Aviation Safety: Management Improvement Needed in FAA's Airworthiness Directive Program

Published by the Government Accountability Office on 1990-02-16.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United   States   General   Accounting   Office

Report to the Chairmen, Subcommittee
on Surface Transportation and
Subcommittee on Aviation, Committee
on Public Works and Transportation,
House of Representatives

Improvement Needed
in FAA’s
Directive Program
     , s
                   United States
GAO                General Accounting Office
                   Washington, D.C. 20648

                   Resources, Community, and
                   Economic Development Division


                   February 16,199O

                   The Honorable Norman Y. Mineta
                   Chairman, Subcommittee on Surface
                   Committee on Public Works and Transportation
                   House of Representatives

                   The Honorable James L. Oberstar
                   Chairman, Subcommittee on Aviation
                   Committee on Public Works and Transportation
                   House of Representatives
                   This report responds to an October 11, 1988, request that we explore,
                   through several assignments, the Federal Aviation Administration’s
                   (FAA) ability to provide meaningful oversight of aviation safety. Pursu-
                   ant to your request we previously reported on FAA’S removal procedures
                   for pilot examiners,’ the agency’s inspection management system,2 and
                   changes under consideration regarding aviation medical standards3 As
                   agreed with both subcommittee staffs, this report focuses on FAA’S over-
                   sight of the airworthiness directive (AD) program because ADS are key
                   elements of FAA’S safety responsibility. ADS are rules that FAA issues
                   requiring airlines to correct conditions in their aircraft, such as cracking
                   and corrosion, that can jeopardize safety. Because of the AD program’s
                   critical nature, we agreed to examine whether (1) FAA’S oversight is ade-
                   quate to determine airline compliance with AD requirements and (2)
                   safety-related information maintained by FAA could be used to improve
                   the program’s effectiveness. Our review focused on FAA’S oversight of
                   the AD process, not on the merits or validity of individual ADS.

                   FAA’S oversight of the AD program is inadequate to determine whether
Rebults in Brief   the airlines are complying with ADS.The National Transportation Safety
                   Board’s (NTSB) investigation of the widely publicized April 28, 1988,
                   Aloha accident, in which the aircraft lost the upper portion of its cabin

                   ‘Aviation Safety: FAA Has ImprovedIts RemovalProceduresfor Pilot Examinen (GAO/

                   ‘Aviation Safety:FAA’s Safety InspectionManagementSystemLacksAdequateOversight(GAO/
                   3Aviation Safety:FAA Is ConsideringChangesto Aviation MedicalStandards(GAO/RCED-90-68FS,
                   Jan. 9,lQQO).

                   Page 1             GAO/RCED-99-94 Management Improvement Needed in FAA’s AD Program
while in flight, and other FAAspecial inspections have documented sev-
eral important examples of AD noncompliance. FAAdoes not know the
extent of AD compliance throughout the airline industry because FAA
inspectors do not, and are not required to, verify AD compliance during
each inspection. In addition, when AD compliance is checked, current
guidance requires inspectors to report only noncompliance. As a result,
FAAdoes not have information on the extent to which airlines are in
compliance with ADS.FAAneeds to measure the extent of noncompliance
and decide what actions it should take to ensure AD compliance through-
out the airline industry.

FAAinspection guidelines are very broad, in that they allow inspectors to
decide whether to check for AD compliance, which ADSto include in their
check, and which aircraft to inspect. FAAinspectors do not routinely
check for AD compliance during airline inspections. For example, during
our review we accompanied FAAinspectors on 10 routine surveillance
inspections and noted that AD compliance was checked in only 2
instances because the inspector decided to emphasize non-AD-related

In addition to obtaining more complete and comprehensive information
from its safety inspectors, FAAshould better use its existing safety data
bases. Use of such data could help focus airline inspections on problem
areas, thereby improving the effectiveness and efficiency of FAA’Slim-
ited inspector work force.

the safe travel of U.S. air passengers-about 492 million in 1988-as a
joint responsibility of FAAand the airlines. FAApromotes aviation safety
by issuing regulations that stipulate certain requirements that airlines
must meet to operate commercial aircraft. FAA’Saviation inspectors then
monitor to ensure that airlines comply with these safety requirements.
When airline accidents do occur, mechanical failures-such as in land-
ing gear and aircraft structural components-are factors in 40 percent
of the accidents. FAA’sAD program addresses such unsafe conditions and
is a key element of FAA’S safety responsibility.

