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A Code Shared Accident A television documentary finds the roots of the Flight 3407 accident in the changed structure of the U.S. airline industry.

AUDIO-VIDEO a dramatically changed airline industry, where regional carriers now account for half of the na- Regionals Under Scrutiny tion’s daily departures. The rise of the regionals Flying Cheap and arrival of low-cost carriers have been a huge Frontline. WGBH Boston. Producers: Rick Young and American boon to consumers, and the industry insists University School of Communication, Investigative Reporting that the skies remain safe. But many insiders are Workshop. Aired by Public Broadcasting System (PBS), Feb. 9, 2010. 56 minutes. Available on the Internet as a video, audiocast and DVD worried that now, 30 years after airline deregu- at . lation, the aviation system is being stretched beyond its capacity to deliver service that is both or those who did not view the Frontline pro- cheap and safe” (see “Startled and Confused,” p. gram, “Flying Cheap,” when it aired on U.S. 20, and “Mutual Aid,” p. 26). Ftelevision, PBS has made it available on the According to the program, the “code shar- Internet. The video and its full-text transcript ing” sales and marketing relationship between may be viewed and read online at no charge. the regionals and the major carriers is a cause The program is also for concern. available for purchase The program includes interviews and as a DVD or as a free discussions with a number of individuals who downloadable audio play significant roles in the commercial aviation podcast. industry, including William R. Voss, president The introduction and CEO, Flight Safety Foundation (FSF); John to “Flying Cheap” Prater, an airline captain and president, Air Line says, “One year after Pilots Association, International (ALPA); Roger the deadly airline Cohen, president, Association; crash of Continental former Colgan pilots; and former and current [Connection Flight, officials of the U.S. Federal Aviation Administra- operated by Colgan tion (FAA) and the U.S. National Transportation Air] 3407 in Buffalo, Safety Board (NTSB). There are also interviews New York, U.S. Front- with family members of accident victims. line investigates the The video is formatted into six discussion accident and discovers topics.

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“The Harrowing Crash of Continental a way of controlling costs,” Prater says. (Voss 3407” gives an overview of the flight and commented on cost controls and safety in begins to address issues identified in the NTSB ASW, 2/10, p. 1.) hearings and investigation. Clay Foushee, “The Life of a Regional Pilot” peers into the investigator for the U.S. Congress, says, “[The lives of regional pilots in which the workload is accident has] become a symbol of everything challenging, days are long, lengthy commutes to that’s wrong with the industry.” Foushee work are the norm, hourly pay is low, and time and the narrator refer to it as a “watershed on duty does not correspond to time paid, ac- accident.” cording to the program. Corey Heiser, a Colgan Air pilot from “Who’s Responsible for Safety” says, “Some 2005 to 2009, says, “We are only paid when major airlines don’t take responsibility for safety the door’s closed and the engines are running. of their regional partners — they rely on the … We may be on duty for 80 hours a week FAA. Is that agency up to it?” Congressional and get paid for 20 of it, if we’re lucky.” The hearings raised questions about who takes ‘The major airlines narrator and reporter, Miles O’Brien, says, responsibility for safety — major airlines or their created regional “Low pay and high living costs have created contractual regional airlines. Questions about an underground housing market in the airline the FAA’s mandate and its relationship with the airlines as a way of industry.” Chris Wiken, a former Colgan Air airlines it regulates are explored. pilot, says that “you can picture a one- and “A Decade of Missed Warning Signs” controlling costs.’ two-bedroom apartment with eight, 10, 12, 14 reveals documents, interviews and conver- guys in it, on roll-out mattresses and sleeping sations intended to support the program’s on the floor, sleeping on the couch, sleeping assertion that “the FAA was aware of signifi- in bunk beds, air mattresses, waiting in line cant and repeated safety concerns at Colgan for the shower.” Such quarters are known col- Air” and raises questions about safety culture loquially as “crash pads.” within the airline. Roger Cohen, speaking for the Regional “Raising Safety Standards at Regionals” Airline Association, responds: “Let’s get the discusses government and industry recommen- facts out on the table on this, Miles. The average dations and public comments that have resulted salary for a regional airline captain is $73,000. from the accident about pilot training and quali- The average salary for a at a regional fications, pilot work rules, best practices, audits airline is about $32,000, $33,000 a year.” To and other safety issues. (Additional information O’Brien’s suggestion that regional airline pilots about the FAA’s “call to action” plans appear in paid less than the average are in “an untenable ASW, 2/10, p. 36.) position economically,” Cohen replies, “Abso- The video is accompanied by a companion lutely not, because there are many other people Web site produced by WGBH and contains who earn less money than that, who work more several special features that are not included days in these communities, that can afford it … in the program, such as two short videos and do it responsibly.” about work hours, rest/fatigue issues and “Growth of Regional Airlines” describes operational pressures on pilots of regional Colgan Air’s growth from a fixed-base operator carriers. There are expanded interviews to a charter company and, with deregulation with regional pilots, government regulators, of the airline industry, to a regional carrier. An industry representatives, family members of explanation of changes in the industry’s busi- victims, and others. A map of regional airlines ness model, the hub-and-spoke concept and flying into and out of major U.S. airports dis- development of code sharing leads to a discus- plays airline safety records. sion about financial pressures facing airlines. An online discussion includes extended “The major airlines created regional airlines as consideration of the issues raised by the Colgan www.flightsafety.org | AEROSafetyWorld | March 2010 | 53 InfoScan

