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Agency Accuses Airline of Sloppy Maintenance While Sidestepping Its Own Safety Oversight Shortcoming

Tue, May 27, 2008 — David Evans

Articles

The recent groundings of hundreds of airliners for inspections raises serious questions about federal oversight (see Aviation Safety & Security Digest, ‘Committee Vows to Legislate Changes to Strengthen Oversight of Airlines’). The perception given by the Federal Aviation Administration (FAA) is that the agency is on top of safety issues and has acted with alacrity when that safety appeared threatened. What is not addressed is why it took so long for the FAA to rectify numerous long-standing safety issues.

The most recent effort at FAA salesmanship comes from a 2 May 2008 report the agency submitted to Transportation Secretary Mary Peters, which was prepared in response to her request for a documentation of events that led to the grounding of 367 airplanes by American Airlines on 8 April 2008.

This report said, basically, that maintenance work by American Airlines was so sloppy that it posed a safety risk.

“Left uncorrected, the workmanship errors would have increased the odds that [a plane] would have experienced arcing, smoke, or fire problems that have caused serious incidents and fatal accidents in the past,” the FAA reported.

The regulators added that the poor quality of work on wire bundles in the wheel wells of the airlines MD-80 jets “raised the specter of a cumulative safety risk.” Accompanying the report were 22 pages of photographs documenting the deficient work on the airplanes (see below).

Photographic Report of Deficiencies

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Examples of FAA inspection findings.

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Example of deficiency and the correct method of repair.

American Airlines, in its own assessment filed with the Department of Transportation (DOT) 2 May 2008, took strong exception to the FAA report, saying “at no time was there a safety of flight issue.” The carrier blamed the four days of groundings that ended 12 April 2008 on communications failures between the FAA and the airline. The airline said, “The groundings in this instance occurred because FAA Southwest Region officials repeatedly told American that they intended to ground the MD-80 fleet if American did not do so immediately.”

The question not asked in the many media accounts is why all this frenetic activity over MD-80 wiring. After all, the FAA has grappled, some say tardily and ineffectively, with the aircraft wiring problem for years.

One should point out the political context in which the grounding occurred. The Transportation & Infrastructure Committee of the U.S. House of Representatives held a hearing 3 April 2008 on the alleged “cozy relationship” between Southwest Airlines and other carriers. Whistleblowers from the FAA testified that their efforts to guard safety were repeatedly thwarted by more senior officials within the organization. Top FAA officials in Washington DC denied any knowledge of these machinations at the Southwest Region, which covers both Southwest Airlines and American Airlines (see Aviation Safety & Security Digest, ‘The FAA’s Failure to Protect the Skies’). Southwest, too, grounded some of its B737 aircraft for structural inspections of the fuselage out of concern that the original inspections either could not be documented or were not done.

At this hearing, Congressmen were clearly upset at the FAA’s failure of oversight. Comments from the legislators included:

“Southwest Airlines allowed 117 planes to fly without AD [airworthiness directive] compliance … the most egregious lapse of safety that I’ve seen in 23 years,” groused T&I Committee chairman, Rep. James Oberstar (D – Minn.).

“Why did it take the actions of this committee to get the FAA to act,” complained Rep. Jerry Costello (D – Ill.).

“You’re lacking some hall monitors; we need action, true monitoring and validation. We’re working the angels overtime and I’d prefer more action on your part,” said Rep. Laura Richardson (D – Calif.), speaking directly to Nicholas Sabatini, associate FAA administrator for aviation safety.

It was against this backdrop that the FAA’s report to DOT Secretary Peters was submitted. The 9-page report accused the airline of shoddy work performed in response to AD 2006-15-15, which required inspection and, if necessary, repair of chafed wiring in the wheel well of the MD-80 jets.

The AD was issued 31 July 2006 to correct chafing of wires that could expose the conductor, leading to electrical arcing and ignition of fuel/air vapors emanating from the wing fuel tank. The AD provided 18 months to do the work, which was to be done in accordance with a Boeing service bulletin.

The FAA report to DOT said:

“From April 8 – 12, 2008, American presented 351 aircraft to FAA inspectors [as part of the special audit], who initially found 207 aircraft were not compliant with the AD. This represents a 70 percent failure rate. Each of these 207 aircraft required additional work before being accepted as in compliance and returned to service.

