The FAA’s Failure to Protect the Skies

Tue, Apr 22, 2008 — David Evans


An insider’s analysis

By Gabriel Bruno

My name is Gabriel Bruno and I am a former Federal Aviation Administration (FAA) manager and whistleblower who retired from the agency in 2006.

I attended the 3 April 2008 U.S. House of Representatives Transportation & Infrastructure Committee hearing, on “Critical Lapses in FAA Safety Oversight of Airlines.” Sadly, what I witnessed during the proceedings indicates that things remain unchanged, and that until FAA Associate Administrator for Aviation Safety Nicholas Sabatini is removed from office, nothing will change in the agency.

While the Committee probed Mr. Sabatini with questions to determine where the breakdown in the FAA organization took place that allowed Southwest Airlines to fly thousands of passengers in noncompliance with Airworthiness Directives (ADs), Sabatini tried to convince the Committee that the problems were “not evident at [his] level”.  Considering the magnitude of the evidence presented to the legislators, his assertion strains credulity.

My personal experience with Sabatini would lead me to believe that he was fully aware and likely actively engaged in the acts of retaliation to which the Southwest CMO (Certificate Management office) inspectors testified at the hearing. In 2001, when I was the FAA manager responsible for the oversight of the ValuJet/AirTran merger, I personally briefed Sabatini on the critical need for FAA resources to provide proper oversight of that rapidly growing carrier in accordance with the new ATOS (Air Transportation Oversight System) program. He refused my requests for resources.

Sabatini attempted to convince the Committee during the hearing that the Southwest Airlines scenario was an “aberration” that he would correct, and not a systemic problem.  But the Southern Region operates in the same manner under Sabatini’s personally placed Division Manager, Ms. Dawn Veatch. One example is an inspector that was transferred out of his position because of maintenance violations that he was filing when he had oversight responsibility for AirTran Airlines. This happened in 2003 and it was the same pattern that we heard much testimony about occurring at the SWA CMO.  The carrier wrote complaints about this inspector and his supervisor promptly removed him. This was an act consistent with the spirit of Sabatini’s “Customer Service Initiative” (CSI).

Sabatini himself demonstrated this pattern of favoritism when, as the Eastern Region Division Manager, he became personally involved in and ordered the certification of a new applicant, JetBlue Airlines, to be fast-tracked. This was at a time when, as a result of the ValuJet lessons, the FAA knew that it should have been exercising due-diligence in certifications and not invoking an artificial fast-track timetable. His cozy relationship with JetBlue was once again evidenced when it was discovered that their management conducted pilot fatigue experiments during passenger-carrying service, an illegal action that had the tacit approval of the FAA.

As the Transportation & Infrastructure Committee continues its investigation, leading to a possible second hearing, it will not be able to avoid seeing an agency filled with responsible adults who are harassed, abused and terrorized with fear for loss of their livelihood.  However, there are many individuals from every region who, if put under the protection of subpoena, will tell the truth.


A critical lapse in the safety oversight of airlines is something I have witnessed and experienced from a vantage point inside the FAA chain of command. I was the FAA manager that was given the responsibility of overseeing the merger between AirTran Airlines and ValuJet Airlines (VJA), after the 1996 crash of ValuJet Flight 592 that claimed 110 lives. This is not ancient history; the lessons learned from that tragedy provide key insights into the current problems with Southwest Airlines.  It was the VJA accident that brought about the Airline Transportation Oversight System (ATOS), which the FAA pours millions of dollars into today. ATOS was the FAA’s ultimate response to the following investigations, reports and review: 1) The National Transportation Safety Board (NTSB) VJA Flight 592 investigation that cited lack of FAA oversight as a causal factor; 2) a post-ValuJet Department of Transportation/Office of Inspector General (DOT IG) investigation to determine what was wrong inside the FAA; and 3) the FAA’s own “90 Day Safety Review,” which made recommendations intended to preclude the recurrence of another tragedy by rapid growth air carriers.