Although FAAcertifies new aircraft models as safe before they are used
in commercial service, it also issues ADS to address unsafe mechanical
conditions that surface after the aircraft has been in use. ADSare
requirements that FAA issues for the airlines to identify and correct
unsafe aircraft conditions that have occurred, or are likely to occur, in

Page 2         GAO/RCED-90-94 Management Improvement Needed in FM’s AD Program

                      other aircraft of the same design. ADSalso prescribe corrective actions
                      that airlines must take to correct identified problems in their aircraft.
                      For example, a 1988 AD identified several incidents involving Boeing
                      737s in which an engine bolt failed. In one case, the engine separated
                      from the aircraft. The AD required airlines to add a secondary engine
                      mount support, install a failure indicator for the bolt, and periodically
                      inspect the indicator.

                      FAA becomes aware of most unsafe aircraft conditions through communi-
                      cations with aircraft manufacturers or reports of significant incidents or
                      accidents. Using engineering judgment, FAA decides if these conditions
                      warrant an AD. If needed, FAA engineers work with the aircraft manufac-
                      turer to develop the AD. The manufacturer usually prescribes the proce-
                      dures needed to monitor and correct the unsafe condition, and FAA
                      reviews and approves these procedures. FAA also establishes the time
                      allowed for the airlines to comply with the AD. In determining the com-
                      pliance time frames, which can range from immediate action to several
                      years, FAA engineers consider factors such as the severity of the unsafe
                      condition, the availability of parts needed to correct the condition, and
                      the potential economic impact the AD will have on the aviation industry.
                      In addition, some ADSrequire a one-time repair of an unsafe condition,
                      while others require a combination of repetitive inspections, monitoring,
                      and eventual repair.

                      FAA issues about 200 ADSeach year for large commercial aircraft. At any
                      one time, a particular aircraft type may have many ADS requiring recur-
                      rent inspections or repairs.

                      After issuing an AD, FAA monitors compliance through its airline inspec-
                      tion program. When FAA inspectors find AD noncompliance, the airlines
                      must comply with the AD before operating the aircraft again. Inspectors
                      may also recommend that FAA impose a civil penalty or take other
                      administrative action against the airline.

                      Recent accident investigations and special inspections by the NTSB and
FAA’s Management      FAA found instances in which airlines have not complied with ADS.
and Oversight of AD   Because FAA'S guidelines allow aircraft inspectors discretion in deciding
Compliance Needs      when, what ADS, and how many aircraft to inspect for AD compliance,
                      the inspectors do not always verify compliance during their routine
Improveme’nt          inspections. In addition, FAA does not know the industry-wide extent of
                      AD noncompliance because it does not receive information about the

                      Page 3          GAO/RCJD-90-94 Management Improvement Needed in FM’s AD Program

                           number of ADSinspected for or the number of airlines found in

Incjdents of AD            Recent NTSB accident investigations and special inspections by FAA found
                           that several airlines were not complying with ADS. For example, FAA
Nopcompliance              issued an AD in October 1987 that addressed deterioration in the Boeing
                           737 fuselage, the aircraft type that was later involved in the Aloha acci-
                           dent. The AD required airlines to conduct visual inspections for cracking;
                           and if cracks were found, the AD required airlines to perform additional
                           technical inspections. According to NTSB'S accident report, Aloha’s
                           records neither documented these required additional inspections nor
                           accurately reflected the condition of the aircraft. Further, FAA records
                           showed no evidence that its inspector had verified AD compliance. NTSB
                           concluded that Aloha Airline’s maintenance program and FAA's over-
                           sight of the airline’s flight operations were inadequate. NTSB therefore
                           recommended that FAA'S inspection program place greater emphasis on
                           evaluating the actual condition of each aircraft and the airlines’ compli-
                           ance with specific ADS.

