The Perfect Storm

With great fanfare, the Secretary of Transportation recently released the report of the “blue ribbon panel” that was appointed in May to examine the safety culture of the FAA. Their report, “A Review of the FAA’s Approach to Safety,” was a result of the Southwest Airlines and American Airlines oversight debacle by FAA personnel and the fallout from the Congressional investigation.

The report
The Perfect Storm describes the events and their timing that joined together to produce extraordinary events that were viewed as the fault of FAA management and they were accused by many of causing severe economic damage to the parties involved.

The reference to rogue inspectors and cozy relationships is used in the report and stands out in this observer’s eye as the core issue of the report.

All managers, technicians, and executives involved with aircraft maintenance — and in particular air carrier maintenance — should review this report as part of their continuing education on how the bureaucrats look at FAA safety efforts today.

The report itself consists of 75 pages but is summarized in the first few pages. (You can find the complete report at

A word about the authors: there are five appointees to the panel, none of whom were or are frontline people in the maintenance field today or in the past, nor do they need to be, but it would be useful. Ed Stimson is the only general aviation person, having run GAMA for many years. Randolf Babbitt is a former Eastern Airlines pilot who ran ALPA after Eastern’s demise many years ago. Malcolm Sparrow is an author and professor. Carl Vogt is a former NTSB member and William McCabe is a retired Air Force Colonel who was concerned with safety at the NBAA.

You can read their complete resumes in the report.

Notably missing from the group are people like John Goglia, also a former member of the NTSB, but certainly more recently current on maintenance matters relating to the FAA than any one else. Those selected did, however, come up with some good advice for the FAA organization.

The guts of the report
The report starts with 13 safety recommendations as follows. This gives you a good idea what they were concerned about in the report. One must keep in mind that this is a critique of FAA safety efforts. The italicized words are my comments.

“FAA should retain the right to ground any plane not in compliance with an applicable Airworthiness Directive (AD). (No surprise here. FAA inspectors have had this power for a long time.)
The FAA should provide timely information about new AD requirements, in advance of compliance dates, to all relevant FAA field offices. (These notices go out in the normal course to everybody anyway … just get on the list.) Those offices should then be responsive to any carrier that requests assistance in the form of progress toward compliance audits or reviews, in advance of the AD compliance dates. (That’s part of the job of the Principal Operations Inspector or Principal Maintenance Inspector anyway, where an air carrier is concerned.)

The FAA’s voluntary programs are vitally important to the future of aviation safety, and should be retained. (Well … that’s why FAA created them!)

The FAA must abide by the rules circumscribing these programs in order to prevent the erosion of compliance. (That’s why the rules are spelled out. The rules under AC 58A have been tightened up considerably.)

Voluntary Disclosure Program (VDRP) data have not been routinely analyzed at a higher level within the FAA. There are two quite different purposes for such analysis, both of which the FAA should formally recognize. (One purpose is of course to identify safety risk; another is to eliminate any risks that may result from abuse of the program.)

The number of voluntary disclosures made by a regulated entity is a composite measure, and should not be used either as a performance metric or as a risk factor, in any context. (I disagree … I believe the number of voluntary disclosures are a clear attempt to insulate people and carriers from FAA sanctions. Most of the users feel that it is a sort of get out of jail free route ... not true, never has been true … the language has always been clear and unequivocal. The rules of 58A are clear to the inspectors, but apparently not to FAA lawyers!)

It is clear to the IRT (the panel) that participation in all of the voluntary disclosure programs is dependent on the assurance of confidentiality for the information submitted. The IRT believes the FAA should resist any efforts to relax or eliminate any restrictions on disclosure. (The recent signing of the Bilateral Aviation Safety Agreement (BASA) includes the exchange of “safety information” and what may be confidential safety data between the FAA and the European Safety Agency. Whether or not EASA or others will have access to confidential and or proprietary air carrier information remains to be seen. Like the whistleblower protective laws against retaliation by employers, this information should be rigorously protected from release to anybody.)

The FAA should explicitly focus on wide divergences in regulatory ideologies, where they exist, as a source for potentially serious error. (This deals with the differences between various FAA offices and different inspectors’ opinions on enforcement and gives rise to the rogue inspector expression.)

Training for managers and Principal Inspectors should explicitly cover the management of contrasting regulatory views within the workforce, methods for moderating extremes in regulatory style, and methods for optimizing the regulatory effectiveness and coherence across a diverse team of inspectors. (Extremes in style deal with the so-called “rogue inspector.” This area is an extremely sensitive one that will require whips and candy to reign in the diverse parties.)

The FAA should deploy the Internal Assistance Capability (IAC), recently established to review the composition and conduct of any offices or teams under recommendation one above (another FAA self-help program.).

The FAA also should deploy the IAC on a routine basis to review the culture and conduct of any airline certificate management office (CMO) where the managerial team has remained intact for more than three years. (This deals with the “cozy relationship” issue in general, and in particular at Southwest CMO.)

The IRT (panel) would urge the FAA to embrace its own operational role in risk identification and risk mitigation as formally and energetically as it has embraced its role in overseeing industry’s safety management system (SMS) implementation system before the end of 2010. (This statement is somewhat ambiguous.)

We recommend that without delay the FAA commission a time and motion study of its frontline inspection operation to empirically assess the time demands of air transportation oversight system (ATOS) and other IT implementations. (This seems to be just another finding that the field inspectors on the front lines are overworked and just cannot do all the things they are tasked to complete.)

It is clear that five of the items listed deal generally with voluntary disclosure programs and the system described in AC 58A, which was a key item in the Southwest debacle. One deals with ADs. The rest deal with the disparity in FAA enforcement philosophy and how it affects various offices. The “rogue inspector” fits into this category along with the so-called “cozy relationship” expression that is the other side of the coin.

ATOS (a brief comment)
ATOS stands for the Air Transportation Oversight System. It was designed to use system safety principles and systematic processes to assure that air carriers have safety “built into” their operating systems. Not all air carriers participate in this program. It was originally offered to a short list of carriers to see if it could be expanded. It has apparently languished somewhat since its inauguration in 1998 and now there is a big push to get it up to speed so that it will do what it was intended to do — namely to provide a significant safety trigger when the collected data shows something is out of line. I am told that more staff will be added to this program to provide more thorough analysis of the data. ATOS is only one of the voluntary reporting systems that air carriers can use. Aviation Safety Action Program (ASAP) and Flight Operational Quality Assurance (FOQA) are two additional data-gathering programs.

ATOS will get more focus because the report recommends a time and motion study of its frontline inspection operations to determine the time demands of ATOS (and the other IT programs). FAA management should finally realize that the time demands of all these data collection programs do not give the frontline inspectors much time for anything else.

It does not seem possible for field inspectors to collect, collate, and analyze all the data that is collected (much less their managers). It is becoming more apparent that the field inspectors do not have the time to do all the work. The time and motion study should show this. It seems to me to be a no brainer!

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