Safety Culture to Blame?
Could this Event Have Been Avoided?
The only way to create change is to stand up and tell the truth, despite the repercussions. However, sometimes individuals stay silent because they have families to feed and mortgages to pay and their careers are threatened. Thus, we needed a little government reform to help. Safety Management Systems (SMS) is an FAA mandate to improve safety. However, SMS demands a positive Safety Culture. Yet, without a Reporting and Just Culture, Safety Culture declines.
Southwest Mechanics Fired
I received the following information from Attorney Lee Seham-- who fought on behalf of the SWA mechanics who were subject to retaliation for reporting maintenance issues. He also provided supporting documentation as attachments verifying the accuracy of this information. Thanks to Lee Seham, they resolved the Air 21.
But does anyone really win when a company fires an employee, harasses, or subjects them to a mental health review, because they speak out for safety? I think not. A negative safety culture keeps people from speaking out, similar to the fear of reporting at Allegiant.
Heavy checks are conducted outside the US and the FAA does not evaluate overseas. The safety system becomes the mechanics when the aircraft return. But when the mechanics walk by an aircraft and see corrosion, then are told to look the other way or they will lose their jobs... where is our safety net? A question that should be asked is: Where was this engine last serviced?
Outsourcing and The Degradation of
Safety Culture at Major Airlines
By Lee Seham-Air 21 expert
Prior to the 1978 Airline Deregulation Act, the industry’s business model was that, in exchange for a purchased ticket, an airline provided a properly trained flight crew to operate an airworthy aircraft maintained by the carrier itself. The second half of this business model has been abandoned.
Deregulation prompted a frantic effort to reduce costs, which manifested in a number of dramatic fashions, including the creation of B-scale wages, the use of bankruptcy courts to abrogate collective bargaining agreements, and the termination of employee pensions. Under the proverbial radar, however, the major carriers also made the determination that they would, for the most part, no longer maintain the airworthiness of their own aircraft.
Federal agencies have expressed concern at the rate of this transformation and their inability to monitor the impact on aviation safety. Thus, in 2005 the Department of Transportation’s Office of the Inspector General (OIG) reported:
"In efforts to reduce maintenance costs, many airlines are increasing the amount of total maintenance that is performed by outside maintenance providers. In fact, major carriers now outsource an average of 53 percent of their maintenance expense, as compared to 37 percent in 1996."
In 2013, the OIG reported the trend continued to accelerate:
"Over the past 15 years, major U.S. air carriers
increased spending for contract maintenance
by nearly $2.7 billion.
Industry experts expect this trend to continue
as airlines increasingly attempt to cut maintenance costs
and maximize profitability."
In response to congressional concern that the “FAA might not be well positioned to effectively carry out the responsibility of monitoring” the work performed by outside repair stations, the OIG conducted periodic audits of the FAA audits.
In July 2003 and September 2008, the OIG reported that the “FAA’s oversight did not ensure that work completed at repair stations met FAA standards….” In 2013, the OIG again concluded that:
"FAA’s oversight of foreign and domestic repair stations
lacks the rigor needed to identify deficiencies
and verify that they have been addressed"
"FAA does not have an effective system for accurate
and timely risk assessment of foreign and domestic
repair stations because of critical weaknesses
in its repair station oversight process."
Still more recently, a 2015 OIG audit concluded that, even with respect to facilities located in the European Union (EU):
"FAA’s inability to fully evaluate foreign authorities’
capabilities, coupled with inspector training weaknesses,
process differences, and data limitations, hinders
FAA’s assurance that repair stations in the European Union
receive quality oversight and maintain aviation safety."
Proper aircraft maintenance depends on the individual technician’s adherence to the standards and procedures mandated by the manufacturer. Irrespective of the technician’s skill, airworthiness cannot be met in legal environments where there is no oversight and the individual technician is subject to retaliation for reporting delay-inducing discrepancy reports. Nonetheless, outsourcing to jurisdictions where the rule of law in the aviation context does not exist – China, El Salvador, Brazil, and Mexico – has mushroomed.
