R. Doug Wicker — Author

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:

Chapter Five
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.

A couple of years ago I wrote a book about what happened to the Federal Aviation Administration under the direction of whom I personally believe to be the most incompetent and destructive administrator to ever head the Agency.  Alas, my agent was unable to find a major publisher willing to publish this book.  Some deemed it too terrifying.  Others said that no one who flies would want to read it, thus limiting its marketability.  But the one thing nearly every editor agreed upon was that they couldn’t put the book down and that it scared the heck out of them.

Two of the chapters in this book became relevant yet again this past week when for the second time in less than twenty-one months a Southwest Airlines Boeing 737 experienced a breach in the fuselage while flying above 30,000 feet.  The first was Southwest Flight 2294 on July 13, 2009.  The second occurred just days ago, on April Fools’ Day, aboard Southwest Flight 812.

A lot of this goes back to Marion Blakey’s reign of error at the FAA, in which her subordinates were told in no uncertain terms that she considered the Agency’s “customers” to be the airlines.  Yes, you read that correctly.  You, the flying passenger, were not her concern.  The airlines were.  As such, FAA inspectors suddenly found themselves facing disciplinary action or even termination if they did their jobs and found airline maintenance lacking.  There were in fact numerous instances of this occurring throughout her tenure and beyond.  And while the Administrator has changed, those whom she placed in what I laughingly call “positions of responsibility” are still deeply embedded and destroying the Agency from within.

So, with this second Southwest near-disaster making news, prepare to be terrified as I bring to you Chapter Two of the book that never was, The Tombstone Agency.  The outrage part will follow on Wednesday, with the posting of the first part of Chapter Five.

Chapter Two
Why Inspectors Inspect Airplanes—
Death and Near Disaster Over Maui

Out of the ninety-five passengers and crew boarding the airliner that day only Gayle Yamamoto garnered so much as a hint of the disaster about to strike Aloha Airlines Flight 243.  It was April 28, 1988, when she boarded the Boeing 737 200-series aircraft at Hilo International Airport for the scheduled flight to Honolulu.  As she approached the passenger doorway her eyes fell onto a small but very visible crack just aft of the hatch opening.  Shrugging off the observation for whatever reason, perhaps thinking nothing was amiss or not wanting to appear an unduly nervous passenger, she kept silent about her observation as she passed by the flight attendants on the way to her assigned seat.

This Boeing 737, U.S. registration N73711, was unique.  It wasn’t all that old, a mere nineteen years since manufacture, but it was positively ancient in terms of fuselage pressurization cycles.  When a jetliner takes off and climbs into the thin air of high altitude, the fuselage is pressurized to an atmospheric pressure equal to about 8,000 feet.  When the aircraft descends, the fuselage is allowed to equalize to the outside atmospheric pressure.  You feel these changes in pressure on your eardrums after takeoff and again as the plane descends for arrival, but the fuselage is under much higher stress than your eardrums.  It cannot ever allow an equalization of pressure at high altitude.  People would lose consciousness within seconds from the lack of oxygen.  They could experience irreversible brain damage or even die very shortly thereafter.

Because of the short-haul nature of interisland travel, N73711 had gone through 89,680 cycles during its relatively short history.  That’s over 14,000 cycles beyond the 75,000 cycles for which it was designed.  That’s an average of almost thirteen cycles every day of every year for nineteen years.  In subsequent, world-wide inspections, only one jet airliner would be found with a higher number of cycles.  N73711 was also operating in a highly corrosive environment—the salty sea air associated with any oceanic island or coastal area—which only exacerbated the potential for problems.  N73711’s luck was about to run out.

Twenty-three minutes into the flight, at 24,000 feet above the sea, that little crack noticed by Gayle Yamamoto opened enough to allow air to escape from within the pressurized fuselage into the relative atmospheric vacuum outside.  Standing in Row 5 just a few yards back from the opening, Senior Flight Attendant Clarabell ‘C.B.’ Lansing collected cups from the earlier beverage service.  The small crack widened suddenly, becoming a large and growing hole.  Catastrophic rapid decompression of the passenger compartment had begun.

Cups, magazines, newspapers, eyeglasses, every light object in the aircraft rushed toward the breach.  Larger objects closer to the hole were also picked up, including Ms. Lansing who suddenly found herself airborne.  Her body slammed against the fuselage, plugging for a few milliseconds the hole that threatened the aircraft, but this only briefly interrupted the destruction that had begun.

The outer metal skin of the fuselage peeled back along the controlled area breakaway zones, cleanly stripping the roof of the aircraft from above the first five passenger rows all the way down to the floor of the passenger cabin.  Passengers saw only clear, blue skies above and to either side as the oxygen expelled from their lungs.  Passengers in the window seats suddenly found nothing beside them except a terrifying view of the Pacific Ocean and Hawaiian Island chain over four miles below.  C.B. Lansing disappeared from the cabin as though she had never been aboard, cast into the void.  Her body would never be recovered.

In the cockpit Captain Robert Schornsteimer occupied the command seat.  First Officer Madeline ‘Mimi’ Tompkins sat to his right.  There would normally be only two people in N73711’s cockpit.  On this day there were three.  Riding in the jump seat behind the pilot was a Hawaiian-based FAA Air Traffic Control Specialist who was taking an FAA-authorized familiarization flight.  His flight was free but, as is frequent in life, you get what you pay for.

