate the accident. We determine the
findings, conclusions, probable cause, and then make
recommendations.
Over the last 25 years, as I alluded to in my oral
testimony, we have investigated accidents and determined that
oversight, whether it be operational or maintenance oversight,
has been an issue. And we have cited the FAA in that regard in
a lot of our recommendations as well.
As a matter of fact, we did a data search for this
testimony, and in the written testimony that we gave you, you
will see a table [not printed] in there that discusses that for
the last 25 years gives you some numbers of how many times that
has appeared in either our findings and conclusions, probable
cause, or recommendations.
As I said in my oral remarks, we have made recommendations.
Over the last 10 years, we have made 29 of those on maintenance
oversight alone to the FAA. Of those 29 recommendations that we
have made, 75 percent of those are still open, still in the
letter-writing campaign----
Senator Klobuchar. Could you give me some examples of some
of the ones you think are most important?
Mr. Chealander.--well, if you will give me a second here, I
can----
Senator Klobuchar. And probably the ones that are most
pertinent to what we have been talking about today.
Mr. Chealander.--I can cite right now for you five aircraft
accidents that have recommendations that have come from them in
the last 10 years of these 29 that I am talking about. And the
most recent for sure, but one that is really a characteristic
example of what we are talking about was the Chalk's accident
that I alluded to in my oral remarks. That was a Grumman
Mallard airplane down in Miami where a wing came off and 18
passengers were killed and 2 crew members. So 20 people were
killed in this accident when the wing came off and it fell on
the beach. You may recall the videos of that accident.
In that accident, we found that maintenance was sorely
lacking at the airline in question, but moreover, maintenance
oversight of that airline was lacking.
Again, we look at it in a different perspective than the IG
does. We look at it after the fact. We look at it and see that
possibly proper oversight of the maintenance of that airline
would have prevented this accident from happening. They would
have found the corrosion that was in these wings and the wing
may not have come off. So that is where we lead in our
investigations, our recommendations.
There are other examples.
Senator Klobuchar. So the implication here is that you made
that recommendation and it was not taken.
Mr. Chealander. Well, that is still ongoing. That one is
still open because it is a recent one, and we are still in the
campaign of writing back and forth with the FAA to determine
how we are going to handle this recommendation. The way we do
that, we write them a letter and tell them these are the
recommendations we are making based on this accident, and they
then write us back and tell us how they are going to implement
our recommendation. So that stays open until we get
satisfactory conclusion to that recommendation.
And there are several others I can talk about. But one I
also talked about in my testimony was the Alaska accident,
Flight 261, off the coast of California where the jackscrew in
the back that Senator Stevens talked about was lacking of
maintenance and oversight by the FAA that would have caught
that. So a lot of procedures have come out subsequent to that,
but 88 people had to die so that we could make that
recommendation.
So that is where we come from as an agency, the NTSB, as
opposed to where the IG comes from. And that is why I say we
have 29 recommendations in the last 10 years on maintenance
oversight, and 75 percent of those are still open in one way or
another.
Senator Klobuchar. Why is that, Mr. Sabatini, that 75
percent of them have not been responded to?
Mr. Sabatini. Well, we take the recommendations very
seriously, and we evaluate them. As Mr. Chealander has said, on
this most recent one, the Chalk, we are in the process of
addressing what they have recommended and what we think is a
proper solution to that.
Senator Klobuchar. Well, my problem with the adverb
``seriously'' is that he said that 75 percent of them have not
been implemented. So it does not really seem like they are
taken seriously. If they were taken seriously, maybe 70 percent
of them would have been implemented.
Mr. Scovel. Senator, can I interject briefly? Seventy-five
percent of the NTSB recommendations remain open. That does not
mean they have not been implemented. That means they are still
open and awaiting a satisfactory or unsatisfactory conclusion.
Senator Klobuchar. Do you think that they need to move more
quickly?
Mr. Scovel. In some cases, yes.
Senator Klobuchar. Is there a specific case that is your
worst example?
Mr. Scovel. We can get you that data. There are reams of
letter-writing campaigns that have gone on. I have got, as a
matter of fact, our recommendations expert sitting right behind
me, and we can get that answer for you and get it pretty
quickly, if you like.
Senator Klobuchar. Thank you.
Mr. Brantley, you indicated maybe in your prepared remarks
that inspectors--spend more than 70 percent of their time at
their desks. This, of course, means that for more than two-
thirds of their week, these FAA inspectors are not in the field
performing actual hands-on inspection. What do you think is the
right mix of work, and are we operating under the right mix
today?
Mr. Brantley. Well, I think the right mix may very well
differ from case to case. It depends on the type of oversight
they do and the particular job. But I think it has to be more
than 30 percent of their time in the field.
I think the inspectors are very experienced. They are very
knowledgeable. And I think there needs to be a lot more trust
in not just their instincts but their experience and allow them
to determine how often they need to go out.
I think systemically it needs to be a greater part of the
agency's oversight program. They need to emphasize the hands-on
checking.