“During this time period, there were instances where FAA inspectors waited for hours for an aircraft to be ready for inspection. Also, onsite reports from inspectors included instances of parts shortages, as well as American personnel shortages, that were needed to inspect or repair aircraft …

“While it may be argued that any one of the discrepancies – or non-compliance issues – may not pose an immediate safety risk, the aggregate findings of the workmanship quality raised the specter of a cumulative safety risk. Left uncorrected, the workmanship errors would have increased the odds that one or more of American’s large MD-80 fleet would have experienced arcing, smoke, or fire-problems that have caused serious incidents and fatal accidents in the past. …

“In answer to the question, ‘What could have been done to prevent the extreme impact to the flying public,’ American Airlines could have done the work properly in the allotted time or applied for a comprehensive AMOC [alternate method of compliance] earlier in the process …

“The FAA has formed a joint industry/Government task force to review the AD process, starting with AD 2006-15-15. The task force will look into how the affected airlines developed the mechanics’ work instructions and how the airlines could have managed this AD better … After completing that effort, the task force will look at the overall FAA process for developing ADs, how we communicate critical AD information to operators, and what, if any, procedures need to be changed to improve this process. …”

To this report, American Airlines responded, in part:

“Due to manufacturer differences in aircraft within the MD-80 family, implementation of the AD was not a ‘one size fits all’ proposition, and American’s process for implementing this AD was the same process we have used for the implementation of hundreds of ADs over decades of service.”

In this point/counterpoint exchange, a few items have not been discussed. For example, in its report, the FAA admitted: “Prior to this audit, there was no requirement for the FAA to inspect the aircraft for this AD.” (Emphasis added)

In other words, the photographs appended to its report, clearly taken by FAA officials galvanized to document American’s shoddy maintenance, and allegations that FAA inspectors were waiting idly to inspect the work done by American’s mechanics, were anything but routine. The FAA, stung by charges of being too collegial, was energized in this instance to demonstrate its stern oversight of the airlines.

So point one must be the failure of the FAA’s vaunted Air Transport Oversight System (ATOS). When it was introduced in 1998, the system was propounded by the FAA as replacing the need to inspect airlines and airplanes with a more analytical approach of searching through records and documents to identify trends that could be a hazard to safety. Through trend analysis rather than actually inspecting aircraft, the FAA hoped the airlines would be able to assess themselves and FAA inspectors would only have to watch for precursors to egregious breakdowns of airline self-management.

Congressmen were not convinced of this approach at the 3 April hearing. As Rep. John Mica (R – Fla.) said of ATOS at that hearing, “We put in place a self-reporting, risk based system, but we didn’t put in place a system to check the checkers.”

“Do we have enough FAA people?” Mica asked. “We have a serious problem with retirements and hiring.”

ATOS, truth be known, could be more pragmatically viewed as a cost- and people-saving response in an FAA that lacked the resources to oversee the industry.

Another issue is the general tardiness of relevant ADs. For American Airlines (and other carriers operating the MD-80), AD 2006-15-15 was issued in 2006, fully 10 years after TWA flight 800 exploded in 1996 and eight years after Swissair flight 111 crashed in 1998; both disasters were believed to have been caused by faulty electrical wire. In the case of TWA 800, the National Transportation Safety Board (NTSB) concluded that wire arcing in a bundle allowed excess energy to find its way into the center fuel tank, where it arced, igniting the explosive vapors in the tank of the B747. The airplane exploded and plummeted into Long Island Sound shortly after takeoff from New York. In the case of the Swissair MD-11, the Transportation Safety Board (TSB) of Canada found that electrical arcing caused a fire in the space above the ceiling in the forward passenger cabin, which quickly became a runaway fire because of the flammable materials in the area and the lack of fire detection and suppression. The airplane crashed in Canadian waters.

The AD was issued after the FAA ordered a manufacturer review of all possible ignition sources related to electrical wiring. The review was completed in 2004 and some 80+ ADs were deemed necessary to correct deficiencies in thousands of aircraft. Although the ADs identified various “unsafe conditions,” they were not all issued at the same time; rather, they were issued in phases to the industry. While this approach minimized the cost and inconvenience to the industry, it also extended the time taken to redress the numerous safety deficiencies that affected the various aircraft.

Note that this particular AD allowed 18 months for operators to inspect and correct the electrical wiring in the wheel well. The frenetic activity to complete the work in the last month of the time window allowed by the AD raises additional questions: (1) if the FAA determined that the wiring was potentially an unsafe condition that could lead to ignition of fuel/air vapors that could blow the wing off the airplane, why was such a generous time allowed for the inspections, and (2) why were the inspections by the carrier apparently scheduled at the last minute?

The whole approach by the FAA rings hollow. Wiring was identified as a major hazard by the NTSB, by the Aging Transport Rulemaking Advisory Committee (ATSRAC), and has been the subject of numerous conferences and symposia on aging transports. Yet the AD was issued years after the problem was identified and allowed months for the inspections to be accomplished.