The first indication in the cockpit that something was amiss was a loud clap and a sudden rush of wind.  Every mote of dirt and dust in the cockpit lifted into the air along with bits of insulation material, briefly obscuring visibility.  Captain Schornsteimer glanced over his right shoulder.  The cockpit door was missing, and beyond that was the incredible sight not of the ceiling above the passenger cabin, but rather clear, blue sky.  He lunged for his oxygen mask and thrust it over his face.  First Officer Tompkins parroted his action as did the Controller sitting behind them.  The occupants of N73711 were lucky so far.  Because of the short route, they were at only 24,000 instead of the much more dangerous higher altitudes at which Boeing 737 aircraft normally fly.

Schornsteimer nosed the aircraft over into an emergency dive in a desperate struggle for denser, life-sustaining, oxygen-rich air.  The control column shook violently in his hands as N73711 picked up speed and the disrupted airflow pounded into the vast opening behind him.  He throttled back the engines and deployed the speed brakes to keep from exceeding the maximum design airspeed and additionally overstressing the already compromised airframe.  The aircraft wallowed from side to side like a circus clown atop a board balanced on a ball.  The controls were mushy, responding slowly to his inputs.  A glance at the instruments told him that engine number one had failed, probably having ingested debris from the disintegration of the fuselage.

Acting autonomously Tompkins dialed the emergency code into the transponder.  She transmitted a distress radio call to Honolulu Air Route Traffic Control Center (ARTCC).  The noise level made it impossible for her to hear any replies or for Air Traffic Control at the other end to understand her transmissions.  However the ARTCC Controller did know that something had placed Flight 243 in danger.  The emergency transponder code, 7700, flashed on his radar display over the location of the aircraft and its remaining ninety-four occupants.

As the stricken Boeing descended through 14,000 feet Tompkins dialed in the frequency for the Control Tower at Kahului Airport on Maui.  For the first time since their ordeal began she was able to establish direct two-way radio communications with Air Traffic Control.  The Tower Controller acknowledged the emergency condition and directed Tompkins to reset her transponder so as to establish radar identification.  The ‘crash phone’ was activated by Control Tower personnel, sending emergency response vehicles to positions along the runway.

In an amazing display of piloting, Robert Shornsteimer and Mimi Tompkins brought the severely damaged Boeing, minus eighteen feet of critical roof and side cabin structure and with one engine not working, safely back to Earth with no additional fatalities.

Aftermath—Lessons Learned

The final toll was one fatality, eight serious injuries (several life-threatening), and fifty-seven minor injuries.  Had the failure occurred just a few thousand feet higher many more would have died, and in all likelihood the aircraft would have been unrecoverable.  As it was, N73711 was a total loss that would never again take to the skies.

Recommendations made in the wake of the investigation led to the retirement of many older jet aircraft around the world.  Inspections were increased and mandated for all aircraft at regular intervals.  The legacy of Aloha Flight 243 is that it represents a major change in philosophy in aircraft life-expectancy, maintenance, and the importance of inspecting for metal fatigue.  It is incredibly fortunate that the lessons learned came at so low a price in terms of lost lives.  This is not usually the case, as evidenced by the nickname given the Federal Aviation Administration by pilots and industry insiders decades ago—The Tombstone Agency.  Usually, such changes come only after much higher body counts.

Twenty Years Later—Lessons Forgotten

On March 6, 2008, the FAA proposed a record $10.2 million fine against the highly respected Southwest Airlines for failing to inspect its aircraft.  But the really disturbing news was to come almost one week later.  Six days after the proposed fine was announced Southwest suddenly grounded forty-three Boeing 737 aircraft.  Required safety inspections had not been performed, yet those aircraft continued to fly for almost a week after the lapse was exposed.  Worse, the inspections skipped had been for the precise cause of the Aloha 243 mishap—metal fatigue.  It was soon revealed that Southwest was not alone.  Fatigue inspections had not been performed at other airlines, including Delta.

But the most startling revelation was yet to come.  The lapses at Southwest Airlines had not been uncovered just one week before as the press were misled to believe by FAA spokespersons.  In actuality, Inspectors from the FAA’s Flight Standards District Office (FSDO) in Dallas, Texas, informed their superiors of inspection lapses one year before.  In March, 2007, these inspectors advised their superiors that several of Southwest’s Boeing 737 fleet were beyond required inspection timelines, yet no enforcement action was taken.  Indeed, Southwest was left with the impression that the FAA had given implied approval to continue to delay required fatigue inspections until the aircraft were taken out of rotation for normal, routine servicing.  There was not the slightest hint of urgency from the agency.  So it was quite understandable that Southwest’s spokesperson expressed outrage that the FAA had proposed a record fine since agency personnel were in fact aware of the lapses and had taken no enforcement action for one full year.

From the time FAA inspectors revealed to their superiors the lack of inspections at Southwest until the time Southwest announced the grounding of part of its fleet, the airline had operated 59,791 flights using forty-six aircraft considered unsafe by the FAA’s own regulations.  If one conservatively estimates an average load factor of ninety passengers and crew for those 59,791 flights, then almost 5,400,000 people were placed unnecessarily in danger.  And something else to consider—Southwest’s routes are generally longer than Aloha’s.  Thus Southwest’s Boeing 737 aircraft are operated at considerably higher altitudes, exposing the fuselages to much higher pressures, and the occupants to much greater dangers in the event of a fuselage failure.

Eventually, the FAA agreed to reduce the fine to $7.5 million dollars paid in three installments through the year 2011.  In other words, Southwest got off paying just $125.44 per illegal flight, or about $1.39 per endangered passenger and crew.

(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.