                           FAA'S own experience with direct inspection of airline operations has
                           also found instances of serious AD noncompliance. In 1986, as a result of
                           an Eastern Airline aircraft accident, FAA conducted an in-depth review
                           of the company’s adherence to FAA regulations. This effort combined
                           records reviews and direct aircraft inspections. FAA found, among other
                           problems, that Eastern had flown two aircraft for almost 6 years with-
                           out complying with an AD pertaining to the landing gear and without FAA
                           inspectors’ detecting the noncompliance. One aircraft made over 10,000
                           flights while not in AD compliance. The aircraft was damaged when the
                           landing gear-which was the subject of the An-failed. Another aircraft
                           flew more than 8,900 flights while not in compliance with the same AD.
                           Furthermore, during one 6-day period, Eastern operated 37 aircraft on
                           over 1,100 flights without properly complying with an AD that required
                           recurrent inspections for cracks. On the basis of this review, FAA
                           imposed a $9.6 million fine for a variety of violations, including AD non-
                           compliance. Also, FAA'S 1987 “white glove” inspection of 8 airlines
                           found 26 instances of AD violations.

Monitoring ADdCompliance   When issuing an AD, FAA relies on the airlines to comply with its require-
                           ments but does not require them to report compliance. Instead, FAA relies
                           on its aircraft inspectors to monitor airlines’ compliance during routine
                           surveillance inspections. However, FAA'S guidelines are too discretionary

                           Page 4         GAO/RCELW@94 Management Improvement Needed in FAA’s AD Program
     + ’

                             to ensure that critical safety areas, such as AD compliance, are ade-
                             quately covered during inspections. We also found that FAA does not
                             have information on the number of ADSchecked by inspectors or the
                             extent to which airlines comply with ADS.

J&q&ion GuidanceDoesNot      ADSare critical elements in maintaining aviation safety because they
Requ@e  Verification of AD   require airlines to correct potentially unsafe aircraft conditions. How-
Corn liance                  ever, FAA cites AD compliance as 1 of more than 20 area&such as pilot
                             training and emergency equipment, that inspectors may consider includ-
   f                         ing in an inspection. The guidelines do not specify how much emphasis
                             inspectors should place on reviewing each inspection area, nor do they
     I                       require inspectors to verify AD compliance during each inspection. In
     ,                       addition, the guidelines allow inspectors discretion to determine how
                             often to conduct AD inspections, which ADSto check for compliance, and
                             how many of the airline’s aircraft to inspect.

                             Inspectors do not always verify AD compliance during routine inspec-
                             tions because some discretion in the inspection process is necessary to
                             allocate FAA's limited work force among an increasing number of aircraft
                             and, hundreds of ADS. In addition, some types of inspections, such as
                             enroute and ramp inspections,4 do not lend themselves to inspecting for
                             AD compliance. Other types of inspections, however, such as mainte-
                             nance records checks and spot checks of aircraft undergoing periodic
                             service, are appropriate for verifying AD compliance. Because Aos pre-
                             scribe corrective actions that airlines must take to correct known unsafe
                             conditions in their aircraft and because several recent incidents suggest
                             serious weaknesses regarding airline compliance with ADS,FAA needs to
                             require its inspectors to test for AD compliance as part of each

                             We accompanied FAA inspectors on 10 routine inspections. In only two
                             instances did the inspector check for compliance with an AD during the
                             inspection-once by reviewing maintenance records and once by com-
                             paring maintenance records to work done on the aircraft. In the other
                             eight instances, due to FAA'S discretionary inspection policy, the inspec-
                             tor decided to emphasize non-m-related inspection duties, such as fol-
                             lowing up on reported mechanical problems during a flight, reviewing
                             maintenance records for current work being performed on an aircraft,

                             4An “enroute”inspectionis a checkof an aircraft during a flight and includesobservingthe flight
                             crew’susageof aircraft equipmentand the performanceof the equipment.A “ramp”inspectionis a
                             checkof an in-serviceaircraft and includesobservingthe refuelingof the aircraft, passengerhan-
                             dling, and the conditionof the aircraft.

                             Page 5              GAO/RC~BO-94       Management Improvement Needed in FAA’S AD tim

                           and reviewing training records for airline personnel, instead of checking
                           for AD compliance.