A similar criticism concerns the fuselage inspection AD that prompted the Southwest Airlines grounding of B737s in March 2008. AD 2004-18-06 was published in September 2004 and was intended to inspect for weaknesses in lap joints on the fuselage which led to the explosive decompression of an Aloha Airlines B737 in 1988. Here was the FAA issuing an AD fully 16 years after the Aloha disaster.

The lack of timely action, and the generous time granted in the ADs to conduct necessary inspections, raises a question about the FAA’s seemingly cavalier attitude about safety. In a 13 May 2008 speech to the Radio Technical Commission for Aeronautics (RTCA), Sabatini declared, “It would be irresponsible and reckless to wait for the next accident to make additional safety enhancements.” But that is precisely what the very deliberate approach in the AD process virtually guarantees.

A potential source of information on the safety implications of non-compliance with the ADs is not exploited because it is incomplete. The source is the Service Difficulty Report (SDR) system, by which airlines are supposed to file with the FAA the action taken in the event of various malfunctions, such as smoke in the cockpit, an engine failure or a crack in the wing.

The first problem is that the SDR system is incomplete. Some airlines rigorously file reports, as they are required to do. Others file occasional reports, and some carriers do not file at all.

Further, if the SDR reports are passed through another filter, that of the FAA’s requirement to record an “apparent cause,” then the requirement both to file and to record the apparent cause is cut in half.

Moreover, airlines are only required to submit SDRs on malfunctions that occur in the air. An FAA proposal to submit SDRs for malfunctions that occur on the ground met with fierce industry resistance and was never implemented.

As a consequence of these reporting shortcomings, the SDR database is not a useful tool for FAA analysis of industry-wide incidents and trends. Thus, while Sabatini declared it “irresponsible and reckless” to wait for an accident, one might argue that it is equally “irresponsible and reckless” to tolerate the gaps in SDR reporting that would give the FAA insight into accident precursors. It takes an accident, or findings from a special audit of selected AD compliance, to galvanize the FAA into action.

The utility, or lack thereof, of SDR reports is so controversial that Marketplace of National Public Radio is now examining how airlines report mechanical difficulties to the FAA. Marketplace is now conducting a survey of those who work in aviation (see box below). The questions in that ongoing survey get at the heart of the issue: do service difficulty reports matter?

Marketplace Morning Report Survey

on Service Difficulty Reports

(Sample questions)

  • If you work for an airline or repair station, who decides which defects or malfunctions get documented in Service Difficulty Reports and which don’t?

  • What criteria are used to decide when to file an SDR? Please provide a concrete example of an incident or defect that would not merit an SDR and why not.

  • Can you recall an instance where the FAA regulation appeared to call for an SDR to be filed, but you or your company decided not to? What was the reasoning?

  • How is the SDR system used to detect patterns or problems with aircraft?

Your answers are confidential. We will not quote you on the air or on the Web without getting your explicit permission.

Regarding wiring, it is clear from the many photographs taken of electrical work, or one could argue “malpractice,” on American Airlines MD-80 jets that mechanics remain woefully ignorant of “best practices” regarding wiring husbandry. This situation persists despite FAA efforts to foster good practices.

As part of the Aging Transport Systems Rulemaking Advisory Committee (ATSRAC) effort, a joint FAA/industry initiative to assess the state of wiring in the fleet and to propose corrective action, a guide for sound wiring practices was published in July 2004. Produced by two FAA wiring experts, it showed in clear visual form wiring practices to be avoided, and those to be emulated. Known as Job Aid 1.0, the 164-slide PowerPoint presentation distilled into one document guidance on wiring practices that was spread among numerous other documents, to include federal aviation regulations (FARs), advisory circulars (ACs), wiring recommendations from the NTSB, wiring-related research papers produced by the FAA’s Technical Center, the 1996 “Gore Commission” report on aviation safety and security, the White House report known as the “Wire System Safety Interagency Working Group,” and other materials produced by manufacturers. As the Job Aid said, “For now, there is no one rule or AC that ties everything together.”

Overall, Job Aid 1.0 provided a readily accessible answer to the question of “How do you know what you’re supposed to do about wiring maintenance?” It was a Cliffs Notes guide, readily accessible and useful enough to avoid committing harm through ignorance.

Job Aid 1.0 outlined the numerous causes of wiring degradation, to include: vibration, moisture, improper maintenance (such as drill shavings contaminating wire bundles), chemical contamination (e.g., solvents), exposure to heat (which can accelerate degradation, insulation dryness and cracking), and installation (e.g., wire installed under tension).

Job Aid 1.0 did not have the force of a regulation; rather, it was an interim guide made available to the airlines to help them achieve a high standard of wiring maintenance (see box below).

It is obvious that the practices propounded by Job Aid 1.0 did not percolate down to the maintenance shop floor. For example, Job Aid 1.0 specifically cautioned that wire should not ride on structure, lines or cables. More specifically, the wire should be routed in a manner intended to eliminate the potential for chafing against structure or other components. One can only describe the FAA’s effort to publish voluntary guidance on wiring maintenance as a flat failure.