One of the things that I am very concerned about is I hear
a lot that the airlines or a repair facility are responsible
for ensuring compliance, and that is true. But in the end, they
seem to be accountable for it, and the FAA is not. I think the
FAA is not accountable for tracking compliance. They are
accountable for ensuring it. And without getting out and
looking at things, kicking tires--I do not like the phrase, but
I will use it because it is easy and everyone understands it.
They need to be able to get out and kick the tires.
Senator Klobuchar. Well, also we talked earlier about this
gaming the system, whether or not we have the facts to support
this, but there is some thought that what sometimes goes on is
people are told that they are going to show up and inspect and
things like that. It would seem to me if you had a higher
percentage, even a slightly higher percentage, out in the
field, you could do more surprise inspections.
Mr. Brantley. Yes, ma'am, absolutely. And I think
unannounced inspections are one of the most important tools
that an inspector has to ensure compliance. But even that is
very much frowned upon because if they show up unannounced, an
airline can--and not all do all the time, but the airline or
repair facility can complain and say they showed up without
notice. They are asking people questions. It is slowing us
down. It is costing us money. And they will be told not to do
it.
We have an example where in Hawaii, Hawaiian Airlines had
complained to the local FAA management, and they instructed
their inspectors to no longer do a ramp inspection unless the
turnaround time was at least 90 minutes or more because they
did not want to impact their operations.
Senator Klobuchar. Now, Mr. Sabatini, is this consistent
with what the policy should be of the FAA inspectors?
Mr. Sabatini. Senator, if you would just bear with me for
just a few minutes, I would like to put this in perspective.
Senator Klobuchar. Sure. You and I are the only things that
come between everyone's lunch. So that is OK.
Mr. Sabatini. I apologize for a late lunch, but I think
this is critically important for everyone to understand.
Senator Klobuchar. That is why I am asking the questions. I
mean, I think earlier you talked about how it was important
that we not have all these planned inspections the day before.
And then Mr. Brantley just gave me some actual examples of
where airlines have pushed back and said, ``oh, you have got to
give us enough notice.''
Mr. Sabatini. Well, I would suggest that if Mr. Brantley
were to bring forward the actual evidence, the objective
evidence concerning what he just stated, I think the facts
would prove to be a little bit different. But let us put that
aside.
What I would like to share with you--I am not a theorist. I
am an actual practitioner of this business. I started as an FAA
inspector in Charleston, West Virginia. And back then, I was
left to my own devices to determine--and I was a principal
inspector--I was left to my own devices to decide how I would
inspect that carrier. I would also say that during that time,
there were 110 field offices, and anyone applying for an air
carrier certificate could be certificated in 110 different
ways, all in accordance with the rules, but the degree of the
depth of what was required to meet the regulation had variation
to it.
We now have an ATOS system. Thank goodness for that. It is
far more robust than we ever had. It has produced for us what
we now know to be a very safe system. And I will say again I do
not rest on that laurel.
But what is important to know and is clearly stated in the
guidance--and it is open to anyone who wishes to know about it
to read it--it clearly says that an FAA inspector in the
conduct of--let us just take what just happened: Airworthiness
Directives. In the conduct of that oversight, that assessment
of the performance of the carrier, that inspector can look at
the airplane as many times as they want. There is no
limitation. There is no requirement to be at your desk 70
percent.
And let me again draw a comparison. When I was an
inspector, I went out into the field and it was random. Today
what we are doing is collecting data so that before you go out
to conduct an inspection, you need to be well informed. You
need to download the information that pertains to your carrier
so that you know exactly what it is that you will be looking
for. And while you are out there, let us take an evening
surveillance of maintenance. When you are conducting
maintenance, no one says you cannot look someplace else. You
have a duty and obligation to report everything that you see,
and inspectors are free to do that. Again, they can touch as
many airplanes as they like within the construct of the
performance assessment of whatever it is that has been
determined to be an area to be examined.
Senator Klobuchar. Well, it is just this really concerns
me, though, about the surprise visits. I think about like if I
know my mother-in-law is coming over with 4 hours' notice, my
house is cleaner than if she just shows up. So what Mr.
Brantley has been pointing out here is that when you have
advance notice, it is a lot different situation than if you
just randomly show up.
Would you be troubled if you found out that what Mr.
Brantley was saying was true, that there was what Mr. Scovel
called an overly collaborative relationship to the point where
there was much advance notice of when these inspectors would
show up?
Mr. Sabatini. There is no requirement for advance notice.
Senator Klobuchar. I just wondered if it would--I am not
saying there is, but it sounds like it is possible that it has
been going on. So does it trouble you if it has been going on?
That is my question.
Mr. Sabatini. Not necessarily because what that would imply
is that people on an ongoing basis are in noncompliance and
because the FAA inspector shows up, suddenly they are going to
be in compliance. This is a very complex business. You cannot
fix something in just a few hours because you heard an FAA
inspector is coming. It is clearly obvious. We have very
experienced safety professionals, our inspectors. They can tell
the difference whether someone is hiding something or whether
it is as a matter of routine and is embedded in the system. And
our processes today clearly identify whether you are faking it
or whether it is ongoing on a regularized basis.