The operational consequence is that the dwindling population of carrier-employed technicians is confronted with an increasing volume of maintenance discrepancies and outright maintenance fraud with respect to aircraft returning from foreign and domestic repair stations. The result has been a ratcheting up of management pressure on technicians to turn a blind eye to aircraft damage that renders an aircraft unairworthy. In the last three years, the gravity of the situation at U.S. major carriers has been repeatedly recognized by the FAA.
Southwest Airlines, which has the lowest ratio of aircraft technicians to aircraft of any major carrier. FAA investigators have determined that Southwest suffers from a degraded supervisory maintenance culture, which manifests itself in the pressuring of the carrier’s Aviation Maintenance Technicians (AMTs) and Inspectors to subordinate safe maintenance practices to the carrier’s schedule. Moreover, the FAA has further determined that, in the last several years, Southwest’s practices have resulted in scores of aircraft operating in revenue passenger service in an unairworthy condition.
In a September 2017 report by the FAA’s Technical Aircraft Maintenance Branch addressing whistleblower complaints raised by Dallas-based Southwest maintenance inspectors, the FAA found that coercive conduct toward maintenance employees was having an adverse impact on “all forms” of the maintenance operations, including “troubleshooting, completion of work, inspections, technical support and training.”
The FAA report provides a
of Southwest’s coercive culture:
"The motivation behind management questioning AMTs and Inspectors when they discover anything outside the scope of a maintenance task and the subsequent use of formal [disciplinary] fact-finding meetings which management utilizes to formally document an inquiry into airworthiness discrepancies, appears as a tool used to influence a relaxing of standards, to look the other way, or to gain a degree of approval through a leniency of standards.
The result of this pattern is a capitulation of airworthiness and a culture of fear and retribution. … The influence being utilized to pressure technicians and question findings influences the programs and reliability tracking of the aircraft both of which have a negative impact on the overall Continuous Airworthiness Maintenance Program (CAMP)."
The FAA reported that, despite the environment of intimidation, one inspector insisted on documenting damage to an aircraft’s flight control rudder balance weight that was “substantial,” but that, “rather than being praised for finding a serious airworthiness issue,” the inspector was “questioned as to how and why he came to notice” the damage. The courage of this particular inspector led to the fortunate disclosure of a “systemic” issue affecting fleet-wide safety:
"Although the carrier will point out the discrepancy was addressed, the impact to the employees and the overall maintenance organization arguably is impacted by the questioning. As noted above, this event led to the discovery of a systemic issue with the fleet and now has involvement with the carrier’s engineering and the aircraft manufacturer."
In a separate and independent FAA field investigation of the carrier’s Los Angeles maintenance operations conducted on September 20, 2017, the agency’s investigators reported that:
"All of the mechanics interviewed except two felt pressured and under scrutiny as to whether they were either doing their job correctly or if they were finding too many things wrong with the aircraft …."
“Mechanics are told, ‘Dallas is watching us’
don’t make us look bad with delays.”
FAA investigators determined:
"There is the absence of a “Just Safety Culture”. Safety Promotion, a key part of an effective SMS [Safety Management System] seems to be deficient. There seems to be a lack of an environment of trust, effective communication and the willingness for employees to share mistakes, concerns or failure without the fear of threats or reprisal. This ultimately leads to a degraded level of safety that the SMS is trying to maintain at the highest possible level."
In response to whistleblower complaints by aircraft mechanics at Southwest’s Las Vegas maintenance station, an FAA determination letter, dated October 5, 2017, “substantiated that a violation of an order regulation or standard of the FAA related to air carrier safety occurred,” which required “appropriate corrective and/or enforcement action.”
The FAA determined that Southwest had improperly issued a memorandum entitled “Cargo Door Handle Housing Assemblies” designed to accelerate the evaluation of delay-causing aircraft damage. The FAA’s regional investigators expressed their particular concern that “[Southwest Maintenance] Leaders did not remove it from circulation once aware of its existence.”
Southwest’s deliberate violation of federal aviation standards is echoed in an FAA complaint in November, 2014, which alleged that the company had flown 44 aircraft in an unairworthy condition as a result of improper repairs to skin panels that undermined the structural integrity of the fuselages.