Oddly, when the FAA implemented the ATOS program, they did not involve any rapid growth carriers, including the newly merged ValuJet/Airtran airline, under the oversight umbrella of their new expensive program. In fact, I was flatly denied oversight resources and authorization to include the carrier that began the whole chain of events that resulted in the program. Instead, the FAA included only the top ten legacy carriers that were not the subject of the recommendation to develop the program in the first place. During the ensuing years, the FAA has spent millions of taxpayer dollars on ATOS.  Meanwhile, the GAO (Government Accountability Office) has audited and reported continual problems with ATOS. The merged ValuJet/AirTran operation was finally admitted into ATOS nine years and eleven months after the May 1996 VJA tragedy.

As a result of this month’s hearing on the Southwest Airlines/FAA expose’, the FAA launched the so-called “Tiger Team.” The ostensible purpose of this team is to investigate and correct the “breakdown” that occurred with Southwest (SWA) maintenance procedures, and the “breakdown” in their own oversight of those procedures.

The premise that this is merely a hiccup in an otherwise effective system is faulty. A “breakdown” implies a one-time event that is easy to identify and repair. A dysfunctional system, on the other hand, is an entirely different matter that requires extensive overhaul. It defies reason to assert that the system is otherwise effective when field inspectors have to risk their careers to get corrective action on such flagrant safety violations.  A look at other incidents helps to shed light on the fact that the problems go much further than a mere “breakdown.”

Did the FAA inspector that also came forward over Northwest Airlines (NWA) maintenance issues risk his career over a simple “breakdown?” In the NWA case, the DOT IG found, “FAA’s handling of safety concerns appeared to focus on discounting the validity of the complaints. A potential negative consequence of FAA’s handling of this safety recommendation is that the other inspectors may be discouraged from bringing safety issues to FAA’s attention.” The FAA’s ATOS program did not uncover this “breakdown” either.


Two other recent examples are the 8 January 2003, U.S. Airways Express crash in Charlotte, NC, with 21 fatalities, and the 19 December 2005 Chalk’s Airways crash in Miami, FL, with 20 fatalities. In both of these accidents the NTSB cited “faulty maintenance and lack of FAA oversight” as causal factors. Are these tragedies also the result of “breakdowns,” or do they demonstrate a larger pattern of FAA negligence?  Close examination of the causal factors identified by the NTSB reveals that these accidents were preventable and contain the seeds for a “major” accident.  They resonate with the unmistakable echoes of the VJA and with the Alaska Airline (AKA) Flight 261 accident investigation findings about the missed jackscrew lubrication that came out in 2000.

Despite this grim history, FAA officials, notably Sabatini, continue to repeat the mantra that this is the safest period in air transportation history. That empty phrase is routinely used as a defense against any criticism and findings of FAA deficiencies. The full measure of safety is not the singular fact that we have not experienced a “major airline” accident in recent years, but rather, how effective are our oversight and accident prevention programs?  Can inspectors do their jobs? The fatalities that have occurred, and the findings of the whistleblower inspectors, amount to something, even if they don’t register on the current FAA regime’s Richter scale.  Once the “major” accident happens it’s too late. The finest accident investigation cannot undo the damage.


Today’s “partnership programs” are, for the most part, “don’t ask, don’t tell” understandings.

  1. One illustration of this is the Service Difficulty Reporting (SDR) program. An independent snapshot review of Southwest’s use of this program revealed 32 reports from various sources of SWA flight emergency returns and diversions from 2002 to the present. Of these 32 reports, only 10 are in the SDR database, demonstrating approximately 31% compliance rate with the SDR program. Only 6 of those 10 show a cause. With FAA acceptance of this type of deficient reporting, how can any “partnership program,” designed to identify adverse safety trends, have any validity?

  1. Another example is the recent flurry of activity by air carriers grounding hundreds of their in-service aircraft to bring them into compliance with Airworthiness Directives (ADs). Numerous “legacy” carriers, carrying thousands of passengers, had not complied with ADs to address fuselage cracks, rudder controls and wire arcing that could result in fires. The FAA’s “partnership programs” did not reveal this gross non-compliance.  It took intense media reporting to motivate the airlines to come into compliance. Most likely these unairworthy aircraft would have remained in passenger service if the media had not scrutinized the FAA’s inattention and ineffectiveness.

The FAA’s complicity allowed thousands of fare-paying passengers to be at risk.  The “don’t ask, don’t tell” mentality has to go. A demonstrable change in culture is needed and today’s’ FAA management is incapable of accomplishing that.