Senator Klobuchar. Mr. Scovel, do you think that is true?
Mr. Scovel. Mr. Sabatini talked about faking it or hiding
it. I think in one of your earlier questions, you made the
point that this is really not the issue. It is whether the
carrier is going to use the opportunity to voluntarily self-
disclose and perhaps avoid a penalty that FAA might levy had
they----
Senator Klobuchar. Because of that advance notice.
Mr. Scovel.--perhaps. Right.
Let me make one more point. We are talking about requests
by carriers back to FAA for advance notice. That is certainly
troubling, but what is even more troubling to me is what we saw
happen in the Southwest and Northwest cases, both of which I
referred to in my testimony. In these cases, a carrier either
used subterfuge, made an anonymous complaint to FAA, or simply
pulled credentials from an inspector so that he was unable to
access maintenance facilities. In effect, carriers were
deciding which inspector was going to get to do their
inspections. That is very troubling.
In his House testimony last week the whistleblowers called
that ``cherry picking.'' I called it putting an inspector on
the bench with FAA's complicity. That is troubling. It is a
dismissive attitude on the part of the carriers, and, as I
mentioned last week, it signals a regulator that no longer
commands the respect of the regulated entity. That should be
very troubling to all of us.
Senator Klobuchar. Mr. Sabatini, are you troubled by that?
Mr. Sabatini. Absolutely. I am outraged.
Senator Klobuchar. What are you going to do about it?
Mr. Sabatini. Well, I have taken steps already with the
individuals concerned, and I am putting steps in place to make
sure that does not happen again.
Again, we are a learning organization. We are in that level
of that chart where we keep identifying remaining risks. Those
are risks, and we are actively and proactively addressing
those.
Senator Klobuchar. Mr. Barimo, as we have this hearing and
we are all sitting here comfortably asking questions, we have
got thousands of airline passengers that are stranded because
routine inspections were not taking place, and instead it was
just suddenly the flights were stopped so that things could be
looked at. I do not think anyone questions that we should have
safety inspections, but clearly members of this committee
question know how this was handled.
What is going on for these passengers right now? Are they
going to get redemption coupons? Are they going to get expenses
paid? What is happening?
Mr. Barimo. I will address that as best I can, and then I
would like to add a comment just to what we talked about
earlier.
Each carrier will determine what is appropriate from a
customer service standpoint. I am not up to speed on the
specifics of how each carrier in this particular instance is
going to address taking care of their customers. I am certain
that they will. Some have already announced plans on how they
will address their customer issues.
So just if I could take a step back, let me just point out
that airlines do not rely on the FAA or the ATOS system to keep
them safe. Airlines are not safe because they are trying to
avoid a fine, and they are not cleaning house because they hear
that tomorrow the FAA is coming over. Safety is good business
for airlines. It is essential for airlines. It is taken very
seriously. And we recognize that. As we talked about earlier,
the goal is 100 percent and we will not stop until we get
there.
But let us keep in mind that this is a collaborative
effort, and the last thing we want to do is rebuild the wall
that existed a couple of decades ago between airlines and the
regulator. What scares me is that we return to an era where we
had accident rates that at today's volumes would generate a
fatal accident every month. I do not want to go there. I know
that there are changes that need to be made to the tools that
we are using today and we will absolutely support those
changes.
Senator Klobuchar. Well, thank you, Mr. Barimo, for
pointing that out.
I will say this. I believe that things have tilted too far
in the other direction. I believe you that there have been
improvements made to safety. Our State of Minnesota has
Northwest Airlines, and we are proud of the work that they do.
And they have not grounded any flights yet as of this moment.
That is a knock on wood for the record.
But I will say this. Just as we saw with the tainted dog
food or the toys from China or a bridge that falls down in the
middle of the Mississippi River, perhaps we have gone too far
in terms of the collaboration being on one side, and that is
the side of industry. And I agree there should be
collaboration. I think that is the way to go, but the whole
system was set up so that there is backup enforcement.
I can tell you that Target and Toy-R-Us did not want these
toys to come over. They have a market reason to want to do
well. But they most likely, like the rest of us, thought that
there were going to be inspectors that were looking at things,
just like I would assume the airline CEOs believe that there
are going to be competent inspectors that really balance the
system that are going to call their employees that they cannot
watch every day just to make sure things are going well.
And I think that is what seems to have broken down here,
not that we want to throw out the whole system, but that we
want to talk intelligently about what we need to do with some
of the recommendations that Mr. Scovel has made to try to move
in the right direction.
And then I just have one more question related to the air
traffic controllers and whether some of the things that we have
been talking about today with the FAA inspectors are some of
the same issues where they have voiced their concerns, whether
they were whistleblower concerns or whatever, that some of
their concerns are not moved up the chain, so to say, so that
people at the top can find out about things, which is all we
are talking about.
Mr. Krakowski, do you want to comment on that?
