FAA Impose Fines After Maintenance Errors – Just Culture?
The Federal Aviation Administration (FAA) have proposed fining two helicopter emergency medical service (HEMS) operators and one airline a total of $12.4 million for allegedly operating non-compliant aircraft after various maintenance errors. However does this encourage a just, open reporting culture?
The Cases In each case it should be noted that the FAA have publically proposed these fines but the organisations can appeal or negotiate for a lower penalty.
…that beginning in 2006, Southwest conducted so-called “extreme makeover” alterations to eliminate potential cracking of the aluminum skin on 44 jetliners. The FAA conducted an investigation that included both the airline and its contractor, Aviation Technical Services, Inc., (ATS) of Everett, Wash. Investigators determined that ATS failed to follow proper procedures for replacing the fuselage skins on these aircraft… All of the work was done under the supervision of Southwest Airlines, which was responsible for ensuring that procedures were properly followed.
It is interesting that the FAA do not also propose fining the FAA approved Part 145 Repair Station who are alleged to have not followed proper procedures.
Southwest returned the jetliners to service and operated them when they were not in compliance with Federal Aviation Regulations, the FAA alleges. The regulatory violations charged involve numerous flights that occurred in 2009 after the FAA put the airline on notice that these aircraft were not in compliance with either FAA Airworthiness Directives or alternate, FAA-approved methods of complying with the directives.
Retrospectively Southwest submitted data that allowed the FAA to approve the alternative procedures used. Also:
During its investigation, the FAA found that ATS workers applied sealant beneath the new skin panels but did not install fasteners in all of the rivet holes during the timeframe for the sealant to be effective. This could have resulted in gaps between the skin and the surface to which it was being mounted. Such gaps could allow moisture to penetrate the skin and lead to corrosion. As a result of the improper repairs, these airplanes did not comply with Federal Aviation Regulations.
The FAA also alleges that ATS personnel failed to follow requirements to properly place these airplanes on jacks and shore them up while the work was being performed. If a plane is shored improperly during skin replacement, the airframe could shift and lead to subsequent problems with the new skin.
Corrective maintenance action is only mentioned in the final allegation:
…the FAA alleges that Southwest Airlines failed to properly install a ground wire on water drain masts on two of its Boeing 737s in response to an FAA Airworthiness Directive addressing lightning strikes on these components. As a result, the aircraft were not in compliance with Federal Aviation Regulations. The airplanes were each operated on more than 20 passenger flights after Southwest Airlines became aware of the discrepancies but before the airline corrected the problem.
These allegations highlight the importance of:
- Conducting all maintenance in accordance with approved maintenance data
- Seeking approval for justified alternative data in advance
- Ensuring that data is referred to and followed
- Promptly responding when maintenance errors are detached
- Ensuring maintenance organisations/continuing airworthiness management organisations have effective assurance processes to monitor actual maintenance standards
According to Southwest:
Having fully resolved the repair issues some time ago, none of the items raised in the FAA letter affect aircraft currently being operated by Southwest Airlines. As always, Southwest is committed to continuously making enhancements to our internal procedures, as well as improvements related to oversight of our repair vendors.
The FAA said Boeing discovered in September 2008 it had been installing non-conforming fasteners on its 777 airplanes, but then took more than two years to implement a plan to correct the problem, which violated regulations by failing to maintain its quality control system.
…violated its operations specifications by flying the helicopters despite failing to perform required inspections of their Night Vision Imaging System Compatible Lighting Filtration (NVIS) installations. The FAA also alleges the failure to perform the required inspections rendered the helicopters unairworthy.
Between June 8 and Sept. 7, 2011, Air Methods allegedly operated one of the helicopters on 489 flights totaling 144 hours when the NVIS inspections were overdue. During the same period, it allegedly operated the other helicopter on 431 flights totaling 139 hours when the inspections were overdue.
“Operators must be vigilant when maintaining aircraft, especially companies that have people in their care,” said FAA Administrator Michael Huerta. “It’s critical that operators perform required inspections of their safety systems to ensure they’re working as intended.”