Air Flight 3407 crash. Participants include Chris Additional maintenance-related complaints Wilken, former Colgan pilot; Loretta Alkalay, for- were submitted. mer FAA regional counsel; Mary Schiavo, former In response, the OIG audited the U.S. Federal inspector general, U.S. Department of Transpor- Aviation Administration’s (FAA’s) oversight of tation; Scott Maurer, father of Lorin Maurer, who American Airlines’ maintenance program be- was killed in the accident; and Rick Young, writer, tween June 2008 and December 2009. The audit producer and director of “Flying Cheap.” work was performed at FAA headquarters and For readers unfamiliar with PBS or Front- the FAA Certificate Management Office (CMO) line, the corporate facts section provided on the for American Airlines in Fort Worth, Texas. FAA PBS Web site, , says that “PBS inspectors and analysts were interviewed, as were is a private, nonprofit corporation, founded in officials at American Airlines headquarters. 1969, whose members are America’s public TV “FAA’s oversight of American Airlines’ stations.” Programs distributed to PBS member maintenance program lacks the rigor needed to stations for broadcast are produced “by PBS identify the types of weaknesses alleged by the stations, independent producers and other complainant — at least four of which were con- sources around the world. PBS does not produce firmed and have potential safety implications,” programs.” the report says. Frontline is produced by WGBH, , a Boston public media network, and American Airlines’ maintenance-related events describes itself as “the only regularly scheduled have increased,” the report says. “Further, the long-form public affairs documentary program National Transportation Safety Board (NTSB) re- series on American television.” It provides cently found that American’s Continuing Analysis “engaging documentaries that fully explore and and Surveillance System (CASS) — a system illuminate the critical issues of our times,” the intended to monitor and analyze the perfor- Web site says. mance and effectiveness of a carrier’s inspection — Patricia Setze and maintenance programs — failed to detect repeated maintenance discrepancies, which, if REPORTS found, could have prevented an in-flight engine Oversight Overlooked fire that occurred in September 2007.” According to the report, in the 13 days prior FAA’s Oversight of American Airlines’ Maintenance Programs to the accident involving American Airlines U.S. Department of Transportation, Office of Inspector General (OIG). Flight 1400, the aircraft’s left engine air turbine AV-2010-042. Feb. 16, 2010. 27 pp. Figures, exhibits, appendix. starter valve had been replaced six times because Available via the Internet at . of an engine-start problem, but to no avail. The merican Airlines, one of the world’s report says that the issue was not recognized by largest passenger airlines, has not expe- the airline’s CASS personnel. “A rienced a fatal accident in eight years,” “While we did not identify any immediate the report says. “Despite this safety record, we safety-of-flight issues, our analysis of mainte- received a complaint in February 2008 al- nance-related incidents at American Airlines leging that the overall operational reliability found that the carrier’s overall operational reli- of the airline’s aircraft had diminished and ability has decreased since 2004, which increases that previously reliable aircraft systems were the risk of serious incidents,” the report says. regularly failing. Specifically, the complaint “The rate of operational events across all fleets included 10 maintenance-related allegations — including cancellations, in-flight diversions and highlighted several incidents, includ- and other delays — rose from 3.9 events per 100 ing three flights that the complainant alleged departures in January 2004 to 5.8 events per 100 had experienced cockpit windshield failures.” departures in December 2008.”

