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!
Seems a bit irresponsible pointing fingers when an investigation hasn’t been completed.ReplyDelete
Only sharing FAA findings of a lack of safety culture and reporting due mechanics getting fired for reporting maintenance issues. This lack of reporting culture is a serious issue and the reason the FAA mandated SMS.Delete
I don't think Karlene is referring to this specific incident but the numerous FAA audits going back many years.Delete
I hope you can see the irony in criticising a blog about people being criticised (or worse) for raising safety concerns.
Cap'n Dan, that's actually kind of funny. I had not thought of that irony... but so true. Many people would stop telling the news afraid they would get criticized.Delete
What concerns me is not that the airline was trying to cut costs, but that they were taking administrative actions against employees who spotted legitimate safety issues. This action was so outside of norms that the FAA itself had to admonish the airline, most recently just 6 months ago, Sept 2017. That is a huge 'safety culture' deficiency, supported by management bullying and threats, that must not be allowed. Not just at WN, but anywhere. Ugh!ReplyDelete
JR, I could not agree more. This is going on currently and within many airlines and organizations.Delete
Things happen. But you should never retaliate or fire an employee for reporting safety. Also... we say the "airline", but the reality is there are people making these decisions that might be behaving in contrast to the corporate view. Holding people accountable will be the deciding factor. But, when they promote management who behaves badly, then that sends a really bad message.
There are many people at the airline who would never do such a thing. But, the CEO must remove those bad apples (not the mechanics identifying the worms).
Now with SMS... the CEO is responsible.
Technically, if this accident were to be attributed to the violation of SMS, the CEO could be personally liable for the event, and the loss.
Hard to believe this is happening in 2017.
This blog should be shocking but it’s not to those of us within the industry. SMS is often used to justify Performance Based Oversight which really mean no oversight or self-regulation.ReplyDelete
Reference the comment above by ‘Anonymous’... clearly the irony of branding as ‘irresponsible’ a blog about people being criticised for raising safety concerns is lost on them.
Cap'n Dan, Thank you for your thoughts on this. I could not agree more!Delete
Marlene. When America sneezes Europe catches a cold. Some maybe all that you describe with regards to safety cultures happens over here. On behalf of the UK Air Safety Group may I have your permission to copy and post your article on our blog www.blog.airsafetygroup.org please?ReplyDelete
Nigel, Yes... thank you for asking. That would be much appreciated. Without transparency, we will never have compliance. Thank you!Delete
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These so called "whistle blowers should be rewarded for their diligence and professionalism.All they are doing is wanting the job done right.Especially in an industry where lives are at stake.ReplyDelete
John, so true. And doing their job right was taking the safest course of action too. Thank you for your comment!Delete
The anonymous person is a coward and most likely works for the airline, the airline industry, insurance company. FAA, NTSB, et al havingReplyDelete
Acquired a recent degree in Emergency Management in addition to reporting a safety hazard to Frontier’s Airline then getting canned from Flight Attendant training (purportedly wearing
A dress too short which it was NOT) (in retrospect I’m so glad I’m not with that airline) the Safety Director forwarded my email to InFlight Recruiting
Instead of THANKING me or commending me for saving
Someone from being injured and them being sued during Pilot & FA training.
During winter storms where the floors stayed perpetually wet from melted snow and ice on our boots and umbrellas etc. Discovered from
Friend who was hired that they were flying with only new FA on flights in which all lights were turned off the whole duration of the flight and they couldn’t find where to turn them back on! Imagine a safety issue..and after one of their planes emitted toxic fumes that made passengers ill,
Instead of retiring “Woody”, it’s still flying out of EWR regularly. 50% of Allegiant pilots won’t allow their wives and family to fly on their own planes because they KNOW how poor the mechanics and maintenance is! It’s as dangerous in the sky as it is on the ground.
The anonymous person most likely works for the airline, Airline industry, insurance company, FAA, NTSB, et al and is a coward! Having acquired a recent degree in Emergency Management, I concur with the Pilot here who’s had phoenominal success in all her investigations of airplaneReplyDelete
Crashes and has a PhD in Aviation Safety. During Flight Attendant training, after sending an email to the Safety Director as there was water all over the break room floor from melted snow and ice and training
Was during a winter storm. We had to walk from the hotel and I requested a shuttle to be provided on the worst day of the storm, loaned a brand new watch to a girl who would’ve been dismissed for showing up to training without one. (She didn’t
Return it and I had to report it stolen to get it back!) The airline lost my luggage for the 1st 3 days and when I finally got it after emails and calls to numerous departments, my new $75 shirt was sliced up as if a utility knife was put to it amd I filed a claim and was never reimbursed! Oh! Did I mention that I was Dismissed from training right after this for a fabricated reason? I was written up for sending that email. Meanwhile, a friend
Who flies for them told me her crew was all brand new & flew a whole flight without lights on the cabin at night because they couldn’t find how to turn them back on! Passengers became ill from toxic fumes emitted from a very old plane called “Woody.” Instead
Of retiring it as they said they would, They just patched it up and it’s still flying out of EWR. It’s becoming as dangerous in the air as it is on the ground and that’s saying
A lot as the population is much more expoential on the ground.
