Sunday, May 20, 2018

Federal Aviation Administration Moved Slower Than Usual on Engine Warning Ahead of Southwest Fatality: Lag between industry alert, inspection mandate underscores challenge of identifying serious hazards in era of unprecedented safety

The Wall Street Journal
By Andy Pasztor
May 20, 2018 7:00 a.m. ET

Investigators have yet to issue their final report on a Southwest Airlines Co. flight last month that ended in an emergency landing and a passenger’s death. But one thing is clear: Regulators had been weighing enhanced inspection requirements covering a suspect engine part for nearly two years after warnings about it first emerged.

Questions about the time it took regulators to mandate more comprehensive inspections—and whether an alternate response would have made a difference in uncovering what emerged as the greatest danger—remain unanswered.

More than any commercial aviation accident in recent years, circumstances surrounding last month’s events have spurred industry officials, regulators and independent experts to reassess the best way to identify, rank and combat risks in an industry where safety statistics have become so exemplary.

In the April accident, serious metal fatigue caused a single, fast-moving engine-fan blade to break into pieces at roughly 32,000 feet. The violent rupture ended up spewing remnants of the front engine cover into the plane’s wing and body, killing a passenger who was partly sucked out a window that had been destroyed by the debris.

A similar but nonfatal accident in August 2016 drew industry attention to the potential for blades in the engines to crack, after the engine maker quickly notified regulators and some airlines that it was working on stepped-up inspection procedures. Roughly seven months later, the engine maker began recommending ultrasound inspections, rather than just visual checks, for certain fan blades based on the number of flights in service.

Several months after the manufacturer’s initial recommendation, the Federal Aviation Administration proposed similar stepped-up checks. But the FAA was still weeks away from making those checks mandatory when last month’s fatal accident occurred. After that, some airlines accelerated voluntary inspections almost immediately, and the FAA quickly mandated comprehensive inspections, which are now under way.

That roughly 20-month interval from the August 2016 accident was more than twice as long as the average time lag between the industry’s first steps to raise concerns about serious engine malfunctions or defective parts to the FAA, and publication of final FAA inspection or replacement mandates to resolve the problems, according to a Wall Street Journal analysis of federal safety documents.

A review of more than 100 engine-related safety rules—officially called airworthiness directives—since the beginning of 2015 indicates that on average final federal regulatory action occurred roughly nine months after the release of nonbinding industry safety bulletins. Nearly one-third of the FAA directives were published within five months of the bulletins. The FAA sometimes acts within days in rare emergency actions, instances not included in the analysis. The data covered engines installed on airliners, turboprops, private planes and helicopters, including internal parts and electronic controls.

An FAA spokesman earlier this month said there is no typical timeline for airworthiness directives, saying they are prioritized according to “the complexity of the issue, a risk assessment based on the likelihood of occurrence and the severity of the outcome.” He said other variables include costs along with “the number and type of comments we receive, how long it takes to respond to the comments and whether we make changes to the original proposal.” On Friday, the FAA said the agency concurred with the engine maker’s “proposed inspections and compliance time.”

The manufacturer, CFM International, a joint venture between General Electric Co. and France’s Safran SA, has said results from airline inspections around the world haven’t revealed anything warranting changes to the enhanced-inspection plans adopted after the deadly accident in April.

Southwest has said that before the accident, it complied fully with all FAA maintenance rules including repetitive visual tests relying on a dye to highlight surface cracks. Afterward, it rushed to conduct ultrasound inspections of all engines on its more than 700 planes.

It isn’t clear whether the accident would have been prevented, or the damage reduced, if the FAA had acted sooner on an initial inspection proposal it was weighing before the accident. The FAA has said the initial proposal itself didn’t focus on what later turned out to be the biggest potential hazard.

The proposal, issued in August 2017, wouldn’t have applied immediately to the plane involved in last month’s fatal accident, because the proposal mandated ultrasound inspections based on the date of the last visual inspection of blades rather than the number of flights they had been in service. The most hazardous cracks can’t be detected visually, and the Southwest engine had been visually inspected fairly recently.

Some safety experts say the FAA’s timetable was understandable. For one, with an exemplary record stretching over two decades and more than 300 million flight hours, the engines had been considered among the industry’s safest and most reliable. Engine models with far fewer hours have experienced significantly more serious failures.

So far, emergency inspections prompted by last month’s engine breakup identified roughly a dozen suspect parts out of tens of thousands checked so far, though none appeared to pose an imminent flight hazard, according to people familiar with the details.

After examining more than 77,000 fan blades on CFM International engines that power Boeing Co. 737 jetliners world-wide, industry and federal experts said they haven’t found an exact recurrence of the April event.

The isolated parts that have been removed from engines as a result of the inspections are undergoing additional testing, according to Southwest Chairman and CEO Gary Kelly and other people with knowledge of the process. The focus, they said, is on checking seemingly benign coating imperfections, or to differentiate between damage caused by external sources such as rocks or other objects sucked in during takeoffs or landings and internal defects in the metal parts themselves.

As they have after other airline fatalities, some critics blasted the FAA. Unprecedented low accident rates (this was the first fatality on a U.S. passenger airline since 2009) “have lulled us into complacency,” said Robert Clifford, a veteran plaintiff’s attorney who has litigated numerous major airline crashes. “We need to re-energize and reinvigorate inspection procedures.”

Agency supporters often credit nonpunitive collection of pilot incident reports, combined with close cooperation between airlines and regulators, for making engines increasingly safe.

“The true safety story of the last few decades has been the reliability of modern engines,” according to Kenneth Quinn, a lawyer and former senior regulator who has represented a number of engine manufacturers over the years.

Sometimes because of staffing constraints, inspectors rely on the airlines to rank hazards, says Al Diehl, a former military and commercial accident investigator. “Inspectors often act like coaches rather than cops,” says Mr. Diehl. It is likely, he said, that for FAA officials, the engine hazards “simply didn’t rise to the level requiring emergency action.”

Limited budget and staffing require regulators to concentrate on the greatest perceived safety threats, says consultant Bill Voss, a former international air-safety official. FAA managers “can’t focus on everything” as a priority, he said, “and still deal with the most important risks.”

Original article ➤


Anonymous said...

We need the airworthiness inspectors to function as coaches instead of cops. Inspectors are typically the most experienced mechanics. If young mechanics fear the inspectors, important questions won’t be asked and mistakes will be hidden. If the inspector is seen as an important source of knowledge and expertise, mechanics will open up and the overall quality of aircraft maintenance will go way up. The FAA began to encourage this policy over a decade ago. If the plaintiff attorney quoted above is so concerned about airline safety, he needs to come drive with us in Atlanta rush hour traffic...

Anonymous said...

The sheer logistics of an expedited ultrasound inspection of the turbine blade on, in SWA's case, 700 planes is an amazingly daunting task.

The phrase "Regulators had been weighing enhanced inspection requirements covering a suspect engine part for nearly two years after warnings about it first emerged" seems tilted toward inferring a deficit in the FAA process.

Consider that 2 years for creation and system-wide implementation of a new mandated process on thousands of working aircraft would definitely be a miraculous pace.

While any passenger fatality on any flight is unacceptable, I am amazed this plane landed with no more than that one fatality, thanks to crew skill and other safety and redundancy factors.

25 yrs ago, we'd be limited to black (or orange) box data.

Indeed this is an era of unprecedented safety with reference to the number of daily flights that are completed safely, and the FAA inspectors, along with the airline in-house safety team are doing rather well.