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The OIG confirmed the allegation that was at a gate ready to depart with passengers.” maintenance deferrals had increased signifi- According to the report, American Airlines of- cantly. “From 2004 through the first five months ficials said that by December 2009, the airline of 2008, American’s number of open mainte- had implemented all but one SAT recom- nance deferrals increased by 32 percent, from an mendation; that recommendation was to be The airline average of 298 per day to an average of 394 per implemented in April 2010. day,” the report says. “Despite this increase, FAA The report says, “According to FAA’s princi- submitted at least only tracked the number of deferrals but did not pal maintenance inspector, FAA will continue identify the types of aircraft parts being deferred to monitor American’s compliance with RII 13 self-disclosures or the causes of the deferrals.” requirements until it is satisfied that a long-term concerning improper The report adds that from January 2007 to corrective action is in place. To date, however, the end of the study period, the airline sub- FAA’s actions have not elicited confidence that use or issuance of mitted at least 13 self-disclosures concerning its oversight is sufficient. For example, in re- improper use or issuance of minimum equip- sponse to the RII allegation, the CMO assigned minimum equipment ment lists (MELs). Examples included deferring one inspector to review only one MD-80 aircraft maintenance on a navigational component that — even though the MD-80 fleet is American’s lists (MELs). was not listed in an MEL, which therefore could largest, with 279 aircraft.” not legally be deferred. Finally, the report said, “We confirmed the The audit also “confirmed the allegation that allegation that American did not implement a American was not following procedures for re- Boeing service bulletin alerting carriers to prob- quired maintenance inspections. We found that lems with aircraft windshield heating systems FAA has not taken appropriate action to address that could cause the windshield to crack or shat- American’s longstanding failure to comply with ter if left uncorrected.” required maintenance inspection procedures.” The service bulletin, issued in 2006, con- The report cites the FAA’s failure to force cerned the Boeing 757 and instructed air carri- American Airlines to comply with procedures ers on how to correct the problem, which if not for required inspection items (RIIs): “Ameri- attended to could cause a component to over- can has a history of noncompliance with RII heat, possibly leading to smoke in the cockpit requirements. For example, in 2007, American and a cracked or shattered windshield. self-disclosed nine noncompliances — three “Although American took steps to imple- disclosures involved expired technician qualifi- ment the inspections, neither FAA nor the cations, and six disclosures related to RII inspec- carrier ensured the mechanics performed tions that were not conducted.” the work,” the report says. “For example: The In May 2006, a System Analysis Team engineer responsible for drafting the engineer- (SAT) formed of FAA and airline representa- ing change order — which is required to issue tives made 35 recommendations, including work cards to mechanics — left the company, promptly notifying employees whose qualifica- and the order was never released. Without the tions were about to expire. “Despite the SAT’s order, American personnel could not issue numerous recommendations, we confirmed the work cards instructing mechanics to perform allegation that an American Airlines techni- the work.” cian with an expired authorization performed The report points out that the service bul- an RII inspection on the fire-damaged MD-80 letin was not a requirement, and even had it [from the September 2007 engine fire] after been followed, correcting the identified prob- mechanics had performed significant repairs lem would not have prevented a January 2008 on the aircraft,” the report says. “American incident as the complainant alleged. In that did not discover the RII noncompliance until incident, a 757 crew made an emergency land- the aircraft had been returned to service and ing after the cockpit filled with smoke, and the www.flightsafety.org | AEROSafetyWorld | March 2010 | 55 InfoScan

inner pane of the copilot’s windshield shattered, review, [and] (b) coordinating all safety-re- blocking visibility. lated independent reviews conducted using “However, service bulletins often high- the IAC process through its new Office of light safety issues that lead to the issuance of Audits and Evaluations; [and,] an airworthiness directive,” the report says. • “Determine why FAA’s oversight did not “While an airworthiness directive has not been identify the weaknesses discussed in this issued, Boeing stated that the bulletin did have report and whether these are agency-wide safety implications based on prior incidents issues or limited to American’s CMO.” and that all carriers were expected to com- ply.” The report adds that “since the January The FAA concurred with the first five 2008 incident and subsequent February 2008 recommendations and partially concurred with allegations, American and FAA have initiated the last. or taken actions to address windshield heating — Rick Darby system concerns.” The FAA assembled an internal assistance BOOKS capability (IAC) team to review independently the February 2008 allegations and the CMO also It’s a Snap conducted a review. “However, neither review The Legacy of Flight: Images from the Archives of the Smithsonian National Air and Space Museum was comprehensive,” the report says. Romanowski, David and Melissa A.N. Keiser. Piermont, New Hampshire, The OIG recommends that the FAA: U.S.: Bunker Hill Publishing, 2010. 288 pp. Photographs, index. • “Begin a review of American’s CASS and hotography was well established by the be- reliability system to ensure that problems ginning of powered aviation, and the camera are identified and needed improvements has served the historical record. Early “flying are made; P machines” were sensational enough to attract the • “Conduct comprehensive inspections attention of any photographer who happened to of the allegations regarding operational be nearby, and many photographers ever since reliability, MELs, RII requirements and have found that aviation offers dramatic subjects. windshield inspections; • “Improve data analyses by requiring the CMO analyst and inspectors to regularly and thoroughly review available operational reli- ability data, track the types of maintenance items that are deferred, closely monitor trends in maintenance deferrals, and identify reasons for any significant negative changes in reliability or increases in deferrals; • “Issue the proposed airworthiness direc- tive that would require implementation of The Legacy of Flight includes 132 photo- the Boeing service bulletin on repairs to graphs that illustrate flight’s development, windshield heating components on 757s; through peace and war, into the space age. The • “Improve the independent review process emphasis is on people — both famous and by (a) performing verification work at air anonymous — as much as the equipment. An carriers rather than just reviewing FAA accompanying page of text offers commentary inspection records and ensuring that the re- about each photo.  view results are shared with the office under — Rick Darby

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