Job Aid 1.0 – A 2004 Guide to Wiring Maintenance

Three examples of wiring practices to be avoided taken from the document; compare to photos above of wiring problems documented at American Airlines

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To prevent chafing, wire should not ride on structure, lines or cables. (Job Aid 1.0 slide 38)

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A number of problems are shown: the wires in the bundle are not tied properly; the wire bundle is riding hard on the hydraulic lines; the wires appear to be contaminated with hydraulic fluid residue. (Job Aid 1.0 slide 44)

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Chafing against a control cable leads to a ‘sawing’ effect that can expose conductor, creating conditions for arc tracking. The heat of electrical arcing is more than sufficient to burn through and sever the control cable. (Job Aid 1.0 slide 51)

The FAA has now launched a mandatory inspection of wiring throughout the fleet. By a final rule issued 8 November 2007, certificate holders (e.g., airlines) have until 10 December 2009 to issue revised Instructions for Continued Airworthiness (ICA) that must include inspections of aircraft wiring.

These Enhanced Zonal Analysis Program (EZAP) inspections require examination of wires in close proximity to flight critical systems. Since the wiring in the MD-80 wheel wells, the subject of the recent controversy, is in close proximity to hydraulic lines, experts familiar with the EZAP protocol believe the wiring will be subjected to required inspection once again. Moreover, the poor routing that allowed for contact and chafing would need to be corrected.

According to a new Part 121.1111, “After March 10, 2011, no certificate holder may operate an airplane … unless the maintenance program for that airplane includes inspections and procedures for electrical wiring interconnection systems (EWIS).” By this regulation, the airline industry will be allowed three years for full implementation of the new wiring requirements.

Considering the 2011 deadline, one must point out that the TWA 800 tragedy in 1996 started the whole examination of wiring and all the subsequent activity. Therefore, it will take the FAA fully 15 years to put in place the changes and procedures thought necessary to prevent a recurrence of the disaster.

As one might say, “Moving at the speed of government.”

Instead of taking the recent FAA report to DOT as the full story, one might instead pose the following questions:

  • What has changed in American Airlines maintenance practices that led to such a dismal outcome in the recent inspections? Readers may recall that after the crash in January 2000 of an Alaska Airlines MD-80 from a failure of the jackscrew on the horizontal stabilizer that industry-wide inspections of the jackscrews on all other MD-80s were required by the FAA. Those inspections revealed that American Airlines had one of the best maintenance programs, with timely inspections and lubrication resulting in like-new conditions of its jackscrews.

  • Why does it take the FAA so long to implement NTSB recommendations, in this case regarding wiring that contributed to the destruction of TWA 800, other airplanes, and numerous in-flight emergencies and incidents?

  • Why has the FAA allowed so much time in its ADs to correct a problem that is defined as an “unsafe condition”?

  • Why is the survey now being conducted by National Public Radio not being conducted by the FAA? The SDR system should provide the FAA with alerting information on accident precursors, but in its present state of disorganization and bureaucratic lassitude, the SDR is best defined as a “data morgue” with, at best, partial and imperfect reporting.

  • Is ATOS in its present guise appropriate? The system requires FAA inspectors to examine paperwork for threats to safety, but it’s fair to argue that the FAA learned more in its recent audit of AD compliance by looking at the state of wiring an actual airplanes.

  • Does the FAA have enough inspectors to provide oversight of the airline industry? One gets the impression that 3,600 inspectors is too few, especially if the FAA were to shift inspections to actual airplanes as opposed to maintenance records.

  • If FAA inspectors “tripped over” the anomalies at American Airlines in the course of the audit of AD compliance, a larger question is posed: “If pre-eminent operators cannot be trusted to reliably complete directives, what then is the alternative?” Must an FAA inspector be tasked to sign off on each AD implementation?

  • Does the FAA have a coordinated, single program for assuring safety? Apparently not, as evidenced by the numerous ADs issued on wiring and other hazards, the disconnect between ADs and other safety-assurance programs like the forthcoming general wire inspections, and certification standards that permit wiring to be routed close to hydraulic lines and other flight-critical systems in the first place.

One gets the impression of the wholesale application of salve and bandages after the fact, rather than a systemic, well coordinated pro-active approach to flight safety. This dismaying conclusion is not likely to be examined by either the FAA or DOT, as it could portend painful adjustments that could lead to calls for increases in personnel, budgets and more active oversight of the aviation industry.

(The full FAA report to DOT, appendices of wiring photographs and American Airlines’ response, may be viewed at www.dot.gov/affairs/aviation080516/index.htm)


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