Mr. Krakowski. Thank you, Senator. I think this has been a
very important couple of weeks in that effort with air traffic.
As you may know, I come from industry as a chief safety officer
of one of the largest airlines during a time where the airline
had its worst time in 5 years in the company's history. Two
airplanes lost on 9/11, bankruptcy, a lot of churn in the
organization.
There are some techniques there that we used that were very
effective in actually improving our safety. One of those
techniques, the Aviation Safety Action Program, or ASAP, for
air traffic was signed by Acting Administrator Sturgell and Pat
Forrey from NATCA 2 weeks ago, and we are going to begin
rolling this program out. This is going to give us some insight
into the human factors and the real issues, whether fatigue is
real or not, what should we do about it, what are the human
factors issues around incidents, operational errors, runway
incursions.
I believe in my heart that my former company would not have
achieved the safety record it had without an effective program
in this area, and it is my fervent passion to make this program
successful.
Senator Klobuchar. Very good.
Anyone else like to comment on this?
[No response.]
Senator Klobuchar. Well, thank you very much. I will say
that I think the general consensus up here, whether it is
Democrats or Republicans, is that the FAA needs to do more than
just trust these airlines, that we have to have a collaborative
effort, but they need to be vigilant in ensuring that the
airlines comply with the regulations and, when necessary, take
the enforcement action. We have some good ideas on the table,
and I think we need to go beyond the letter writing back and
forth and get into action. Thank you very much.
The hearing is adjourned.
[Whereupon, at 1:24 p.m., the hearing was adjourned.]
A P P E N D I X
Prepared Statement of Karen E. Casanovas, Executive Director,
Alaska Air Carriers Association
To the Honorable Chairman Inouye and Vice Chairman Stevens and
members of the Committee:
My name is Karen Casanovas and I am the Executive Director for the
Alaska Air Carriers Association. Our Association (AACA) was founded in
1966 and represents over 160 commercial airlines and aviation
businesses throughout Alaska and the world. Our organization's mission
is to provide educational training, advocate for the interests of
aviation in the public process, and act as a facilitator of aviation-
related information. Additionally, we provide resources for safety,
security, air-space, insurance, or weather-related issues, and act as a
conduit between government and industry leaders. It is an honor to
comment on crucial safety issues. I'll address the challenges facing
commercial air carriers in our state, along with the successes of
Alaskan aviation safety.
Since air travel is a way of life for Alaskans, we are dependent on
aviation for activities that are normally accomplished by using the
existing road system in the Lower 48 states. As a consequence, per
capita there are 6 times the number of pilots, 14 times the number of
aircraft, and 76 times as many commuter airline flights. As a pilot,
Senator Stevens, you are aware of the wide variety of services provided
by the aviation industry. Because commuter airlines and air taxi
operations need to provide highly reliable service for rural area
medevac and economic purposes (oil, fishing and tourism) in an
environment of unpredictable weather and high terrain, they need an air
traffic system that enables them to communicate, navigate and manage
operational control of their aircraft.
Alaska has been an ideal location to implement key new
communication, navigation, and surveillance technologies that improve
safety. These new technologies have allowed pilots to more effectively
handle navigation, terrain, traffic and weather hazards and enabled the
Federal Aviation Administration (FAA) to provide more efficient and
cost effective services.
The FAA Capstone Program was a technology-focused research and
development (R&D) safety program in Alaska, which sought near-term
safety and efficiency gains in aviation by accelerating implementation
and use of modern technology. The Capstone Program linked multiple
programs and initiatives under a common umbrella for planning,
coordination, focus and direction. ADS-B was a major component of the
Capstone Program and much success was achieved in the developmental
phase of ADS-B technology. On September 9, 2005, the FAA selected ADS-B
as the preferred alternative for meeting the future surveillance needs
of the agency. ADS-B is a critical component for meeting the Next
Generation Air Transportation System (NGATS) goals, now known as
NextGen. In December 2006, the Capstone Program transitioned to the
Surveillance and Broadcast Services (SBS) Program Office and
assimilated into the National ADS-B Program.
The Surveillance and Broadcast Services Capstone Statewide Plan is
a joint industry-FAA plan with a goal of equipping Alaskan-based
aircraft and installing ground infrastructure such that 90 percent of
Alaskan air operations would be covered by the FAA NextGen aviation
technologies. Doing so will expand the Capstone Program's demonstrated
47 percent safety improvement record across Alaska. FAA estimates a 33
percent reduction in fatal accidents statewide and $824 million in
combined public benefits from reduced aircraft accidents, enhanced
rural area medical evacuation, and more effective accident search and
rescue operations (over the next 27 years).
While the FAA will make an investment in this NextGen airspace
system in Alaska, the funding will be limited or delayed unless Alaskan
commercial operators and general aviation airplane owners equip
approximately 4,000 aircraft. Currently, the increase in the FAA
investment in Alaska is estimated to be $493 million, much of which
will be used for ground system installations over the next 5 years in
accordance with the Statewide Plan.