The FAA determined that Southwest
continued to operate the unairworthy aircraft
for six months after the FAA had advised
the carrier that the aircraft were non-compliant.
The FAA also found that additional aircraft were rendered unairworthy by faulty wiring related to gray water drain mast modifications that were necessary to address the planes’ susceptibility to fires and electrical disruptions in the event of a lightning strike. Here again, the FAA determined that Southwest continued to operate these aircraft in an unairworthy condition even after it was discovered that the case ground wire terminal had not been properly relocated and connected.
Maintaining safe aircraft in accordance with federal aviation standards takes time and money. Violating the law is faster and cheaper. As a result, AMTs at Southwest found themselves subjected to a Hobson’s Choice – jeopardize your FAA license or lose your job. In Las Vegas, when an AMT expressed concerns about retaliation in response to his reports of aircraft discrepancies, his supervisor responded:
“If you’re worried about your [FAA] license …
write them up. …
If you’re worried about your job,
then I don’t know.”
Presumably in response to pressure from the FAA, Southwest has acknowledged in stark language that the carrier suffers from a maintenance culture that subordinates aircraft safety to on-time performance.
On December 6, 2017, Southwest’s Vice President Technical Operations Trevor Stedke described a problem-plagued maintenance program that ignores its own policies and procedures and releases unairworthy aircraft into revenue service:
"We’ve had several examples recently. Everything from calls to the FAA in DC, to AD over flies, engine operation. We had a wing that flew around [that] was damaged from an unknown period of time with of course nothing documented.
We’ve been through a dent program. We’ve had several dents found to be non-compliant, re-worked without anything documented in our maintenance systems. Damage events, lockout, carryout.
And you all know that the list goes on and on about several things that examples of where we’re bypassing or policies and procedures and we have got to get that rectified and cleaned up if we have any hope of getting ETOPS and maintain ETOPS in the future."
Safety Culture at Fault
Stedke identified the degradation of Southwest safety culture as the principal culprit behind these safety lapses:
"There is a perception, I think from some, that all On Time Performance trumps compliance. And our expectation as a Leadership Team is that we really want On Time Performance higher than compliance. And what we speak to On Time Performance and measure On Time Performance. We say compliance but it’s kind of a wink, wink, you know, make sure you get the airplane out, and that’s, nothing can be further from the truth."
Vice President of Maintenance Operations Landon Nitschke describes Southwest’s maintenance culture in the same disturbing terms:
"And, you know,
sometimes we hide our compliance issues
under the Warrior Spirit, right?"
In order to placate the FAA, and obtain lucrative Hawaiian markets that require prior ETOPs approval, Southwest has proclaimed that 2018 will be the year that it repents of its unlawful past. As the Vice President of Technical Operations declared in December, 2017:
"So compliance effectiveness is going to be a new item on our dashboard this year. We’re going to set those measures and make sure that’s part of our metrics that are driving the right behaviors across the organization."
Confirming that the Southwest’s interest in safe aircraft maintenance is a freshly discovered value, Vice President of Maintenance Operations Nitschke has announced, literally, that Southwest will be singing a new tune in 2018:
"So big effort this year. We definitely need to repair some things with the FAA not only as a Company, but, I think, as people. I think there are some things with, you know, AMTs getting questioned. Supervisors certainly getting questioned. Those are things we want to get into. We want to make sure that we handle that at a Company level, so again, compliance, compliance, compliance is going to be our theme song for 2018."
Southwest concedes that this wrenching shift in gears – from pushing out planes to a genuine concern for safety – has left both management and Southwest AMTs in a state of bewilderment:
"We had a discussion in Breakfast Club, our morning Ops meeting, this morning. And I think [Southwest Director of Quality Assurance] Gregg Brown said it, we are all so confused in the room. It’s like well can you imagine what our front line Mechanics think? And so as Leaders, that’s what we need to correct. But to Trevor’s point, it goes throughout the organization all the way through everyone to make sure that we are compliant."
Safety Culture Is
the Answer to Safety!
It's just so simple
to do the right thing.
One life lost is one too many.
If you have been violated for reporting safety
contact me, I will point you in the right direction.
Enjoy the Journey!