As you saw in Monday’s installment, Southwest appears to have trouble keeping its fleet from partially disintegrating in midair. Today you’ll find out how it got to this point. You will also find out why the Federal Aviation Administration allowed this unsafe operation to continue. While you’re reading this please keep in mind that these prophetic words were written in 2009.
Monday’s blog entry should have terrified the frequent flyer. Today, be prepared for total outrage as I present the first part of Chapter Five (it’s a long chapter; look for the rest on Friday) of The Tombstone Agency:
Why Inspectors Don’t Inspect—
Unlawful Retaliation at the FAA
His name is Charalambe ‘Bobby’ Boutris, and he is a certified American hero. He has the award to prove it. On June 12, 2008 he and fellow FSDO Inspector Douglas E. Peters were awarded the U.S. Office of Special Counsel (OSC) Public Service Award for 2007. His is a story guaranteed to leave the average Southwest Airline traveler shaking their head in disgust while shaking in fear as to how close they came to depressurizing at high altitude.
Mr. Boutris works as an FAA Aviation Safety Inspector. He works for the FSDO (Flight Standards District Office) with oversight responsibility for Southwest Airlines in the Southwest Airlines Certificate Management Office (SWA CMO). His specific responsibilities are Southwest Airlines’ Boeing 737 700-series aircraft. In addition to the 700-series, Southwest also operates the older 300- and 500-series.
In 2003 Mr. Boutris noticed discrepancies in the record keeping at Southwest Airlines. Southwest’s documentation regarding engine maintenance was so haphazard and incomplete that he could not tell if required maintenance had been completed. Indeed, the records varied from aircraft to aircraft with absolutely no consistency. He notified his boss, Supervisor/Principal Maintenance Inspector (S/PMI) Mr. G. (name withheld by author), but his reports were routinely ignored. In due course Mr. Boutris forwarded his concerns over the head of Mr. G., notifying superiors by e-mail, memo, and even in direct meetings that G. was actively suppressing his reports and in so doing was endangering air safety.
In congressional testimony Mr. Boutris stated, “All my findings were direct violations of the federal regulations and the SWA (Southwest Airlines) procedures, but under the direction of my supervisor Mr. G. I was sending SWA Letters of Concern in lieu of Letters of Investigation. In doing so I was finding out through follow-up inspections that the original findings were not getting corrected. In addition, routine surveillance inspections at different locations were revealing the same findings which was a characteristic of a systemic problem that was not being properly addressed. On September 16, 2005, I listed all the chronic noncompliance issues and via a memo I complained to the Office Manager Mr. Michael Mills that my supervisor was overlooking the systemic noncompliance issues that were the result of my surveillance inspections and informed him that my supervisor was suppressing my authority and responsibility to report them is accordance with mandated FAA guidance. Additionally, via e-mail I informed my supervisor that I did not feel that it is ethical as an Aviation Safety Inspector to continue writing Letter of Concern which are not part of our mandatory guidance to document and correct noncompliance issues with SWA.”
Michael Mills testified he was well aware that Mr. G. had an uncomfortably close relationship with Southwest Airlines, and that this relationship was causing problems within the SWA CMO. Mr. G. would frequently name-drop his close ties to FAA Director of Flight Standards James Ballough and the agency’s Associate Administrator for Aviation Safety Nicholas Sabatini. It appeared that Mr. G. was using such intra-agency ties to justify his hands-off approach to oversight at Southwest Airlines, thus implying he had both the ear and the approval of two of the agency’s top safety officials.
Mr. Mills also stated that he forwarded Mr. Boutris’ concerns about Mr. G. to Mr. S., who was the manager of the FAA’s Southwest Region Flight Standards District Office. But Mills’ concerns went unaddressed at this level and the trail stopped there. For reasons known only to Mr. S., he treated the complaints as personality conflicts requiring mediation rather than as wake-up calls that something serious was amiss at the SWA CMO. How he could come to this conclusion in light of Mr. Boutris’ specific enumerated and documented allegations and Mr. Mills’ corroboration are a complete mystery. At a minimum one would assume at least a cursory inquiry of such dramatic and potentially dangerous disclosures, but none were initiated.
Things only got worse for Mr. Boutris after he became the Partial Program Manager (PPM) for Boeing 737-700 airframes and systems. As with the engine maintenance problems he’d uncovered several years before he found discrepancies in this area as well. Repeated attempts to get Mr. G. to respond with a letter of investigation were rebuffed. And as with the engine maintenance disclosures before, Mr. Boutris saw once again that nothing was going to come from the SWA CMO to force the airline into compliance. Airworthiness Directives directly affecting the safety of Southwest Airlines’ aircraft were once again not enforced.