This substantial investment by the FAA in Alaskan based aviation
infrastructure is directly tied to equipage of Alaskan-based aircraft.
In other words, the Federal investment of nearly one-half billion
dollars is contingent upon aircraft equipage. While most commercial
operators will equip their aircraft, currently, these avionics are not
affordable for the private pilot and Alaska will not be part of any
Federal mandate to equip. Without incentives, equipage may never happen
or will be many years after the Lower 48 is enjoying NextGen aviation
capabilities. Alaska desperately needs to be an accelerated part of the
nationwide airspace modernization plan.
Recently, Alaska's 25th State Legislature unanimously approved a
revolving loan program to provide assistance for avionics equipage.
This low-interest loan program, if signed by Governor Palin, will be
administered by the Department of Commerce, Community and Economic
Development, Division of Investments. With future additional funding
from the private sector and/or the Federal Government, this could
result in 90 percent of all flight operations across the entire state
of Alaska enjoying safety and reliability capabilities proven by the
Capstone R&D Program in southwestern and southeast Alaska.
I launched my career in this industry 33 years ago and can
personally verify the widely diverse types of commercial operations in
Alaska and the need for improving aviation access and economic
viability of our rural communities. There are many different and unique
aviation companies conducting business under Parts 91, 121 and 135 of
the Federal Aviation Regulations (FARs). There are single engine
airplanes up to turbo prop equipped aircraft, wide-bodied jets,
rotorcraft and float plane operators. The Alaska Air Carriers
Association is committed to assisting all of them in maintaining safer
operations; that's why our Safety Committee initiated the idea of the
Medallion Foundation, a voluntary program based on best practices that
has changed the culture of aviation in Alaska.
The Medallion Five-Star Program established standards that exceed
regulatory requirements for participating air carriers and pilots.
Maintenance Resource Management and Safety Officer training are just a
few of the valuable courses offered by the program managers. By
providing system safety attributes and showing participants how to
collect, analyze, and share data in the Air Transportation Oversight
System (ATOS) program--trends can be spotted before accidents occur.
Data analysis has revealed that Medallion participants have a
significantly lower accident rate. The Medallion Foundation has
partnered with the FAA on several initiatives that have measurably
improved aviation safety in Alaska, which resulted in a 27-month period
with no fatal air carrier accidents. Although fatalities for last year
were not zero, the numbers are still considerably lower than pre-
Medallion years.
Medallion's leadership and the FAA have worked together to develop
a detailed roadmap, which has assisted air carriers in implementing
system safety tools. Used by their principal inspectors to monitor
processes, this integration has aided in assessing aviation risks,
perform root cause analysis, and improve pilot training. By taking a
business-like approach to Risk Management and Safety, the Medallion
Foundation provides a framework and guidance for the development of a
proactive corporate safety culture.
Furthermore, Medallion performs as an objective third party for
administering an FAA-industry program that allows aviation employees to
report safety issues without fear of punishment. This has allowed the
FAA and industry management to solve safety or operational issues that
would not have come to light had the employees not made the reports.
The Alaska Air Carriers Association encourages continued
improvement of accident rates through programs such as the Medallion
Foundation and the Surveillance and Broadcast Services Capstone
Statewide Plan. We thank you, Senator Stevens, for your continued
support of both programs, which have improved performance, safety and
efficiency for air operations. This has allowed the delivery of goods
and services to communities in a reliable manner through the use of
technology in concert with a precise risk management philosophy.
We've made great strides in Alaskan aviation safety through
Capstone, the Medallion Foundation, the Surveillance and Evaluation
Program, (which uses principles of system safety to identify risk-based
inspections of airlines) and through operational control audits. In
order to continue improving aviation safety, however, we need monies
directed toward a Safety Equipage Incentive Program (SEIP) for the
Capstone Statewide Plan to step up aircraft avionics equipage
statewide. Alaska urgently needs to be an accelerated part of the
national airspace modernization plan. A State-Federal-Private
investment through a public-private partnership will foster economic
development and aid in equipping as many aircraft as possible with
navigational, communications, surveillance and weather information.
Avionics in airplanes can save lives.
Thank you for the opportunity to comment today and do not hesitate
to call on the Alaska Air Carriers Association as a resource for
aviation issues in the future.
______
Response to Written Questions Submitted by Hon. Daniel K. Inouye to
Nicholas A. Sabatini
Question 1. Beyond the ATOS program, what are the other keys
aspects of the FAA's activities for ensuring system safety?
Answer. FAA's approach to system safety is based on the statutory
requirement of an air carrier to demonstrate that it can operate safely
in order to hold an air operator certificate. This means that the
systems an air carrier uses to conduct its business must be capable of
managing the risks in the operating environment. This concept underpins
FAA's safety regulations, which are risk controls that must be
implemented by air carriers. FAA certification and surveillance are
structured to determine compliance with safety regulations, thereby
ensuring system safety. The following programs supplement certification
and surveillance activities:
Aviation Safety Action Program--identifies systemic problems
and implements corrective actions.