F*   NeedsMoreCompleteAD   FAA does not know the extent of AD compliance throughout the airline
Compliance Information     industry because the agency does not have information on the extent to
                           which inspectors check for, or find airlines in compliance with, ADS.
                           Inspectors, in accordance with FAA'S procedures, report instances in
                           which they find that airlines are not in compliance; they are not, how-
                           ever, required to report when they observe AD compliance. Requiring
                           inspectors to both verify AD compliance during inspections and report
                           complete inspection results-compliance as well as noncompliance-
                           would provide FAA with (1) a data base to measure the extent of AD non-
                           compliance and (2) a management tool to help administer the program
                           more effectively. Without such data, FAA cannot determine whether it
                           has established appropriate emphasis and policies regarding AD compli-
                           ance inspections.

-FA1A.Can More
                           safety-related information to help focus its inspections and thereby
 Acitively Use Available   improve the effectiveness of its limited inspector resources. Because FAA
 Safety Data               relies on inspectors to verify An compliance, a more effective inspection
                           effort would also help FAA identify where changes should be made in the
                           AD program to further improve aircraft safety. The NTSB and the Airwor-
                           thiness Assurance Task Force, a technical panel of industry and govern-
                           ment aviation experts, both recently concluded that FAA'S inspection
                           efforts are largely reviews of paper records with limited hands-on air-
                           craft observation. FAA acknowledges it would prefer more hands-on
                           inspections, but it cites manpower limitations as precluding it from
                           inspecting all aircraft and verifying compliance with all ADS. Therefore,
                           FAA must judiciously allocate its limited resources to achieve the maxi-
                           mum effectiveness from its inspection program.

                           Analyzing existing safety-related data, such as in FAA'S Service Diffi-
                           culty Report system, could provide this focus by raising warning signals
                           regarding specific aircraft, aircraft types, or airlines that warrant a
                           closer hands-on inspection. FAA uses these data to help focus its special
                           inspections but does not as a matter of course use the data for routine
                           airline surveillance.

                           FAA has maintained extensive safety information in various data bases.
                           For example, FAA requires airlines to report mechanical problems that
                           occur in aircraft, such as problems with landing gear, identification of

                           Page 6          GAO/RCED-90-94 Management Improvement Needed in FM’s AD Program

corrosion and cracking, and engine shutdowns, to its Service Difficulty
Report system, which has existed for over 2 decades. In 1988, commer-
cial airlines reported approximately 19,000 mechanical difficulties to
the system.

We analyzed Service Difficulty Report data by aircraft type, such as the
Boeing 727 and McDonnell Douglas DC-g, to determine whether this
information could be used to augment FAA’S inspection process. We
reviewed a limited sample of reports that airlines had submitted to FAA
between January 1983 and June 1989 and noted a wide range in the
frequency of problems reported across aircraft type and airlines. For
example, in reviewing Service Difficulty Report data for 727s, we noted
that one airline reported 37 instances of structural problems involving
cracking and corrosion found during inspections of one of its aircraft.
All of these problems were found during eight aircraft inspections that
began in September 1984 and concluded in January 1988. During the
last inspection, the airline found and repaired 28 instances of cracks and
corrosion in areas such as floor beams, brackets, and fuselage skin.
However, the airline did not submit any additional Service Difficulty
Reports to FAA from January 1988, when repairs were made, to June
1989, the ending date of our analysis. If FAA analyzed these safety data,
the agency could better focus its inspection efforts by selecting for rein-
spection this or other aircraft with similar findings to determine
whether any additional cracking and corrosion have occurred since the
last reported inspection.

FAA could also use Service Difficulty Report information to monitor
whether airlines are finding and correcting generic problems, such as
cracking and corrosion, that can occur in aircraft. For example, for one
type aircraft, we examined six Service Difficulty Reports that airlines
had submitted to FAA. Five of the reports stated that the airlines had
found and corrected cracks and corrosion in their aircraft. Airlines oper-
ating other aircraft makes and models also reported finding these and
other types of deterioration.

While this type information cannot be used exclusively to determine
problems with specific aircraft, aircraft type, or airlines, FAA can use the
data as a warning signal of potential safety problems. FAA inspectors
could use these signals, along with their knowledge of other factors-
such as aircraft age, utilization, airline maintenance practices, and vari-
ous types of normally expected deterioration-to determine which spe-
cific aircraft, aircraft type, or airline should receive increased inspection
emphasis. FAA notes that its reporting system may have some problems

Page 7          GAO/RCEDW-94 Management Improvement Needed in FAA’s AD Program

              regarding the quality and timeliness of the data. In a separate review,
              we are currently assessingFAA’S Service Difficulty Report system to
              determine how to make these data more useful.

