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Authors: William J. McGee

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Alaska: An Airline Without an FAA

After Earlene Shaw lost her husband, Don, in the crash of Alaska Airlines Flight 261 in January 2000, she and other next of kin began an intense journey to uncover the truth. The Shaws, who live in Enumclaw, Washington, and have relatives in Alaska, had been frequent flyers on the Seattle-based carrier, with about 185,000 miles in their account. But when the systemic causes of the tragedy came to light, Earlene was stunned by Alaska's actions, and the FAA's as well. She sums it up: “I must say that to this day the FAA shares a great deal of responsibility for that accident—along with Alaska Airlines and its maintenance. There's a lot of anger and disappointment that a government agency did such a poor job.”

Flight 261 was a particularly harrowing accident. Those on board were terrorized in their final moments after the crew lost control of the McDonnell Douglas MD-83 and the plane dove vertically into the Pacific Ocean off the California coast, killing all eighty-eight on board. The cause? Insufficient lubrication of the jackscrew that held together the critical horizontal stabilizer assembly, thereby preventing the pilots from controlling the aircraft's ability to ascend and descend. But the unusually lengthy NTSB accident report includes detailed discussions of a range of Alaska and FAA deficiencies. As one former FAA inspector told me: “That jackscrew was the last piece of that accident.”

The real problems had begun long before that night. Two months after the accident, the
Seattle Times
published a letter to the airline's CEO from sixty-four Alaska mechanics noting “our pleadings have gone unheeded.” The letter stated that Robert Falla, manager of base maintenance in Seattle, “pressured, threatened, and intimidated” mechanics: “He has directed us to do things specifically contradicting [Federal Aviation Regulations], not the least of which is his persistent demand that we put unserviceable parts back on the aircraft. . . .” By March 2000 the FBI had opened a criminal probe into Alaska's maintenance program, since falsification of federal records is a crime (the case faded away quietly under Attorney General John Ashcroft's watch).

Prior to assuming the presidency of the Aircraft Mechanics Fraternal Association, Louie Key spent thirty-two years as a mechanic for Alaska—including the dark days before and after the fatal crash of Flight 261. He describes Alaska's corporate culture at that time as obsessively focused on Wall Street's industry measurement of Cost per Available Seat Mile: “It was absolutely frustrating. Everything was about cutting costs. It was ‘We've got to get CASM down.' Unfortunately, it had consequences.”

As part of the accident investigation team, Key was on the recovery vessel that retrieved the jackscrew, which the NTSB determined had failed in-flight due to “excessive wear” caused by a lack of lubrication. Key notes that the fatal part was documented as having worn to the “max allowable limit” yet still
should have
made it to the next inspection, though it obviously didn't. He explains a crucial factor was the failure to measure the rate of wear; instead it was just pass-or-fail until the next inspection. When I asked Key if the FAA was lax in its oversight, he responded, “Absolutely.”

A key player in this drama was Mary Rose Diefenderfer, an FAA veteran who in 1997 was named principal operations inspector for Alaska, until her complaints about the carrier's practices caused her to be “pushed out.” She says, “That accident was a maintenance accident but in my view it was a flight operations accident, too. They were test-flying the planes with passengers on board.”

Her eventual court case has filled filing cabinets. Diefenderfer's tale provides harrowing insights into not just how an airline's safety culture can be compromised, but also how the FAA itself can flagrantly fail in its oversight duties. She reported multiple violations on the part of Alaska, including a well-publicized case of the carrier's management using vodka to deice an airplane on a gate in Russia. A clever example of Yankee ingenuity? Hardly—the aircraft's auxiliary power unit was running and there were passengers on board, so only luck prevented an alcohol-fueled fire. Among her other charges were that Alaska management falsified training records, including piloting records for senior executives, and pilots were punished with time off for writing up legitimate maintenance items. In addition, low-level FAA officials were inappropriately spending time with the airline's managers, and complaints were contained within the Seattle office with the admonishment “We don't want Washington to hear about any problems.” Even an FAA team later assigned to investigate this chaos confirmed that maintenance work cards were being “modified or deleted.”