While the background behind these allegations are not clear they highlight the need for:
- Effective continuing airworthiness management to ensure that maintenance programmes and maintenance records are complete so that maintenance can be correctly scheduled (in 2002 the Australian Transport Safety Bureau [ATSB] published an detailed report on continuing airworthiness failures in Ansett)
- That specific requirements for scheduled maintenance are passed to maintenance organisations in a timely manner
- That maintenance organisations/continuing airworthiness management organisations have effective assurance processes to verify that scheduled maintenance is completed on-time and to promptly detect any failures
…a company mechanic installed a chin bubble window on the aircraft without following the manufacturer’s instructions, and then failed to document the installation in the aircraft’s maintenance logbook. The window is located at the front of the helicopter, near the pilot’s feet, and allows the pilot to see below and forward of the helicopter. As a result of the improper installation, the aircraft was not in compliance with Federal Aviation Regulations.
The company, which provides air medical services, returned the aircraft to service and flew it on eight passenger-carrying flights. On Sept. 4, 2012, after only 7.3 flight hours, the chin window fell off during cruise flight, resulting in a precautionary landing.
The FAA alleges Air Evac operated the aircraft in a careless manner that endangered the lives of people on the aircraft and on the ground.
In this case, the FAA allegations highlight the need for:
- Ensuring that maintenance personnel have full access to the necessary maintenance data
- Ensuring that data is referred to and followed
- Ensuring maintenance records are accurately completed
- Maintenance organisations/continuing airworthiness management organisations to have effective assurance processes to monitor actual maintenance standards
FAA Policy – Just Culture?
While the FAA, as a regulator, is acting to enforce regulations by fining these approved organisations and thereby holding them to account, there are downsides to this regulator practice. It is not clear, but it may be plausible to conclude that these were isolated non-compliances because if there were wider systemic failures, the FAA would have cited the wider failings. For a regulator one key reactive issue should be:
Have actions been put in place to prevent a reoccurrence? The travelling public naturally share a similar concern, yet these press releases do nothing to assure the public. These three cases stem from 2009, 2011 and 2012, and one would expect appropriate improvements have been made in the 2-5 years since, but the FAA do not comment. This neither helps the public or the industry. While these press releases do allow the industry as a whole to distil some reminders (as Aerossurance have done above), the lack of investigation detail on the circumstances, causes and contributory factors limits the ability for the rest of industry to actually learn anything new.
A key proactive issue for a regulator is: Are we encouraging open reporting? In practice, if industry believes that a regulator may levy a fine after even honest and inadvertent errors or isolated poor performance then there will be a tendency in some organisations to minimise openness with the regulator, avoid reporting errors internally for fear they will attract fines, correct problems found quietly rather than visibly implementing preventive improvements and avoiding acknowledging known errors and so undermining internal learning.
Equally it is unlikely that other organisations will voluntarily share experiences of similar occurrences with their contemporaries for fear of attracting a fine, stifling wider industry learning. It also may encourage organisations to fire personnel who make errors.
Aerossurance once audited a medium sized US maintenance organisation that had no internal audit findings in three years. When pressed they admitted that they had found problems but because they were corrected before the report was issued they were not recorded. Apart from lacking the insight of trend data and the potential for shallow and ineffective instant fixes at the time of the audit, one might suspect they were happy to be without an evidence trail that could be used against them…
As one source puts it:
People are less willing to inform the organisation about their own errors and other safety problems or hazards if they are afraid of being punished or prosecuted.
Arguable this extend to a fear their employer will be punished or prosecuted.
Such lack of trust of employees prevents the management from being properly informed of the actual risks.
The same applies to organisations and regulators, leaving the regulator blind to some risks.
Managers are then unable to make the right decisions in order to improve safety. However, a totally “no-blame” culture is neither feasible nor desirable. Most people desire some level of accountability when a mishap occurs.
In an attempt to solve that problem, [Prof] J[ames] Reason described a “Just Culture” as an atmosphere of trust in which people are encouraged, and even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
There is more background on just culture here.
A final issue for a regulator is: Are we effective as a regulator? After previous accusations in 2008 of poor standards at Southwest and poor regulation by FAA, the FAA fined Southwest $10.2 million and Acting FAA Administrator Bobby Sturgell said at a news conference:
For those who question our commitment to safety, I would suggest there’s at least one airline today with 10.2 million reasons why those critics are simply wrong.