              In 1987, we issued two reports that identified improvements needed in
              FAA’S airline inspection program. In one report, we recommended that
              FAA use safety data to target its inspector resources toward high-risk
              conditions.6 In the other, we recommended that FAA revise its inspection
              guidance to take into account the need to target airlines displaying char-
              acteristics that may indicate safety deficiencies.6 Consistent with these
              recommendations, FAA could use the kind of data maintained in the Ser-
              vice Difficulty Report system, as well as other systems and data bases
              maintained by the agency, to develop indicators of potentially unsafe
              conditions in aircraft as tools to help target its limited inspection

              Because by their nature ADSaddress critical safety conditions, airline
Conclusions   compliance with AD requirements and FAA’s ability to effectively oversee
              and manage the AD program are vital to aviation safety. Poor implemen-
              tation of AD requirements can potentially result in aircraft accidents.
              This is illustrated by the Eastern Airlines incident involving the failed
              landing gear. Furthermore, the NTSB investigation of the Aloha accident
              and FAA’S special inspection results demonstrate that (1) some airlines
              are not complying with ADSand (2) AD noncompliance can remain unde-
              tected by FAA for long periods of time.

              FAA does not compile information on the extent of AD noncompliance
              because (1) the number of ADS inspected for is left to the discretion of
              each aviation safety inspector and (2) the inspectors report only when
              airlines are not in compliance. Consequently, FAA is not aware of the
              number of ADSinspected for or the number verified as being in compli-
              ance. This information is needed, however, to measure the extent of AD
              compliance throughout the airline industry. The instances of noncompli-
              ance discovered by recent accident investigations and special FAA inspec-
              tions, coupled with the wide discretion given inspectors in verifying ADS
              and incomplete inspection reporting, indicate a need for FAA to improve
              its management and oversight of this critical safety program. FAA needs

              %zpartmentof Trans rtation: EnhancingPolicy and ProgramEffectivenessThroughImproved
              Management(GAO/&87-3,       Apr. 13,1987).
              6AviationSafety:NeededImprovementsin FAA’sAirline InspectionProgramAre Underway(GAO/
              m-62,       May 19,1987).

              Page 8            GAO/RCED-W94 Management Improvement Needed in FAA’s AD Program
                  to know if its inspectors are checking for AD compliance and the extent
                  to which airlines are complying with ADS.With more complete informa-
                  tion, FAA would have the management tools needed to determine
                  whether (1) airlines are complying with ADSand (2) additional regula-
                  tory action is needed to ensure AD compliance.

                  Also, FAA can improve the management of its AD process by analyzing
                  existing safety data to help determine where to focus its limited inspec-
                  tion resources, FAA can use this information to identify which aircraft,
                  aircraft type, or airlines warrant additional hands-on inspection

                  To improve FAA’s management and oversight of the AD program, we rec-
Recommendations   ommend that the Secretary of Transportation direct the Administrator,

                  require a systematic testing for AD compliance as part of each routine
                  airline inspection,
                  require inspectors to report which ADSare tested and the extent of air-
                  line compliance found during each inspection, and
                  maintain and analyze compliance information to determine the extent of
                  AD noncompliance and any additional actions necessary to ensure that
                  airlines comply with ADS.

                  We also recommend that the Secretary direct the Administrator, FAA, to
                  analyze and use available aircraft safety data as a management tool to
                  focus FAA'S limited inspection work force.

                  We discussed the facts presented in this report with cognizant FAA offi-
                  cials. They agreed that the report is accurate. However, as requested by
                  your office, we did not obtain official agency comments. Details on our
                  objectives, scope, and methodology are contained in appendix I.

                  Unless you publicly announce its contents earlier, we plan no further
                  distribution of this report until 16 days from the date of this letter. At
                  that time, we will send copies to the Secretary of Transportation and the
                  Administrator, FAA, and make copies available to others upon request.

