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The Associate Administrator’s Leaky Legacy

Tue, Nov 25, 2008 — Gabe Bruno

Articles

FAA Associate Administrator for Safety Nicholas Sabatini testifies 10 April 2008 before the Senate Subcommittee on Aviation Operations, Safety & Security on oversight after Southwest Airlines and American Airlines grounded their flights because of safety issues.

FAA Associate Administrator for Safety Nicholas Sabatini testifies 10 April 2008 before the Senate Subcommittee on Aviation Operations, Safety & Security on oversight after Southwest Airlines and American Airlines grounded their flights because of safety issues.

‘These problems were not evident at my level.’ On Monday, 20 October, 2008, Nicholas Sabatini, the FAA’s Associate Administrator for Aviation Safety, announced that he was retiring from the agency effective 3 January, 2009. In his broadcast message to employees, he said, “It was a difficult decision to reach because I am so proud to head this organization and to work with such an excellent team of safety professionals. Yet, the time is coming for me to move on to the next chapter of my life.” As a claim for his legacy, he went on to assert, “We can safely say that we are in the safest period in the history of aviation.”

Sabatini’s specious mantra that we are in the safest period in the history of aviation is something he has repeated frequently as if the repetition would make it true.  Our safety statistics for the moment owe much to the reliability of today’s modern equipment. Sabatini boasts that the system is safe because we have not had a major crash of a large airliner filled with passengers in several years. A closer examination of his legacy, and National Transportation Safety Board (NTSB) reports, however, paints a very different picture of the reality. 

The more telling truth is there has been loss of life in air carrier crashes that are just not “large enough” to register on the FAA’s Richter Scale of public reaction.  Two examples are the January, 2003, U.S. Airways Express crash in Charlotte, NC, that claimed 21 lives, and the December, 2005, Chalk’s Ocean Airways crash in Miami, FL, that took 20 lives.  The NTSB found causal factors in both of these tragedies to be “faulty maintenance and lack of FAA oversight.” The post accident investigations that identified the technical reasons for these crashes also unmasked Sabatini’s true legacy. His tenure is one marked by squandered opportunities, avoidance of accountability, and a smug attitude that all is well.

 

THE ‘SAFEST PERIOD’ MANTRA

To use a medical analogy, if the FAA were a patient whose last heart attack occurred several years ago, would a diagnostician proclaim that patient is healthy without a close examination? Of course not. A competent, comprehensive diagnosis would include an evaluation of the patient’s vital signs. An evaluation of the FAA’s vital signs reveals a number of continuing problems.

An examination of Chalk’s fiery crash, that took the lives of both crewmembers and all 18 ticket-buying passengers on board, clearly illustrates the FAA’s indifferent and dysfunctional safety culture under Sabatini.  In its final report, the NTSB concluded damningly, “The FAA’s failure to identify the inadequacy of the Chalk’s Ocean Airways maintenance program was causal to the accident.” And, “The Federal Aviation Administration received sufficient clues from a number of sources to alert it to potential safety deficiencies at Chalk’s Ocean Airways, and these cues should have prompted heightened vigilance and additional surveillance of the operator.”

In referring to applicable FAA internal guidance, NTSB board member Deborah Hersman stated, “Unfortunately, and for no reason our investigators could discern, the guidance was not applied to Chalk’s and the operator did not receive heightened safety scrutiny, despite significant concerns stated by DOT [the Department of Transportation] about the operator’s financial condition.”

NTSB board member Kathryn Higgins referred to the crash as an “avoidable accident” and stated, “I wish we had gone further in our investigation to understand why this accident happened.” She felt strongly enough about the investigation’s lack of answers that she wrote an addendum letter to the accident report that presented a litany of questions:

“Why didn’t anyone with oversight responsibility connect all these facts? Why didn’t anyone look more carefully at this operation? Why didn’t anyone act before this accident? What can be done to assure that another accident clearly waiting to happen is prevented?”

And her questions continue:

“Who is providing safety oversight? And, finally, who is held accountable?  My concern here is that nothing has really changed. The relationship between the regulators and the regulated seems even more attenuated. If that’s true, this important report has not greatly changed the safety equation.”

These are significant questions that come under Sabatini’s purview. They are deserving of a response.

A Freedom of Information Act (FOIA) request for a copy of the FAA’s response to these NTSB questions drew this response from the FAA; ” A records search was conducted in the Office of Accident Investigation. We were not able to locate any records or files responsive to your request, and we are unaware of any other offices likely to possess any additional responsive records.” Incredibly, the FAA has satisfied its own needs by not responding to the NTSB questions about a preventable, fatal, air carrier accident, and it does not appear to have any intention of ever doing so.