The federal government’s Office of Special Counsel (OSC) currently has ordered two separate investigations as a result of disclosures I made about FAA gross mismanagement, resulting in a danger to the public. These disclosures reveal an outrageous dereliction of oversight responsibilities resulting in aviation safety lapses.

With full knowledge of the risk to the public, the FAA has suppressed the information about FAA mechanic certificates that were obtained from a criminal enterprise, St. George Aviation. Mr. Anthony St. George was convicted in May 1999 and sentenced to two and one half years in federal prison for fraudulently issuing mechanic certificates to unqualified individuals.  I was responsible for recertifying the mechanics. This criminal activity was going on in the same place (Central Florida) and at the same time the 9/11 hijackers were receiving pilot certifications from area flight schools. When I instituted a genuine re-examination program, 80 percent of the first 350 mechanics failed to recertify. Inexplicably, Sabatini responded by ordering the FAA cancellation of the program, leaving well over 1,000 untested mechanics working throughout the aviation industry.

As a result of my whistleblower disclosures to OSC, the DOT IG required the FAA to resume the program, because of the potential impact on aviation safety. Sabatini’s cancellation had left the program for dead for three years. The FAA has since admitted to making no effort to obtain information on where these people are employed or to establish liaison with any air carriers or repair stations where air carriers outsourced maintenance. Further, under Sabatini and James Ballough, Director of Flight Standards under Sabatini, the FAA has done no cross referencing with NTSB accident or incident investigations or data bases to determine involvement of St. George certificate holders where “faulty maintenance” has been cited as a causal factor of fatal accidents. They simply do not know if any of these mechanics are involved in the current SWA maintenance “breakdowns” or the broader issues of the T&I Committee hearing.

The FAA finally has an incomplete, partial retesting effort underway that, in my view, does not meet regulatory certification requirements.  The FAA watered-down the test for recertification, removing the requirement that an individual be able to demonstrate “hands on” competence, which is like handing out driver’s licenses without making someone drive a car.

Since possession of an FAA mechanic’s certificate can qualify an individual for employment and give them access to U.S. aircraft and airport security areas, it is astonishing that the FAA did not enact any airline notification/advisory procedures to U.S. air carriers.  Neither Sabatini nor Ballough turned over the St. George list to any national security agency to determine the level of risk caused by foreign nationals on this list. The DOT has requested another extension of time until 12 May 2008 to respond to OSC on this national security issue.


So who is responsible for this state of affairs in the FAA? The FAA is an organization with a noble mandate, but it can only function as well as the individuals inside will allow.  Like any government agency, the FAA is susceptible to all the weaknesses and challenges of any organization, such as positive workforce motivation and variations in the quality of leadership. To truly hold an organization accountable for the way it conducts business you have to hold the individuals, especially the leaders, accountable for their decisions. There are individuals who are not elected by anyone nor confirmed for their ability to properly conduct FAA business. These leaders enjoy the bureaucratic anonymity that comes with their taxpayer-funded jobs. In the case of a government agency, it is the fulfillment of a public trust that requires accountability to that public.

Sabatini and his handpicked Director of Flight Standards, James Ballough, are the main drivers of this culture. There are others who carry their water and the workforce knows well who they are. There is a history of the qualified being replaced by indebted cronies, and unqualified supervisors being promoted into even higher management positions. I can personally point to the FAA’s Southern Region as just one prime example where this has occurred.

Under Sabatini’s leadership, the FAA does not have a functioning safety system in place, only a taxpayer funded illusion of one. What actually is in place is a quid pro quo understanding with the industry masquerading as “partnership programs.” As the T&I Committee has confirmed, the way it works is the FAA buries violations so carriers can operate with little to no negative effect on profits. However, when an outrageously unsafe condition, such as at SWA, breaks through the cover, everyone retreats to their “public position.” FAA management feigns concern and proposes a civil penalty, and the carrier, of course, claims safety was never compromised and vows to appeal the penalty. It is a well-orchestrated show for public consumption. The FAA management responsible for violating the public trust pushes the blame downward in the organization.

Rep. James Oberstar has rightly called for housecleaning of the FAA from “top to bottom.”  Such an effort, for violations of the public trust, must begin with the removal of Sabatini and Ballough.  To have the necessary effect to begin to change the existing culture in the FAA there must be removals, not resignations with parachutes leading to soft landings in highly paid industry jobs.  Only by the removal of the toxic leadership can conscientious inspectors stand up and lead the return of the FAA to its overarching safety mandate and the public trust to guard safety.