In return, Diefenderfer was demoted, ostracized, and humiliated. She says she was confined to a cubicle and ordered to report to a supervisor who frightened her. Within two months of her being reassigned, all outstanding items she had logged on Alaska were suddenly “cleaned up.” She had been removed from overseeing the carrier by the time Flight 261 crashed; I asked her if the tragedy surprised her and she said, “I wasn't surprised by it, but I cried.” She eventually received vindication in 2011, when the FAA quietly settled the lawsuit she had filed.

Such lessons were not lost on the next of kin from Flight 261, who fought for years in the courts and the press to uncover the truth. As Shaw points out, “The safety part of the FAA's mission has become very blurred. Everyone said the FAA and Alaska were in bed together.” But her high-profile mission undoubtedly put additional pressure on both organizations; she recalls, “During my very angry years I said I would drop the lawsuit if [former Alaska CEO John] Kelly or one of his relatives flew on every flight. It sounded like a childish threat, but I was serious.”

Meanwhile, things certainly changed at Alaska after the crash of Flight 261. A small army of feds scrutinized every aspect of the company's maintenance operation. Soon after, Alaska closed its C-check maintenance facility in Seattle and consolidated it in Oakland; then the Oakland facility was shut down. By 2005, some 92 percent of Alaska's maintenance was being outsourced. And as with all airlines, the FAA's surveillance of Alaska had shifted, with a greater emphasis on something called ATOS.

Faith in ATOS

It's called the Air Transportation Oversight System. But for years FAA inspectors have referred to the ATOS program as “A Ton Of Shit.” The anger stems from a long-standing criticism: much of what is entered—or
not
entered—into ATOS is self-reported by airlines and/or is not validated. The NTSB's Haueter puts it like this: “FAA has changed its mind-set. It's all about data analysis. And I think it's garbage in and garbage out.”

Even Congress worried that ATOS was becoming a replacement for the historic inspection procedure and led to an overreliance on an automated system with very little personnel input and hands-on management of the system.
4
Experts stress that data alone are not enough because data have to be validated, and that's why inspections are conducted.
5

But ATOS has a defender in the Flight Safety Foundation's Voss: “I believe in my soul [a risk-based approach] is fundamentally correct. And ATOS is correct, too.” The trick is melding electronic surveillance with traditional inspections; he says, “I think things like ATOS give you a broader picture. And your visits will produce better results.”

There's a saying among FAA inspectors: Airworthiness Directives are written in blood, because ADs tend to originate from fatal accidents rather than routine inspections. If ATOS were as robust a program as was touted, then it would be generating more preemptive regulations. One congressman referred to ATOS as “a computer system to monitor a computer system.” The real concern is what about the data that we now know are
not
being input?

“ATOS is a sham,” says whistle-blower Gabe Bruno. “It's for their internal empire.” This is not your standard employee carping; as the manager of the FSDO in Orlando, Bruno was intimately involved in a key aspect of ATOS development. In the wake of the ValuJet debacle in 1996, FAA officials claimed ATOS would be a way to provide greater surveillance of newer low-cost carriers, yet when it was conceived in 1998 only the major legacy airlines were included in the program, not the start-ups the system was designed around. Bruno began fighting for the inclusion of ValuJet (now AirTran) in ATOS, and the resistance he met from his superiors eventually destroyed his career: “That was the start of my walk into whistle-blowerdom.”

Indeed, the
Seattle Times
reported in 2001 that Nick Lacey, who headed the FAA's Flight Standards Division, was removed from his post overseeing ATOS, because of “its failure to detect serious maintenance problems at Alaska Airlines before the crash of Flight 261.” Bruno maintains little has changed, and points to last year's Boeing 737 debacle: “Shouldn't ATOS have captured Southwest's problems before that fuselage ripped open?”