Emergency Management Guy, what I pulled from this is that you reported water on the floor and a safety issue, and were written up for reporting? All the other issues could be harassment for pushing you out, or just events that happen. But nobody should be written up for reporting anything. Thank you for your comment.Delete
So, let me get this straight. The FAA will enforce provisions of the "Chicago Convention" on a foreign country (see https://www.faa.gov/news/press_releases/news_story.cfm?newsId=16114 for an example); but, they can't enforce safety standards on carriers they certify? Don't get me wrong, I think international airports should be on the same page when it comes to security and safety. I believe that should be par for the course as being a good host, and to take care of your citizens.ReplyDelete
What I find concerning here is how will other entities (think foreign government) respect the FAA when it's becoming clear they can't keep their own house? Not every country in the world will care that an ailing parent has 2 hang on an extra 2 days to see his/her family for the last time because there's no direct route between where they are and the US.
Keith, you make some excellent points and I would love to know the answers to these questions too. I appreciate your comments and concern, and hopefully those questions will be answered soon. Thanks for your comment!Delete
I am not a spokesman for the company discussed above. But as a 29 year retired Dispatcher / flight operations of the aforementioned, I can honestly say - safety is and was always #1. Any disputes on a go / no situation always came from a singular position, not a company mandate and those positions were normally dealt with swiftly. Of course, I can only speak for what I saw, but our office was in contact with all other safety concerned departments and none of the aforementioned was ever heard or rumored.ReplyDelete
As far as the FAA, we have had problems with getting decisions out of them on what we believed to be "no brainers" Once an ASAP was submitted on wording in a manual in ref to severe turbulence, and it took 2 years to get it corrected.
Always, enjoying the journey.
Thank you Dispatcher for your comment. I appreciate that safety being number #1 in your world, as we depend upon our dispatchers. I am sure safety is number one for SWA too. SWA is an amazing airline. But sometimes amazing airlines have employees that might not be doing the most amazing things. They should be held accountable, not promoted.Delete
However, when a VP states "we hide our compliance issues in the warrior spirit" that leaves to question as what else is hidden.
The reality is, everyone who has looked the other way never imagines anything would happen. They do not believe their action is unsafe... as they make judgment. The judgement of redundant procedures we shouldn't have to comply with, the lack of relevance of a procedure, that we know better than regulators... and the judgement of what are the odds something would happen? But nobody should be ordered to or fear for their job when they feel or know it's not right.
Pilots worldwide have made these types of decisions as to what we would "carry" for the company in interest of keeping the mission going. Things that in our opinion were not safety critical, but could have been grounded.
Pilots today cannot take anything, even if it is not safety issue, because the electronic airplanes will rat them out.
However, the FAA, NTSB, OIG have learned that being proactive and preventing those "what ifs" are the best way to go, and we cannot control or train common sense. What one person thinks is okay and is... the other might not be. Thus, we need rules to set standards for the least common denominator. Therefore nobody should be forced or coerced into carrying a plane, or pushing a plane.
There will always be the surprises and broken airplanes. Things that we cannot control. This is the reason I am fighting to keep a full crew compliment in the aircraft.
This is also the reason I am working to improve pilot training worldwide so there will always be an exceptionally trained and proficient pilots such as Captain Tammie Jo Shultz. She was amazing as was her first officer!
I am sorry it's been so slow getting no-brainers from the FAA at your airline. I am not sure what's happening these days... but then, I guess I do know and SMS could fix it. If done correctly.
At NWA I was told the same thing. However, I realized that was not the case. We could write procedures and get FAA approval within weeks and immediately into our manuals.
What I learned it's not always the FAA for being slow. It's easy to blame them. The truth is, if it's important and a human walks it into the office of the correct person who can make that decision, then walk it to the person who write the manuals... change can happen quickly.
Unfortunately it's the processes in place at the organizations that are taking the time. Blaming the FAA for something sitting on their desk when they are already overloaded. Things get lost. But... Get a human involved that is allowed (beyond chain of command) and change can happen quickly. This I know is true.
A culture that discipline those who step outside the box are rewarded with efficiency. A culture that lives by a chain of command and attempts to break the warrior spirit who is trying to make things better, is left with inefficiency, and as you say... no brainers that can't get into the manual for two years.
I have observed super efficient, and super inefficient (3 weeks to change versus 3 years)... and an honest and authentic SMS program will fix those types of issues and make everyone efficient.
I apologize for the lengthy reply, but I applaud your comment and reaching out because you are not hiding behind anonymous, but you do care. Keep up the great work! Your company is lucky to have you!!!
What's important is we con't start basing opinion on opinions. When that gets out of hand we all end up down in front of the O.J. trial out of our minds waiving our guilty or not guilty verdict signs, before due process has been given a chance. Did O.J. kill Ron and Nichole? Since we were not there, we do not know, we merely have an opinion. Court says not guilty as a dirty cop handled the evidence and it is as simple as that.ReplyDelete
Have a great day!
Well, I think that the FAA and OIG rulings are opinions based upon substantiated fact. Therefore, I'm not sure where the opinion based discussion comes from as far as safety culture. It's clearly defined and clearly violated. Thanks for your comment.Delete
Few after reading this I've been sacred out of thr air for awhile. Those FAA reports are damming. It gives me no comfort to know that safety culture violations are rampant among US airlines. Keep up the great work KarleneReplyDelete
Nicnacjak, makes you wonder what else is out there. The safety system will always be the pilot, therefore we must keep them flying ... and provide the best training possible.Delete