Sabatini’s relationships with special interests should be investigated for their influence on his FAA decision-making. He has allocated millions of taxpayer dollars to the ATOS don’t ask, don’t tell masquerade that has proven ineffective and keeps hundreds of inspectors engaged in activities not productive to the FAA’s safety mission.

In his appearance last year before the House T&I Aviation Subcommittee, on 29 March 2007, Sabatini stated, “I can assure you that my office is totally committed to making whatever adjustments the situation demands when it comes to safety oversight.”  Is the emerging evidence of silencing and intimidating safety inspectors his kind of adjustment? In my experience, the answer is “yes!”

The T&I Committee is now engaged in follow-up investigation of the current relationship between the airlines and the FAA, to include FAA actions to suppress the concerns of FAA inspectors. In addition, the Committee is probing probably misleading testimony by Sabatini, Ballough and Flight Standards Southwest Region Division Manager, Thomas Stuckey. On 7 April 2008 Rep. James Oberstar (D-MN), the committee chairman, Rep. Jerry Costello (D-IL) and Rep. Peter DeFazio (D-OR) sent a letter to the three FAA officials, basically putting them on notice that they had given the committee misleading testimony at the 3 April 2008 hearing. The letter said, in part, “In conclusion, you should understand that these are very serious issues to our Committee. We cannot condone misleading testimony in our hearings, and in last week’s hearings you were sworn under oath to tell the truth.”


In addition to removing the managers that are responsible for the deterioration of the FAA’s ability to enforce its safety mandate, there are other actions that can and should be initiated, with a Congressional oversight timetable for completion:

  1. The concept of managing the FAA safety mandate as a “business model” needs to be changed. This “business model” paradigm is inappropriate for a government agency whose expected product is public safety, not financial profit. Referring to the regulated air carriers as “customers” or “clients” is inaccurate and sets up a “business” mentality that facilitates the revolving door. The FAA is a regulatory agency that should be guided by the Congressional legislation that created it, not air carrier profit and loss spreadsheets. The Federal Aviation Act of 1958 (re-codified) contains all the requirements and authority the FAA needs to do its job, and needs to be revisited. This enabling regulatory legislation doesn’t refer to air carriers as FAA customers.

  1. ATOS needs a major overhaul or replacement with a program that actually emphasizes safety inspector findings and input, not rubberstamping whatever the air carrier provides. Analyzing deficient information provides nothing useful and takes inspector time away from real safety activities, such as engaging the air carriers on their shop floor. With less than an optimum size workforce, much can be done by taking advantage of current inspector expertise, and by removing the blinders of ATOS program guidelines that stovepipe inspectors’ attention.

  1. The FAA’s self-initiated, self-serving “Self-Exam,” to be completed by the end of June, amounts to nothing more than the wolf guarding the chicken coop telling you that everything behind the closed door inside the coop is okay. The recently issued FAA Notice 8900.36, which directs a paperwork-sampling audit, is a self-created opportunity to give operators a passing grade. Anyone finding problems would be admitting they did not do their jobs. Predictably, on the eve of the House T&I committee hearing, Acting FAA Administrator Robert Sturgell announced the FAA’s audit shows that the airlines are 99% compliant with mandatory Airworthiness Directives. An independent audit incorporating congressionally mandated milestones, with FAA operatives standing at parade rest would be more believable.

The House T&I Committee could not have received more serious evidence of FAA gross mismanagement, which creates a danger to the flying public, without actually having a major accident occur.  My “insider’s analysis” is that the FAA needs a rebirth of integrity.

Byline: Gabriel Bruno retired in 2006 after 28 years of service with the FAA. Over half of his FAA career was spent as a manager, including positions in FAA Headquarters in Washington DC and managing two Flight Standards District Offices (FSDOs). He earned numerous awards for his outstanding service. A close variant of this article was presented as a statement to the Transportation & Infrastructure Committee. (Bruno e-mail: GBruno3@cfl.rr.comThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it )

(Disclaimer: This article represents the personal opinion of Mr. Bruno and does not represent the views of Aviation Safety & Security Digest.

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