In January 2007 the situation reached a critical stage. Southwest Airlines, using the agency’s fairly recent Voluntary Disclosure Reporting System, disclosed to the SWA CMO that it had missed required airframe inspections on nearly a hundred B-737 aircraft. The recipient of this report was Mr. G. Mr. Boutris pressed his boss for issuance of a Letter of Investigation, but Mr. G. once again refused. Instead, Mr. G. opted to assign Boutris as the team leader in charge of an Airworthiness Directive Management Safety Attribute Inspection (AD Management SAI). His job was to evaluate Southwest’s system and procedures for complying with Airworthiness Directives.
No sooner was Boutris’ assignment announced when Southwest Airlines started pressuring Mr. G. to remove Boutris from the position. Apparently Mr. Boutris was a bit too good at his job for Southwest’s liking. And, yes, for some reason the airline apparently believed they had veto power over which inspectors would run the agency’s AD Management SAI of their operation. One is quickly left wondering here which are the regulatory agency and which are the regulated. The persons making this unbelievable request were Southwest Airlines Director of Quality Assurance Mr. M. and Southwest Airlines AD Compliance Team Leader Mr. K. Only the intervention on Mr. Boutris’ behalf by Mike Mills prevented Mr. G. from relenting to Mr. M.’s and Mr. K.’s heretofore unprecedented request to have veto authority over which FAA inspector would regulate them.
March 22, 2007, the whole house of cards began to topple. Bobby Boutris was at Southwest’s maintenance facility at Chicago Midway Airport. A repair team was working on Southwest B-737 N300SW. The repair was for a crack in the fuselage. A quick review of N300SW’s maintenance records revealed that passengers had been flown in N300SW while the crack was present. Since N300SW was not part of the fleet for which Boutris was responsible, he forwarded the finding to the Inspector who was, Mr. C. That is when Bourtis found out that Southwest had already self-disclosed the violation three days prior, on March 19. Boutris asked pointblank if Mr. C. was knowingly allowing Southwest to fly an aircraft with a known disqualifying safety defect. According to Boutris’ Congressional testimony, “C. stated: ‘No, I am not. He is.’” As Mr. C. stated this, he pointed to the office of Mr. G.
Boutris started digging. From the summary of AD (2004-18-16) requiring fuselage inspections of all Boeing 737-300 and -500 aircraft: This action is necessary to find and fix fatigue cracking of the skin panels, which could result in sudden fracture and failure of the skin panels, and consequent rapid decompression of the airplane. This action is intended to address the identified safety concern. This AD, dating back to 2004, was the one with which Southwest failed to comply three full years later.
Additional investigation led Boutris to learn that Southwest had verbally notified Mr. G. even four days earlier of the lapse, on March 15. And that verbal notification wasn’t for just N300SW, but for many aircraft, possibly as many as 100, but Southwest’s records were in such shambles (despite warnings from Boutris about their record keeping dating back now several years), that Southwest could not put a specific number as to how many unsafe B-737 aircraft were in their system and still flying passengers.
In the written March 19 communication, a Voluntary Disclosure Reporting Program (VDRP) report, Southwest managed to lower the original estimate of up to 100 aircraft downward to ‘only’ forty-seven. In the four days between the verbal communication and the VDRP, Mr. G. documented nothing of what was transpiring. Additionally, the VDRP submitted by Southwest claimed that non-compliance had ceased immediately after detection. This was an outright lie. At least some of the affected aircraft continued flying passengers until at least March 23. Sounds bad, but it’s actually much worse. Subsequent investigation revealed that these aircraft hadn’t been flying illegally for just eight days, eight weeks, or even eight months. They had been flying around the country, carrying unsuspecting passengers while overflying heavily populated areas, for more like two and a half years. When inspections were finally completed, six Boeings were discovered to have fuselage cracks. One had multiple cracks, with one reaching at least 3.5 inches in length. These aircraft were quite literally accidents looking for a time, place, and altitude to happen—flying bombs whose fuselages were waiting to explode in a shower of debris into the thin atmosphere of high altitude flight.
(To be continued)
copyright © 2011 R. Doug Wicker
No portions of this article are to be used, quoted, copied, or retransmitted without the permission of the author.