Study Criticizes Aviation Community

Lack of Communication on Safety Matters Led to Fatal Crashes, Panel Says

Don PhillipsWashington Post Staff Writer
March 21, 2002; Page A11
The Federal Aviation Administration, airlines and aircraft manufacturers have not adequately communicated important safety information within and among their organizations, a failure that sometimes has led to fatal crashes, according to a study released yesterday. "There are too many independent programs without effective interdepartmental coordination or executive oversight," said the study, conducted by a team representing the FAA, airlines, airplane manufacturers, unions, NASA and the Defense Department, among others. In addition, "existing data analysis programs are seldom effective at identifying precursors with accident potential."

While its findings were hard-hitting, the report drew praise for risking inevitable criticism in an effort to improve aviation safety. "This is probably the most positive thing I've seen in the last 20 years," said John Goglia, a member of the National Transportation Safety Board, who has often been critical of the FAA.

Among the problems cited in the study were the lack of formal communications requirements between FAA offices and the failure to adequately communicate information to individual mechanics in the absence of a formal FAA directive. It said airlines and maintenance shops sometimes fail to understand the safety philosophy behind aircraft design, even as aircraft design engineers fail to understand how airplanes will be used in the real world. And it documented a number of crashes that might not have occurred if information had been disseminated properly or if knowledge had not been lost with time.

"There is no requirement for a permanent and commonly available repository of experience from which FAA regulatory and guidance material and industry best practices are derived," the study said. "Additionally, there is no requirement to familiarize personnel in positions with safety responsibilities in the relevant experiences and mistakes of the past."

For example, the study cited the crash of a Swissair wide-body aircraft into the ocean near Halifax, Nova Scotia, on Sept. 2, 1998. While the cause of the crash has not been finally determined, it said, there are questions about why the crew did not act more urgently to get the plane back on the ground before an on-board fire got out of control.

The study said that past incidents had indicated that crews often underestimate the severity of on-board fires. That includes a Boeing 707 cargo crash at Boston in 1973 and a DC-9 crash landing at Cincinnati in 1983.

"It appears that the operational lessons of both [those] accidents may not have been adequately learned by industry," the study said.

The study said there are no formal processes for airlines to review safety recommendations from manufacturers unless the FAA makes the recommendation mandatory. Some airlines do a good job of listening to the manufacturer, some do not, the study said.

As an example, the study cited the Alaska Airlines crash at Point Mugu, Calif., on Jan. 31, 2000. While again stressing that no probable cause has been determined, the study said that either Boeing did not adequately communicate a recommendation about mixing two types of grease on the jackscrew that failed in the horizontal stabilizer, or that Alaska did not adequately evaluate the information.

Questions raised after the Alaska crash led to the study, said John Hickey, the FAA's director of aircraft certification service. "This is something that's never been done before," he said.

Goglia of the NTSB said FAA Administrator Jane Garvey and Nicholas Sabatini, the FAA's associate administrator for regulation and certification, showed "unbelievable" courage in forming the team and giving it free rein. "There were no limits, no sacred cows," Goglia said.

The study also said there is a lack of coordination between two of the FAA's safety-related agencies, the Aircraft Certification Service and the Flight Standards Service.

"The lack of formal processes also impedes the coordination and dissemination of safety-related information and control of guidance material intended for use by both the FAA and industry, allowing potentially unsafe aircraft configurations or operations," the study said.