In 2011 I asked Administrator Babbitt this, and he replied: “The most recent [Southwest] breach was not corrosion or metal fatigue, it was structural [due to its being] an aging aircraft. The airplane had been inspected and signed off. What's important about that breach is the skin ripped—and then stopped. The breach was contained and everything worked fine.” On the topic of outsourcing maintenance, Babbitt said, “The good news is technology is our friend here. We probably do less monitoring on-site because of it.”

Bruno's real troubles began when he uncovered systemic problems with FAA maintenance licensing in Florida, home to dozens of flight schools. He initiated retesting programs, and many “mechanics” could not pass the second exam; thirty-three of them listed their address as the same post office box in Saudi Arabia. Bruno believes exposing this scandal ended his FAA career. But the frightening coda is that individuals bearing these bogus licenses were not identified and retested for years (the FAA finally announced in 2010 that it would follow up). Meanwhile, news reports documented that one of these mechanics worked for Chalk's Ocean Airways when that carrier suffered a crash in 2005, killing twenty.

The FAA's job is all about determining risk, and that's harder with fewer fatal accident forensics. But some worry that we will go too far. Voss thinks it's all about finding the sweet spot on risk: “Are we going to become as risk-averse as Australia? They see ghosts every time Qantas pushes back late from the gate.”

For Voss, the industry's long-standing policy of not publicly promoting individual carriers' safety records has harmed us all: “We've crippled aviation safety by the gentlemen's agreement, an implicit agreement not to discuss safety. So there is no incentive to improve safety.” He notes how automobile makers have used safety in their marketing and advertising campaigns but warns, “Whoever is the first airline to do this will be a pariah in the industry.”

Meanwhile, FAA oversight remains in question. As Brantley says, “There's an analogy with banking and finance. . . . You have an agency that really does not want to police the industry. They seem to default to the carriers.” He adds, “Yes, there are risks regarding bureaucracy and complacency. But people forget what government is about: doing things we can't do for ourselves. That's the common-good part of this.”

9

Threats to Survival:

Why Many Air Crashes Need Not Be Fatal

APPROACH:
At the end of the runway it's just wide-open field.

COCKPIT UNIDENTIFIED VOICE:
Left throttle, left, left, left, left . . .

COCKPIT UNIDENTIFIED VOICE:
God!

CABIN:
[Sound of impact]

—National Transportation Safety Board accident report, United Airlines Flight 232, Sioux City, Iowa, 1989

Part I: The Most Vulnerable Passengers

Who in America is not familiar with “The Miracle on the Hudson”? When that US Airways Airbus A320 ditched in the freezing waters off Manhattan on January 15, 2009, all 155 people on board managed to evacuate without life-threatening injuries. More and more safety experts believe the happy ending was due to enhanced professionalism and advanced technology, not divine intervention. But if a miracle did occur, it was that ten-month-old Damian Sosa survived the initial impact unhurt.

“We were gliding,” Tess Sosa told me. “It looks to me like we were getting down and I could see the river. And here I was with a lap child. I have a lap child and I don't know what to do. . . . In my mind it was fifty-fifty we were going to die.” As we spoke, she slipped from past tense into present tense, and it was clear she was reliving those terrifying moments. Sosa told of searching for a flight attendant. Her husband and daughter were seated several rows away. And then the passenger next to her—a frequent flyer, a father of five named Jim Whittaker—turned and in “such a professional way” he calmly asked, “May I brace your son for impact?”

Sosa remembers that Whittaker placed Damian in a cradle position, with the man's knee against the seat. She heard the words “Brace for impact.” Then the crash. And suddenly her baby son was being handed back to her, unhurt, and the evacuation commenced. All 155 survivors were far from safe, as ice water rapidly filled the fuselage. But both Sosa children soon were handed onto rafts, and their parents followed. And then a new journey began for Tess Sosa.

