Study: FAA fails to act on many NTSB recommendations

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http://www.washingtonpost.com/wp-dyn/content/article/2010/09/28/AR2010092807001.html


Recommendations to FAA often languish, review shows

Investigators search the site of the crash American Eagle Flight 4184 near Roselawn, Ind., on Nov. 4, 1994. All 68 people aboard were killed. (Charles Bennett) Network NewsX Profile

By Richie Duchon News21 Wednesday, September 29, 2010

Every year, planes crash in accidents that could have been avoided.

Ice can build up on the wings of a plane like it did in 1997 when a plane trying to land at the Detroit airport lost speed and crashed, killing all 29 on board.

The problem might be a poor repair job. That was the case in 2005 when the right wing fell off of a Chalk's Ocean Airways flight just after takeoff from Miami. Two crew members and all 18 passengers died.

And then there are the times when a pilot is just too exhausted to fly and does so anyway. That is what investigators believe happened in 2004 when a Corporate Airlines plane crashed short of the runway in Kirksville, Mo.

The Federal Aviation Administration lists pilot error as the leading cause of plane accidents, but an analysis of accident data by News21, a national university student reporting project, and the Washington-based Center for Public Integrity, a nonprofit investigative journalism organization, shows that the major causes of air accidents include ice buildup on aircraft, risks on runways, faulty aircraft maintenance and overtired pilots.

For four decades, the National Transportation Safety Board has urged the FAA to take steps to reduce the likelihood of these kinds of accidents, issuing more than 520 recommendations.

But in many cases those recommendations have gone unmet, according to a review of accident data and government documents and interviews with dozens of industry and safety specialists.


Recommendations languish for many reasons: The process of changing rules is long and complex; industries resist expensive fixes; unions fight changes in work requirements; and sometimes years of research and product development are needed.

But many believe that the biggest cause of delay lies with the FAA itself.

Icing conditions

Tricia Coffman still breaks down in tears when she remembers the phone call telling her that her husband died in a plane crash in Pueblo, Colo., along with seven others in 2005.

"Losing him can't be for nothing," she thought. So she joined the National Air Disaster Alliance Foundation, a group that represents survivors and family members of aviation accidents.

Coffman learned that a similar accident had taken place 10 years earlier. When American Eagle Flight 4184 - in a holding pattern over Chicago O'Hare International Airport for 30 minutes - began its descent, the right wing made a dramatic dip, and the plane crashed in Roselawn, Ind., killing all 68 people on board. NTSB investigators said the crash was caused by the plane flying into freezing rain.

Thirteen years earlier, the NTSB had urged the FAA to certify airplanes based on how each craft might respond to different icing conditions. Dozens of letters between the NTSB and FAA from 1981 to 2010 show that the FAA consistently fought the change, citing cost and lack of research.

After the Roselawn accident, the FAA formed a task force to analyze how rare weather events affect certain types of planes. Seven years later, the NTSB fired off a letter urging the agency to "give this rule-making project a high priority."

A year and a half later, the Circuit City-chartered Cessna Citation 560 went down with Coffman's husband on board.

FAA Deputy Assistant Administrator for Public Affairs Laura Brown said in an e-mail that the agency has stepped up action, issuing several proposed rules and more than 200 directives aimed at reducing icing hazards for specific aircraft, with the result that icing accidents have dropped by half in the past decade.

Still, a Government Accountability Office report released in July noted that at least 188 large passenger flights reported icing problems from 1998 to 2007 and that the FAA has not updated its 1997 plan for improving safety in icing conditions.

Monitoring maintenance

In 2003, a maintenance worker on contract failed to properly tighten a cable on the tail of an Air Midwest plane. His superior missed the error. One day later, the plane took off from Charlotte, N.C., tilted more than 50 degrees upward, stalled and crashed, killing all 21 people on board.

Improper maintenance is the second-leading cause of air accidents and incidents, according to FAA data - responsible, in part, for at least 15,000 accidents or safety incidents since 1973, when the FAA started keeping such records. In these accidents, at least 2,599 people died and 4,189 people were injured, according to a News21 and Center for Public Integrity analysis.

The NTSB issued 21 recommendations after the Air Midwest crash. The FAA still has not implemented two of them: to prohibit the person training a mechanic from serving as the inspector on that same part and to increase oversight of work done by contracted mechanics.

An FAA spokesman said that current inspection practices already address those issues and that the agency has met the intent of the recommendations.

Part of the problem is monitoring the quality of repairs done by hundreds of small and large repair shops here and abroad.

In a written response to questions about oversight of airplane repairs, the FAA said it is doing more to make sure that outsourced repairs meet quality standards by hiring more inspectors and requiring regular audits of maintenance providers.

Recently, the FAA cracked down on some companies for poor maintenance. In 2009, the agency dished out one of its largest fines - $10.2 million - to Southwest Airlines for flying more than 30 planes without inspecting the bodies. FAA inspectors found cracks up to four inches long on some of the planes.

And in late June, the FAA said it would seek a $2.47 million fine against Trans States Airlines and GoJetAirlines, which fly for US Airways, for violating a host of repair procedures. The airlines flew 320 flights using aircraft that were out of compliance with maintenance rules.

Flying fatigued

On Oct. 19, 2004, Corporate Airlines Flight 5966 crashed as it approached Kirksville, killing the two pilots and 11 of 13 passengers. The pilots had started their day at 4 a.m. and worked 14.5 hours. In its report, the NTSB noted that "fatigue likely contributed to [the pilots'] degraded performance."

The safety board told the FAA that it needed new scheduling rules for pilots to ensure they are rested. It was the same message the board had delivered at least 30 times before.

The FAA has tried several times to impose more limited shifts and more rest time between shifts, only to meet with opposition from airlines and pilots unions.

In the meantime, fatigue has contributed to more than 320 accidents and incidents since 1971 and killed more than 745 people, according to a News21 and Center for Public Integrity analysis of FAA and NTSB data. That includes a Colgan Airlines flight that crashed near Buffalo in 2009, killing 50.

The accident produced an outcry from family members, safety advocates and politicians, and led to a directive to reduce pilot fatigue that was included in the Airline Safety and Federal Aviation Administration Extension Act, signed by President Obama this summer. The FAA released a proposal for public comment this month.

"It took an act of Congress," said House transportation committee Chairman James L. Oberstar (D-Minn.). "Fatigue is one area that without a doubt has had the greatest resistance by airlines and which the FAA has been sporadic, to say the best."

News21 reporters Stevie Mathieu, Charlie Litton and Tessa Muggeridge contributed to this report - one of several from a project detailing troubles with the U.S. transportation system. The series was reported by journalism students in the Carnegie-Knight News21 program, based at Arizona State University, in collaboration with the Center for Public Integrity.
 
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