                  Page 9         GAO/RCED9@94 Management hprovement   Needed in FM’s AD Program

We performed our work in accordance with generally accepted gov-
ernment auditing standards under the direction of Kenneth M. Mead,
Director for Transportation Issues, who can be reached on (202) 276
1000. Other major contributors to this report are listed in appendix

J. Dexter Peach
Assistant Comptroller General

Page 10       GAO/RCED-9044 Management Improvement Needed in FM’s AD Program

    Page 11   GAO/RCELMJO-94Management Improvement Needed in FAA’s AD Program
Appendix I

objectives,Scope,and Methodology

              On October 11, 1988, the then-Chairman of the Subcommittee on Avia-
              tion, House Committee on Public Works and Transportation, Norman
              Mineta, requested that we explore FAA's ability to provide meaningful
              oversight of aviation safety. This report is one of several assignments
              responding to the chairman’s request.

              As agreed with the subcommittee staff, we concentrated this current
              review on FAA'S AD program because ADS are key elements of FAA'S safety
              responsibility and critical to ensuring aviation safety. We reviewed how
              FAA identifies and addresses unsafe conditions in commercial aircraft
              and whether (1) FAA'S oversight is effective to determine AD compliance
              and (2) safety-related information maintained by FAA could be used to
              improve the program’s effectiveness. We limited our review to the AD
              process for commercial aircraft because these aircraft transport 96 per-
              cent of all aviation passengers. We did not review the process for
              smaller, general aviation aircraft. We focused on FAA'S management of
              the AD process and did not assess the merits or validity of individual

              To determine how FAA identifies and addresses unsafe conditions, we (1)
              interviewed FAA engineers who write ADS in Seattle, Washington; Long
              Beach, California; and Boston, Massachusetts; (2) reviewed AII documen-
              tation and files; and (3) accompanied FAA inspectors on aircraft inspec-
              tions, In addition, we interviewed engineers from two aircraft
              manufacturers, the Boeing Aircraft Company and McDonnell Douglas.
              Also, we interviewed officials from NTSB and the Air Transport Associa-
              tion regarding their roles in the AD development process. We discussed
              methods that FAA uses to identify unsafe aircraft conditions, the manu-
              facturer’s input into the AD process, how an AD is developed, and the
              engineering judgment used in the process. We reviewed files from 14
              major ADSand identified the extent of documentation supporting the
              judgments and decisions made as the engineers developed the ADS. We
              also tested to determine whether the files contained evidence of proper
              internal controls, such as documented levels of review and approvals.

              To assess the adequacy of FAA's oversight of AD compliance, we accom-
              panied FAA inspectors on aircraft inspections in Pt. Lauderdale and
              Miami, Florida, and Atlanta, Georgia, and observed their routine surveil-
              lance and AD compliance activities. We supplemented these observations
              by reviewing inspector guidelines and discussing inspection practices
              with the field inspectors and with the directors of FAA'S Flight Standards
              in F’t. Lauderdale, Miami, Atlanta, and FAA headquarters. We also
              reviewed FAA requirements for reporting inspection results. Finally, we

              Page 12        GAO/RCED-90-94
                                          Management   Improvement Needed in FAA’s AD Program
Appendix I
Objectivee, Scope, and Methodology

reviewed the NTSB'S report on its investigation of the Aloha Airlines acci-
dent, FAA'S actions taken against Eastern Airlines for AD noncompliance,
and the results of FAA's 1987 special inspection program.

To determine whether safety data could be used to improve the AD pro-
gram, we interviewed FAA officials and analyzed safety-related data
reported by airlines to the Service Difficulty Report system in Washing-
ton, D.C., and the agency’s computer center in Oklahoma City,
Oklahoma. We discussed the feasibility of using existing safety-related
data as a means to focus inspections and identify unsafe conditions in

We conducted our review between February and October 1989 using
generally accepted government auditing standards.

Page 13            GAO/RCED99-94 Management Improvement Needed in FAA’s AD Program
Major Contributors to This Report

                         Robert W. Shideler, Assistant Director
 Cbnmunity, and          William D. McDowell, Assignment Manager
                         Charles R. Chambers, Evaluator
 Development Division,   CarolynKirkpatrick, Evaluator

Washington, D. C.

-Atlanta Regional
                         Allan C. Richardson, Evaluator-in-Charge
 Office                  Cherie M. Starck, Site Senior
                         Janice S. Villar, Evaluator

(341203)                 Page 14        GAO/RCED-99-94 Management   Improvement   Needed in FAA’s AD Program

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