Flight Operations Quality Assurance--provides data to
validate effectiveness of operational procedures and to
identify hazardous operational trends requiring intervention.
Advanced Qualification Program--enables air carriers to
tailor pilot training to fit unique operating environments and
the individual needs of pilots.
Voluntary Disclosure Reporting Program--identifies
inadvertent regulatory violations and implements comprehensive
corrective measures.
Safety Management System Pilot Project--assists air carriers
and repair stations in implementing voluntary safety management
systems.
Question 2. What were the results of the FAA's recent performance
audits of air carriers' compliance with Airworthiness Directives?
Answer. The special-emphasis validation of FAA's Airworthiness
Directives (AD) oversight, ordered on March 13, is to validate our
system for overseeing air carrier AD management. The audit consists of
two phases. In their aggregate, the two phases include a broad sample
of the air carrier's program to comply with ADs. The results of the
audit will allow us to determine whether or not each air carrier's
program is in compliance with our rules and whether or not our system
for determining compliance is adequate or needs adjustment. Results of
Phase 1 validated both the airlines AD management system and FAA
oversight of that system.
Phase 1 of the audit required a sample of 10 ADs for each of the
air carriers' fleets, including AD-2002-07-08 (to find cracking of the
lower skin at the lower row of fasteners in the lap joints of the
fuselage, and repair of any cracking found) and AD-2004-18-06 (to find
fatigue cracking of certain upper and lower skin panels of the
fuselage, and follow-on and corrective actions) for the Boeing 737
aircraft, if applicable.
Our audit revealed a 99 percent compliance rate with the ADs
audited. We have begun investigations into those airlines where there
was a question as to AD compliance.
Phase 2 of the audit requires inspectors to sample additional ADs,
to total 10 percent of the ADs applicable to the air carriers' fleets.
Phase 2 will end June 30. As of May 28, 2008, FAA inspectors had
reviewed operator management of 1,597 ADs, revealing a 98 percent
compliance rate. Again, we will pursue investigations where AD
compliance is questionable.
A copy of Notice N 8900.36, Special Emphasis Validation of Air
Carrier Airworthiness Directives Oversight is attached.
Question 3. Is it accurate that compensation for supervisors and
managers in the safety unit is based on performance measures that
include on-time arrival and customer satisfaction?
Answer from Mr. Krakowski. Yes, they are included in the many
metrics that we use to assess our performance. Our mission is to
provide the safest, most efficient aerospace system in the world. In
line with this mission, we have established both safety and efficiency
metrics by which we are measured and compensated.
As a safety organization, our first priority is always safety, and
we pride ourselves on our safety record. With more than 7,000 takeoffs
and landings per hour, and more than 660 million passengers and 37
billion cargo revenue ton miles of freight per year, the men and women
of our organization safely guide roughly 50,000 aircraft through the
National Airspace System every day.
Question 4. If so, are these performance measures consistent with
the agency's top priority of safety?
Answer from Mr. Krakowski. Yes, they are consistent with our top
priority of safety. The FAA's mission is to provide the safest and most
efficient aerospace system in the world. The FAA's 5 year strategic
plan (the Flight Plan) provides the foundation for achieving this
mission based on four goal areas: Increased Safety, Greater Capacity,
International Leadership, and Organizational Excellence. The FAA
strives for excellence in each of its four performance measures as they
are each a fundamental part of success.
Safety and capacity in particular are inextricably linked, and
critical to performance management. As passengers continue to fly in
ever-increasing numbers, and as more planes continue to fill the skies,
performance measures are specifically designed and implemented to
handle that growth safely and efficiently. These measures involve
constantly increasing the level of safety by implementing new
technology and procedures while simultaneously working to increase
capacity, reduce airspace congestion and meet projected demand.
Question 5. Are on-time arrivals really an adequate basis on which
to judge those charged with ensuring aviation safety?
Answer from Mr. Krakowski. The metric of on-time arrivals is but
one of many measures in our performance management system.
Our safety professionals are charged with ensuring aviation safety
as their highest priority. The FAA's mission is to provide the safest
and most efficient aerospace system in the world. Through the Flight
Plan, we focus on implementing measures that are designed to
accommodate aviation growth both safely and efficiently. We have worked
to increase the level of safety by:
Reducing commercial air carrier fatalities.
Reducing the number of fatal accidents in general aviation.
Reducing the risk of runway incursion and collision risks.
Ensuring the safety of commercial space launches.
Enhancing the safety of FAA's air traffic systems.
Implementing a Safety Management System (SMS) for the FAA.
Question 6. Does the FAA respond to all whistleblower complaints
that are filed?
Answer. Yes, if FAA is notified of the complaint, it opens an
investigation. Complaints may be brought to the attention of the FAA
from the Office of the Special Counsel or by other government agencies.
These agencies determine whether the complaint has merit and may
conduct their own initial investigation before alerting the FAA. The
Whistleblower Protection Program covers external complaints by
employees of air carriers, contractors, and subcontractors. The
Whistleblower Protection Act covers internal complaints by government
employees, which are initially filed with the Office of Special
Counsel.
