Monday, April 07, 2008

Whistleblowing on Southwest Airlines: Cracks of Doom or Paperwork Errors?

The lot of a whistleblower is not an easy one. And I'm not talking about football referees. In engineering ethics parlance, a whistleblower is someone who goes public with information about a safety issue, after trying without success to deal with the problem through normal organizational channels. Whistleblowers can toot either before or after something terrible happens, but the consequences for them are usually the same: isolation, criticism, and often the loss of a job or even a career. Their only compensation is the knowledge that, in most cases at least, they did the right thing.

Charlambe "Bobby" Boutris is finding out right now what life as a whistleblower is like. In 1998, the Federal Aviation Administration (FAA) hired him, and an important part of his job was to make sure that airlines complied with what are called Airworthiness Directives (ADs for short). These are rules that the FAA makes to ensure the safety of aircraft, and detail such things as regular fuselage inspections, especially for older planes.

You'd think nothing much could go wrong with the fuselage compared to moving parts like the engine and so on, but think again. If you've ever been on a jet aircraft and looked through a window with a view over the wing, you have probably noticed that the wingtip wiggles up and down several inches during air turbulence. That is perfectly normal, and designed into the way the plane works. If the wing was built solidly enough not to wiggle at all, it would make the plane so heavy that it couldn't get off the ground.

But if you've ever bent a paper clip back and forth until it breaks, you know about a thing called metal fatigue. And not only the wing, but all stress-bearing parts of the fuselage experience tiny movements that over time, can cause metal fatigue and cracks. Most of the time these cracks are small and don't spread. But in 1988, they were responsible for one of the most spectacular airline accidents in aviation history.

Passengers in the first-class section of an Aloha Airlines flight over Maui were astonished to see the roof of the plane pop off and rip away in the violent decompression, taking a flight attendant with it. The pilot, not even fully aware of what happened, quickly adapted to the altered flying characteristics of his plane and safely landed at a nearby airport. The attendant was the only fatality, but clearly, airlines did not want to take the chance of this kind of thing happening again. Investigation showed that the plane, which was one of the oldest in Aloha's fleet, had developed fatigue cracks that had spread to cause the whole top section of the fuselage to fly off.

For this and other very good reasons, the FAA requires air carriers to inspect their fleets for fatigue cracks on a regular basis. Now, these cracks are a statistical thing, like mortality rates. It's hard to predict whether a given plane will develop a crack at a given place by a given time, but the inspections are timed so that on average, any cracks can be caught and repaired well before they become dangerous. But the system works only if you keep to the schedule.

Well, it appears that Southwest Airlines didn't keep to the inspection schedule. In testimony before Congress on April 4, Inspector Boutris told the story of how he found numerous cases in which inspection records were either too mixed up to tell whether the inspections had been done, or showed definitely that planes had gone as long as 30 months past the time when ADs specified they had to be pulled out of service to be inspected. It's illegal to fly a plane in revenue service if it's behind in certain kinds of inspections.

What made matters worse was that when Boutris asked permission from his FAA supervisor to issue a letter of investigation to Southwest in 2007, the supervisor told him to tone it down to a letter of concern, which does not carry the same impact. Eventually, in late March of 2007, Southwest did finish up the late inspections, but only after some airplanes had gone months or years without them. The FAA has announced its intention to fine Southwest ten million dollars for flying the uninspected planes, at least one of which was found to have fatigue cracks after inspections were finally performed.

On a scale of "who cares?" to "stick it to 'em," you can identify two extremes of how one can view this story. If you take the side of Southwest Airlines, you can point out that besides being one of the most profitable airlines in the business, they have never had a catastrophic accident in which more than one person was killed. And that incident, when a ground crew member was pulled into an engine, was due to pilot error, not mechanical failure. True, they didn't follow all the rules, but no harm was done—none of their planes popped their tops like the Aloha Airlines flight did.

On the other extreme, you can say that you keep good safety records like that by following the rules, even if it means grounding a large fraction of your fleet to make overdue inspections. The attitude of Boutris' supervisor appears to be one of "don't rock the boat," which might indicate that he was more concerned with how Southwest Airlines would fare than he was worried about the safety of the flying public, despite the fact that he worked for the government. That indicates systemic organizational problems both within the FAA and Southwest Airlines.

Back in high school, I attended Explorer Scout meetings that were held in the basement of a telephone exchange building. On the wall of the break room was a brass plaque, as I recall, and its words went something like this: "No service is so urgent or no business need is so critical that we fail to perform our work safely." Back then, Ma Bell had a guaranteed monopolistic income, and could afford to make safety priority number one. But I thought it was a great motto at the time, no matter what the business was or how it was doing financially. And I still do. I hope Southwest Airlines agrees with me, not just in words, but in actions as well.

Sources: A video of Mr. Boutris' opening statement before a Congressional committee investigating this matter can be viewed at A CNN article on the Southwest Airlines actions and the FAA's response is at The Wikipedia article on Aloha Airlines has a brief description of the 1988 accident.


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  2. actually the one person SW killed was a kid in a gas station in Burbank when the plane overran the runway.

    the mechanic that was ingested was a continental plane.