“I think it's discriminatory,” she said of the FAA exclusion that requires only human beings over the age of two to be securely restrained on commercial aircraft. “How can you say a five-year-old should be restrained but a two-year-old should not?” She said she became educated the hard way, because she had no idea of the risks of holding a lap child: “It was wrong. But I'm not the only one who is accountable. The airlines need to do something about this, too.”

Sosa didn't know that just one month earlier, in December 2008, a Continental Airlines Boeing 737-500 ran off the left side of Runway 34R while attempting to take off from Denver; as the NTSB noted, “the aircraft was substantially damaged and experienced a post-crash fire.” There were some serious injuries but no fatalities, which was particularly lucky since there were several small children on board.

One mother, Maria Trejos, also didn't know the dangers of lap children. “It's horrible to think I could have been responsible for my child being hurt,” she says. “You're not superhuman.” During the mayhem of enduring the crash and exiting a burning aircraft, her husband, Gabe, held their thirteen-month-old son, Elijah, “like a football.” Although Elijah had a sprained neck and bruises on his back and arms, thankfully he was not seriously hurt. And neither was Maria, who was pregnant at the time and struck in the stomach by a bag falling from an overhead bin, which almost certainly would have hit Elijah.

When I tell her of the many parents who are not aware of the dangers of flying with lap kids, she says, “They wouldn't because they haven't been through it. I wasn't thinking my child could be a projectile and slammed into the cabin. You don't think about g-forces until you're in a situation like this.” None of the Trejos family has flown since the accident, opting to drive from their home in Colorado for visits to Texas.

Sometimes infants survive unscathed from turbulence, incidents, and accidents—and sometimes they do not. But widespread education about the dangers of lap children on airplanes has never taken hold, even though those dangers have been documented for decades. Sosa told me, “This is terrible to say, but maybe if Damian had perished that day something would have changed. . . . The fact that no one died really was a miracle.”

The Deadly Loophole the FAA Won't Close

This loophole has an extremely long history. As far back as 1953, Civil Air Regulations section 40.174 included this language: “A seat and an individual safety belt are required for each passenger and crewmember excluding infants. . . .” Of course, fifty-nine years ago infants were not secured in cars, either, because there were no safety seats; in fact, only a minuscule number of automobiles had safety belts then. But technology and times have changed—except in the twilight zone of a commercial airplane cabin. Every state in the union has a child seat law for American roads, but there is no similar protection for American skies.

For more than twenty years, the NTSB and the FAA have been at odds—sometimes quite vocally—over this issue. In 1990, the NTSB first recommended that restraints should be required for all children under forty inches tall or forty pounds in weight; that same year United Press International reported there was “little doubt” an infant restraint proposal would soon be adopted. It's been twenty-two years, and the FAA still hasn't acted.

This all stems from what is termed the “diversion theory.” As the FAA put it at an NTSB Passenger Safety Forum I attended: “Requiring the use of [restraints] for children under two would significantly increase the price of family air travel for a small targeted population.” In turn, this may cause some families to drive, where the risk of injuries and deaths is statistically much higher. The FAA surmises this will lead to another sixty deaths every ten years. Therefore, due to the law of unintended consequences, the FAA has not required babies to be properly restrained.

While serving on the FAAC I had the chance to meet some of the FAA staffers who espouse the diversion theory, and I found them to be sincere and well-meaning. Their concerns over diverted highway deaths cannot be dismissed out of hand. But fundamentally I disagree with the logic. If buying a ticket for a small child will force some families to drive and therefore endanger their lives, then by extension
any
fare increase would have the same effect, so why limit the argument to two-year-olds? Adults are in danger as well, yet I certainly don't envision a post-deregulation DOT that would dare to ban airline price hikes for fear some passengers will drive.

What's more, the FAA's reasoning is based on old and suspiciously faulty data. The diversion argument was fashioned in the 1990s, before low-fare carriers remade the industry. Questions abound: At what price threshold would some families divert to driving? What about long-haul and over-water routes where driving is not an option? And how certain are we that parents will divert in the first place? As Tess Sosa puts it, “What parent in their right mind would say, ‘I'm not going to pay three hundred and fifty dollars?' You're taking a risk. My belief is this diversion theory is just a smoke screen.”