______
Response to Written Questions Submitted by Hon. Daniel K. Inouye to
Hank Krakowski
Question 1. How does the FAA track and investigate runway
incursions and operational errors?
Answer. Operational errors are investigated primarily by FAA
management at the facility-level where the operational error occurred.
The findings and corrective actions from these investigations are
approved by regional and headquarters FAA safety personnel. All
operational errors result in an in depth final report that includes
causal factors and corrective action plans. These reports are retained
in electronic databases that may be searched for trends and
commonalities that may be indicators of areas for system-wide
improvement.
Question 2. What is the FAA doing to reduce near misses?
Answer. Investigative reports of operational errors and pilot
deviations provide data that may be mined for trends and commonalities
in root causes to many of the reported losses of separation within the
National Airspace System (NAS). FAA safety personnel implement
procedural and technical improvements to the NAS to correct identified
recurrent causes to separation losses. Recent improvements include a
revision to a graphical depiction of an approach procedure to a major
airport that was the source of multiple misunderstandings by pilots,
and a current effort to revise air traffic controller/pilot
communication procedures for acknowledging altitude clearances.
Question 3. How will the implementation of NextGen improve safety
in the National Airspace System?
Answer. NextGen provides several operational changes that will
improve safety. Some of these directly target safety; others target
improved situational awareness, which support safety, capacity, and
efficiency. A prime example of the first is the traffic and flight
information broadcast services, which are part of the Automatic
Dependent Surveillance--Broadcast (ADS-B) program. This information
service will provide pilots with real-time traffic display and weather
information that will help pilots to avoid other aircraft and hazardous
weather.
Examples of changes that support both safety and efficiency
include: providing digital taxi-clearance for display in the flight
deck, which will improve the efficiency of traffic on the surface while
reducing pilot errors and deviations; data communications between
controllers and pilots, which will greatly reducing readback/hearback
errors while improving the efficiency of flight management; and
integration of weather into controller tools supporting the strategic
reroute of traffic, improving both efficiency and safety. Across the
board, most improvements to flight efficiency or airport access will
provide safety benefits through increased situational awareness and
improved flight path management.
Question 4. Why does the current rulemaking process that will
require the use of ADS-B technology exclude a requirement for the use
of ADS-B ``in'' technology that would satisfy one of National
Transportation Safety Board's top safety concerns?
Answer. Currently, the ``ADS-B In'' requirements are only partially
defined. The FAA is working collaboratively with industry through the
Aviation Rulemaking Committee (ARC) to decide the appropriate way to
move forward with mandating ``ADS-B In''. Below is an outline of the
options that were discussed:
1.``ADS-B Out'' compliance in 2020; ``ADS-B In'' effective in
20XX (to be articulated in the NPRM).
2.``ADS-B Out'' compliance in 2020; ``ADS-B In'' voluntary
equipage (current FAA strategy).
3.``ADS-B Out'' and ``ADS-B In'' effective in 2010.
The ARC currently believes that option 3 is not possible because
``ADS-B In'' cannot be defined at this time. Therefore, at the present
time, option 1 seems to be the best solution for one of the draft ARC
recommendations (final recommendations will be submitted in August
2008). Also as a potential draft recommendation, the Committee would
like the FAA to make a decision by 2012 as to how to proceed with
``ADS-B In''.
In summary, the FAA is working collaboratively with industry and
various congressional committees to define and move forward with a
potential ``ADS-B In'' mandate. Additionally, the FAA has already been
investing in the development of standards to define the symbols for
pilot's displays and is working to accelerate activities for surface
alerting, which directly aligns with the NTSB recommendation for ``ADS-
B In''.
Notice: N 8900.36
U.S. Department of Transportation
Federal Aviation Administration
National Policy
Effective Date: 03/13/08
Cancellation Date: 06/30/08
Subject: Special Emphasis Validation of Airworthiness Directives
Oversight
1. Purpose of This Notice. This notice directs an audit of Title 14
Code of Federal Regulations (14 CFR) Part 121 air carrier compliance
with Airworthiness Directives (AD). The audit is necessary to validate
our system for overseeing air carrier management of ADs.
2. Audience. The primary audience for this notice is Flight
Standards District Office or certificate management office principal
maintenance inspectors (PMI) and principal avionics inspectors (PAI)
responsible for the approval/review and surveillance of air carrier AD
management programs. The secondary audience includes Flight Standards
branches and divisions in the regions and in headquarters.
3. Where You Can Find This Notice. Inspectors can access this
notice through the Flight Standards Information Management System
(FSIMS) at http://fsims.avs.faa.gov. Operators and the public can find
this notice at http://fsims.faa.gov.