Even more incredible, is the fact that the multi-million dollar Air Transportation Oversight System (ATOS), that Sabatini touts as the FAA’s “systems safety” program, never addressed any of the, “…sufficient cues from a number of sources to alert it to potential safety deficiencies at Chalk’s Ocean Airways…” that the NTSB identified. In the wake of the 20 fatalities, the FAA corrective action consisted of moving oversight 200 miles further away from the Chalk’s Miami operation to their Flight Standards District Office in Orlando, Florida.

The story behind the U.S. Airways Express crash is equally as demonstrative of the FAA’s inability and disinterest in meeting its mandated responsibilities. The NTSB determined that the probable cause(s) of this accident that claimed the lives of all 21 on board was, “The loss of pitch control [that] resulted from the incorrect rigging of the elevator system compounded by the airplane’s aft center of gravity…” and, “the FAA’s lack of oversight of Air Midwest’s maintenance program and its weight and balance program.”

The faulty maintenance was conducted at an outsourced maintenance facility in Huntington, West Virginia, by a mechanic who didn’t understand the directions for the task. The FAA inspector who was assigned the oversight responsibility of the outsourced maintenance facility was located 900 miles away in Wichita, KS. Apparently, the FSDO located 60 miles down the road in Charleston, WV, wasn’t suitable for this assignment. Sabatini certainly was aware of the existence of the Charleston FSDO; that’s where he began his FAA career.

It is important to appreciate the NTSB’s identification of the FAA’s contribution to the causal factors of these two air carrier accidents. The causes cast light on the FAA’s culture under Sabatini of coddling the airlines. Although these two examples don’t carry the sensationalism of a jumbo jet crash, they demonstrate the ineffective safety oversight at the FAA today.

These are the same factors that were exposed during the 3 April 2008 hearing of the Congressional Transportation and Infrastructure Committee, chaired by Representative James Oberstar (D-MN). Southwest Airlines’ non-compliance with multiple Airworthiness Directives (AD’s) concerning fuselage cracks, wire chafing, and rudder servos, was the result of faulty maintenance and lack of FAA oversight. The resultant grounding by American Airlines of thousands of their flights was caused for the same reasons. American’s attempt to get ahead of this problem, once it was exposed, caused millions of dollars of damage to their bottom line and to the country’s overall economy.

When questioned about the AD problems by the Congressional committee, Sabatini’s wholly inadequate defense was, “These problems weren’t evident at my level.”

 

ATOS DEBACLE

Let’s start with a simple fact: the major safety problems that resulted in Congressional alarm and have brought about proposed corrective legislation were exposed by FAA inspector whistleblowers, not the ATOS (Air Transport Oversight System) machinery. That is not the way it was supposed to be.

ATOS was implemented as a response to the 1996 Valujet crash that killed 110 people. To preclude another ValuJet-like tragedy, the FAA conducted a “90 Day Safety Review” which produced several recommendations to develop better methods to address the rapidly growing discount carrier segment of the industry. Thus, ATOS was born. Curiously, when ATOS was rolled out two years later, it was directed at the top ten U.S. legacy carriers, not the discount carrier segment. The new “oversight” system surprisingly excluded ValuJet, the discount carrier that started it all.

What does this have to do with Sabatini’s legacy? Well, when he became Associate Administrator for Aviation Safety in 2001, he inherited responsibility for the new program. ATOS matured under his direction for seven years into what it is today. In spite of Congressional attempts to monitor ATOS, and several Government Accountability Office (GAO) reports detailing numerous inadequacies, the program has continued to be a bloated, money-burning fiasco, that increasingly keeps field inspectors chained to their desks doing data entry duties. Testimony to Congress estimates that inspectors now spend 70% and more of their time on data entry.  The steady decrease in actual inspections on the shop floor has devalued the worth of the inspectors. Sabatini’s vision of ATOS has resulted in “clogged arteries” for the FAA patient.

The Department of Transportation Inspector General’s (DOT/IG) report this year to Congress (Report #AV-2008-057), noted glumly:

“The breakdown in FAA’s air carrier oversight occurred because FAA did not implement and enforce effective management controls over its air carrier oversight program. . . . the seriousness of the issues we identified will require immediate and comprehensive changes to FAA’s air carrier oversight program.”

To address the growing public awareness of the management failure and malfeasance going on at the FAA, the DOT commissioned a team, “…charged with the task of evaluating and crafting recommendations to improve the FAA’s safety culture and the implementation of an aviation safety system.” After meeting with several hundred inspectors at 15 different field offices, the team produced a report containing 13 recommendations, only one of which addressed ATOS. The team’s report read, “The FAA [should] commission a time-and-motion study of its front line inspection operation, to empirically assess the time-demands of ATOS and other IT [information technology] implementations.”

The FAA readily accepted this recommendation and said, “The study will commence in March 2009 and be completed within one year. Time frame for implementation will depend on the recommendations.”