In 2010 American Airlines were hit with the potential a record $24 million penalty after following a non-approved means of compliance with a wiring Airworthiness Directives on MD-80s in 2008. In 2012 information emerged that this was one of a series of proposed penalties totally over $160 million. American, coincidentally subject to bankruptcy proceedings at the time, settled this proposed fine with a $24.9 million payment in 2013. This history suggests that fines and the threat of fines may not be effective across the US industry. A subsequent investigation in 2010 by the Department of Transportation’s Inspector General challenged the effectiveness of FAA regulation concluding that:
Although various factors underlie each of American Airlines’ maintenance-related events, a lack of adequate FAA oversight is a critical thread.
Aerossurance is pleased to sponsor this Royal Aeronautical Society (RAeS) Human Factors Group: Engineering conference on 12 May 2015 at Cranfield University: Human Factors in Engineering – the Next Generation
UPDATE 15 April 2015: The FAA has proposed a $1.54 million civil penalty against Air Methods allegedly operating a non-compliant EC130 on dozens of flights. The FAA allege that Air Methods operated two helicopters on 70 passenger-carrying flights, over water and beyond power-off gliding distance from shore, without the required helicopter flotation system and flotation aids for each occupant. The FAA further claim that the company another 13 such flights without flotation aids for the occupants. The 83 flights occurred around Pensacola, Florida.
UPDATE 1 June 2015: The FAA propose another $91,500 civil penalty against Air Methods for allegedly operating a Bell 407 on four flights in October 2014 when a required torque check inspection on its tail rotor drive shaft components was overdue.
UPDATE 14 July 2015: Former NTSB Board member John Goglia highlights a recent case were fines were levied after voluntary disclosure.
UPDATE 9 February 2016: We discuss a Culpable Culture of Compliance. This is based on an Australian Transport Safety Bureau (ATSB) report into a fatal marine accident and discusses how blindly emphasising compliance without considering risk may create a culture that actually undermines safety.
UPDATE 14 September 2016: On 4 November 2014, only three months after the FAA proposed fining Air Methods $428,000 in the second case above, an FAA Inspector allegedly discovered corroded pitot tubes on an EC135 in Tampa, Florida. The FAA have today, almost 3 years later, proposed fining Air Methods $892,500 for allegedly “continuing to operate the helicopter on 51 passenger-carrying revenue flights between 4 November and 11 November 2014 without repairing or replacing the pitot tubes”. The company is reported to claim the aircraft remained airworthy.
This, and the two fines in 2015 mentioned above, just underlines the point that this enforcement based approach is not an effective safety management approach.
UPDATE 9 March 2017: We were concerned when we read this blog article, by a former NTSB Board Member, Torqued: Listen to your Employees’ Concerns as it implies the purpose of reporting is really just about avoiding regulatory action not safety improvement. This again suggests weaknesses in safety culture.
UPDATE 30 May 2017: The FAA propose a a $435,000 civil penalty against United Airlines:
The FAA alleges that on June 9, 2014, United mechanics replaced a fuel pump pressure switch on a Boeing 787 in response to a problem that a flight crew had documented two days before. However, the airline failed to perform a required inspection of the work before returning the aircraft to service, the agency alleges.
United operated the aircraft on 23 domestic and international passenger flights before performing the required inspection…Two of those flights allegedly occurred after the FAA had notified United that it had not performed the inspection.
UPDATE 2 June 2017: The Office of Inspector General (OIG) of the US DoT has begun an audit of the FAA’s oversight of air carrier maintenance programs. Congressmen were particularly concerned about whether corrective actions taken by air carriers actually address root causes of maintenance lapses.
UPDATE 16 November 2018: Results from the FAA’s Compliance Philosophy have been “extremely positive,” said a senior agency official:
Since the initiative began in 2015, the FAA has worked with industry on more than 15,000 compliances actions, estimated John Duncan, FAA deputy associate administrator for aviation safety, during NATA’s recent 2018 Aviation Leadership Conference.
These are actions designed to correct unintentional non-compliance events or issues without using enforcement. “Those 15,000 compliance actions involved risks that were identified and mitigated,” he said. “There are 15,000 things that have made the NAS [National Airspace System] safer. That’s an extremely positive outcome.”