4. Background. Current events involving one air carrier's
noncompliance with ADs make it necessary to validate our system for
overseeing air carrier management of this regulatory requirement.
a. In December 2007, all Federal Aviation Administration (FAA)
Certificate Management Teams (CMTs) for 14 CFR Part 121 air
carriers completed their transition to the Air Transportation
Oversight System (ATOS)-a systems-based approach to ensuring
air carrier compliance with regulations. ATOS requires
systematic, risk-based surveillance of all of the processes
that an air carrier uses to comply with regulations and deliver
its product. ATOS structures air carrier processes into 97
elements. Inspectors use detailed data collection tools to
assess the design and performance of the processes represented
by each element. Inspectors use Safety Attribute Inspections
(SAIs) to collect data for design assessments and Element
Performance Inspections (EPIs) for performance assessments. The
SAI and EPI for element 1.3.6, Airworthiness Directive
Management, provide specific references to regulations and FAA
policy and guidance for an air carrier's management of
compliance with ADs.
b. Element 1.3.6 is extremely complex. Multiple ADs affect
every aircraft used in air transportation. Literally inspecting
each of these aircraft for compliance with all ADs affecting it
far exceeds FAA resources. Therefore, ATOS emphasizes the
importance of an air carrier's responsibility to have a process
that effectively manages the regulatory requirement to comply
with ADs.
c. ATOS requires a performance assessment of element 1.3.6
every 6 months. Many recently transitioned CMT have not yet
completed an assessment of element 1.3.6. For this reason, as
well as the highly publicized noncompliance of one air carrier,
this special emphasis audit is necessary to validate our system
of oversight.
5. Action. PMIs and PAIs shall determine their assigned air
carriers' compliance with ADs by auditing a sample of ADs applicable to
their air carriers' fleets, in conjunction with a retargeted
performance assessment of element 1.3.6. The audit consists of two
phases. Phase 1 of the audit shall sample 10 ADs for each of the air
carriers' fleets, including AD-2002-07-08 and AD-2004-18-06 for the
Boeing 737 aircraft, if applicable. Phase 2 of the audit shall sample
additional ADs to total 10 percent of the ADs applicable to the air
carriers' fleets.
a. PMIs and PAIs shall complete Phase 1 of the audit by March
28, 2008 and Phase 2 as soon as possible but no later than June
30, 2008.
b. The audit shall:
(1) Validate the air carrier's work instructions (e.g., task
cards, engineering authorizations, engineering orders,
engineering change orders) to accomplish the AD by verifying
that the instructions correctly describe the method of
compliance contained within the AD and any referenced service
information (e.g., service bulletins, service letters) or any
related alternative methods of compliance; and
(2) Validate the proper performance of the AD by reviewing
the complete work instructions ``package'' on at least one
aircraft.
c. For Phases 1 and 2, PMIs and PAIs shall audit a different
aircraft, to the extent practicable, for each AD. This review
should also ensure that entries into the AD tracking system
were performed correctly. Give emphasis to sampling those ADs
which involve required inspections of fuselage, empennage, and
wing areas for cracking or similar issues.
d. To initiate Phase 1 of the audit, complete the following
steps:
(1) Use ATOS automation to create a Constructed Dynamic
Observation Report(s) (ConDOR) for airworthiness element 1.3.6.
(2) In the Local/Regional/National use field enter N8900.36.
(3) In the Requested Completion Date field enter March 28,
2008.
(4) Select EPI question 1.2.
(5) Determine and document data collection requirements in
accordance with the instructions above.
(6) Document the results of each AD sampled in the comment
field associated with the yes/no response.
e. To initiate Phase 2 of the audit, complete the following
steps of the ATOS version 1.2 business process:
(1) Step 2.4, adjust the due date of the next performance
assessment of element 1.3.6 to June 30, 2008.
(2) Step 2.6, determine data collection requirements in
accordance with the instructions above.
(3) Step 2.7, document data collection requirements in
accordance with the instructions above. Include instructions
for specific ADs to be sampled and deadlines to save EPI
activities to ``final'' in ATOS automation to comply with Phase
1 and 2 completion dates.
(4) Step 5.1, use the comment field to document the results
of each AD sampled.
(5) Step 7.4 or 7.5, complete the performance assessment of
element 1.3.6. Include ConDOR data collected in Phase 1.
f. If the audit affirms the performance of element 1.3.6, take
no further action.
g. If you cannot affirm performance, follow the ATOS business
process to initiate required action, including scheduling a
design assessment if systemic issues exists.
h. If the audit finds evidence of noncompliance with ADs,
initiate immediate corrective action.
6. Tracking.
a. Document the results of this audit of the air carrier's
compliance with sampled ADs in the comment field of the EPI for
element 1.3.6, Airworthiness Directive Management. Enter
N8900.36 in the Local/Regional/National Use block of the
activity screen.
b. If the air carrier did not comply with any of the sampled
ADs, take immediate corrective action. Use the ATOS Risk
Management Process (RMP), if appropriate.
7. Disposition. This is a special emphasis audit. Therefore, Flight
Standards will not incorporate the information in this notice into
FSIMS. Direct questions concerning this notice to the Certification and
Surveillance Division, AFS-900, at (703) 661-0550.
Original signed by
James J. Ballough,
Director, Flight Standards Service.