In other words, the FAA will consider a time-motion study, not an evaluation of ATOS effectiveness, well after Sabatini retires. We might say this is coincidentally convenient.

 

MAINTENANCE OUTSOURCING NEGLECT

The numbers are fluid but the trend is constant: U.S. air carrier maintenance outsourcing is enjoying tremendous growth under Sabatini’s authority. To cite constantly changing numbers would just give the FAA something to quibble about; however, they can’t argue the conservative, factual statement that most major U.S. carriers now outsource most of their aircraft maintenance. The DOT/IG has found that outsourcing has more than doubled in four years and the FAA has failed to track how much maintenance is farmed out and where it is performed. Simply put, most of the maintenance of our nation’s air transportation system is now being done under contracts to second and third parties, both domestically and at foreign facilities.

The further downstream from the certificate holding airline that the maintenance is performed, the more difficult it is to monitor. Thus, quality control moves further away from both the airline and the FAA. The advantage to the airline is some level of cost cutting; however, it becomes more expensive and difficult for the FAA to perform its core function of safety oversight. So far, under Sabatini, the FAA has lacked the vision and motivation to address this critical 21st century challenge.

If the previously described USAir Express crash, caused by faulty outsourced maintenance and inadequate FAA oversight, had been a jumbo jet with 200 fatalities, the FAA would have been forced to find a more effective approach to meet the outsourcing challenge. Sadly, those ticket-holding passengers’ lives only amounted to a warning that was easy to ignore. The FAA Richter Scale wasn’t moved.

In today’s world of increasing international economic interdependence, outsourcing to foreign repair stations has rapidly become standard business practice. The FAA has failed to standardize its own business to address the additional safety risks this new environment presents. The DOT/IG found that outsourced certified repair shops often turn to uncertified subcontractors who have no FAA oversight, to save money. This is not news to Sabatini, who has been content to take the position that the FAA has no authority to inspect uncertified facilities. That may be safe bureaucratic ground but it does nothing to abate risk.

In a 29 March 2007 appearance before Congress on this subject, Sabatini produced a chart to illustrate that outsourced maintenance was at an all time high. He went on to proudly repeat the FAA “safest period” mantra as evidence that outsourcing oversight was being properly managed, and there he planted his flag. Of course, he didn’t discuss the NTSB citing of lack of FAA oversight of the outsourced maintenance, responsible for the U.S.Airways Express fatal accident that occurred on his watch. Those 21 fatalities would have confounded his presentation. He also failed to present a plan to address the increasing lack of FAA ability to provide the necessary safety oversight.

The FAA’s own inspectors have been sounding the alarm about their inability to address safety issues under the agency’s current posture. Tom Brantley, President of the Professional Aviation Safety Specialists (PASS) union, stated to Congress on 3 April 2008, “FAA management has allowed the culture at the agency to devolve into one in which satisfying airlines has been given preference over aviation safety,” a sentiment supported by DOT/IG findings.

When Congress enacted the Federal Aviation Act of 1958, the legislation that created the FAA, they placed the responsibility for the safety of the nation’s growing aviation system squarely on the FAA. The agency was tasked with promulgating the necessary rules and providing safety oversight of the industry, and was given the full authority to fulfill this public trust.

In spite of the clear responsibility vested in this Congressional mandate, the FAA relies almost completely on the airlines, and the repair stations themselves, to make sure outsourced repairs meet FAA safety standards.

The current state of maintenance outsourcing oversight is the growing aneurysm in our FAA patient.

 

AIRCRAFT CERTIFICATION SCHISM

Just this past 17 September, Sabatini, surrounded by his minions, put on another failed performance before Congress. He was called to explain how the agency gave final certification approval for the production and sale of a newly designed aircraft – the Eclipse EA500 Very Light Jet – that still had issues that did not meet certification standards. It’s easy, if you’re Sabatini’s certification team, you just accept IOU’s from the manufacturer, who has never designed an aircraft before! The FAA stamp of approval, along with a number of IOU’s for the uncompleted certification items, was quickly followed by an in-flight emergency, when a pilot lost control over the new aircraft engine’s power, due to a software design problem. Thanks to the pilot’s skill and a little luck, a fatal accident was narrowly avoided.

Astoundingly, Sabatini and his group sat in front of Congress and stoutly defended their sloppy, unprofessional, life-threatening certification approval of the EA500. They criticized the FAA pilots and engineers that blew the whistle on the airplane’s shortcomings. They said the originally assigned certification team, who balked at the certification approval, wasn’t experienced enough to know how to complete the task, so they were relieved of duty and the sycophants were called in to get the aircraft into production, complete with IOU’s.

Just as with the 3 April hearing on the Southwest Airlines AD problems, this fiasco was exposed by FAA whistleblowers, not by any FAA safety program. The DOT/IG testified, “What this case is about is a strikingly accommodative behavior to certify an aircraft by a date set…The FAA should have developed certification standards…”

Rep. John Hall (D-NY) stated, “We’ve seen the cozy relationship too often. First, it was with the airlines and now with the manufacturers.” 

To cover his tracks for the 17 September Congressional hearing, Sabatini used his favorite gambit, convening a “team” to produce a report that shifted the focus and the blame elsewhere. The FAA issued a press release on 12 September, five days prior to the scheduled hearing, disingenuously titled, “FAA Agrees with Eclipse Certification Review Recommendations”.

This activity is a common pattern of Sabatini’s, to divert attention from his failure to meet his responsibilities, evade personal accountability, and to shift the blame down the line in the organization.

 

PERFORMANCE BEFORE CONGRESS

Sabatini’s performance during his appearances before Congress can best be described as lacking in forthright candor. One is reminded of an aphorism about U.S. Navy officials’ appearance before Congress: “The Navy practices the doctrine of apparent candor.” The same phrase describes Sabatini’s testimony. He could not explain why his organization lost control of the oversight of Southwest Airlines compliance with Airworthiness Directives, which resulted in thousands of paying passengers being carried on unairworthy aircraft. The FAA then proposed a $10 million civil penalty against the airline, as if to signal outrage over the safety violations. These were violations that the FAA helped to commit. Sabatini fatuously claimed that these problems weren’t evident at his level. That claim earned him a letter from Congress telling him that he had given misleading testimony at the 3 April hearing.

Just five months later, Sabatini again sat before Congress trying to defend the certification of an aircraft that was unable to meet certification standards. He was unconvincing.  

One of Sabatini’s poorest performances before Congress was after the 27 August 2006 Comair crash in Lexington, Kentucky, that killed 49 people. Three weeks after the crash he was unable to provide any substantive information to Congress. He was so disconnected that Rep. Bill Pascrell (D-NJ) described his responses to questions as “Gobbledygook”.

Sabatini has a dance he regularly performs before Congress when he is pressed for answers. It goes something like this: Step 1, declare there are “lessons learned” from his particular failed experience; Step 2, claim that he’s formed a committee to study the “lessons learned”; Step 3, assure everyone of his “personal commitment” to safety. It appears that Congress has finally tired of being waltzed around to the “Sabatini 3 Step” and is taking action independent of the Associate Administrator for Safety. 

On 22 July 2008, HR 6493, known as the “Aviation Safety Enhancement Act of 2008,” was unanimously passed by the House.  The bill contains several provisions to address ongoing problems in the FAA; however, the single most important provision is the establishment of an independent “Aviation Safety Whistleblower Investigation Office.”  Keeping in mind that all of the major safety deficiencies that have been discussed in Congress and the media, have been brought to light by conscientious FAA whistleblowers, not by the current FAA safety programs.  This office would give voice to those who are in the best position to suggest remedies for FAA safety deficiencies.  An office like this would allow whistleblowers to come forward without recrimination and fear of losing their jobs.  This is the single most threatening provision to Sabatini’s regime.  Sabatini’s management culture could not exist with a truly independent Aviation Safety Whistleblower Investigation Office in place.

 

THE STAGE IS SET

Even though Sabatini has announced his scheduled retirement date as 3 January 2009, he is leaving behind subordinate officials in his image and likely to act with comparable blindness or culpability. Since he became Associate Administrator in 2001, Sabatini has surrounded himself with yes men that owe their jobs to him personally, not to the merit promotion system. Just a few examples of his selections are:

  • The promotion of an unstable individual to the position of Division Manager who then physically assaulted a Southwest Airlines flight attendant on a flight to Kansas City,

 

  • The promotion of two individuals to positions of Division Manager who were caught giving false testimonies to the judge in an equal opportunity (EEO) case. The judge recommended disciplinary action, but no action was taken against these Sabatini placements,

 

  •  His placement of a former coworker in the position of Office Manager, who was caught and disciplined for maintaining pornography on his government computer.

Sabatini is leaving behind a management culture of non-accountability, an organization permeated with cronyism, and one with an overall lack of motivation to honor the public trust.  His leadership has resulted in an organization wracked by whistleblower disclosures, IG investigations and Congressional inquiries.  As Rep. Oberstar stated, “The FAA needs a house cleaning from top to bottom.”  Unless this cleansing is done, Sabatini will have set the stage for further laxity, lack of oversight – and further scandals.

Gabe Bruno

Gabe Bruno

Byline: Gabe Bruno is a retired FAA manager and is now an independent safety consultant. His 28-year FAA career included serving nine years at FAA Headquarters in Washington DC and managing two Flight Standards District Offices (FSDOs) in the FAA’s Eastern and Southern Regions.

He received numerous awards during his career, including Manager of the Year and Office of the Year. He may be contacted at GBruno3@cfl.rr.com.


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