She is not alone. NTSB chairman Hersman says, “I think the diversion argument is completely spurious. It's a statistical stalemate.” She clearly feels the discussion has ended: “In an industry as safe as aviation, and one that puts such a premium on safety, it's an embarrassment. It's past time. . . . No one who works in safety will tell you that restraint use is not important. . . . I have to really question why we take such an approach with the most vulnerable passengers.”

Once Maria Trejos recovered from the Denver accident, she found fault with the FAA's reasoning as well: “To me, the cost of my child's safety outweighs the cost of the [airline] seat. . . . If the auto industry can [mandate] it, why can't the aviation industry?” She had checked Elijah's child seat as baggage, and when she later learned about the FAA's diversion theory, she felt it was all about money, particularly since many road trips can cost just as much for gas and lodging. Trejos notes that since the airlines charge extra for so many other things, they could find ways to sell seats to infants.

In this age of ancillary revenue, one would expect the airlines to embrace the chance to sell additional seats for babies. In fact, most major carriers do offer discounted tickets for infants on international flights, and Southwest deserves credit for offering such seats on domestic flights. The irony is that in this era of fee-happy airline executives, carriers that decide to rent safety restraints stand to make even more money, but the FAA refuses to change its position.

A Modest Proposal: Ban Lap Kids

Shortly after I was appointed to the FAAC's Safety Subcommittee, I formally recommended that the FAA mandate the use of approved child restraint systems (CRSs) for all passengers under two. I also officially requested the statistics on lap children injuries and deaths on commercial flights. The answer: over the last twenty-five years there have been three infant fatalities that otherwise would have been survivable (those terms
survivable
and
nonsurvivable
can be quite subjective, though here it's clear infants died due to a lack of CRSs). But the shocker was that the FAA was unable to tell us how many lap children have incurred injuries. I was dumbfounded the FAA did not possess these numbers, but we were assured further research would be conducted.

“I'd like to see statistics on how many babies have not become functioning adults because of injuries,” says FAA whistle-blower Kim Farrington. She notes that one major carrier paid millions after an infant flew out of a guardian's arms and hit an overhead bin. She adds, “The FAA is catering to the desires of airline executives.”

After the FAAC asked me to convene a meeting of the nation's experts to further research the topic, we all gathered outside Washington in October 2010: representatives from the FAA, NTSB, DOT, Air Transport Association, Boeing, the Association of Flight Attendants, and the airlines. I opened by asking if
any
experts believe a lap child is as safe as, or safer than, a child in a CRS. And the answer was a unanimous no. This is an issue without pending studies, suspect science, or warring camps. Science has proven that lap children are at greater risk of injury and death, not only during accidents but even during routine turbulence. This discussion begins and ends with the physics, and the physics is irrefutable. As the FAA itself states on its site: “Did you know the safest place for your little one during turbulence or an emergency is in an approved child restraint system or device, not on your lap?” So the “debate” is not over safety but over economics and unintended consequences. Yet there are other factors: the whisper campaign that focuses on FAA indifference and the airlines' concern that charging for infant seats will turn away customers.

More so than any other aviation safety topic I research, more so than outsourced maintenance shops in El Salvador or sleeping air traffic controllers, the issue of unrestrained infants invokes the mantra of the FAA being the “Tombstone Agency.” A longtime airline official says simply: “Not enough babies have died. They [the FAA] deserve being called a tombstone agency.”

One of Hersman's predecessors as chairman of the NTSB, James Hall, believes there's a political component: “It's clear that in government very little attention is paid to those with no voice—the elderly, those with low incomes, and children.”

To its credit, the FAA has attempted to heighten awareness; on Thanksgiving weekend 2010, the agency's home page carried warnings about lap kids, and the FAA has begun utilizing social media and parenting sites. Former administrator Babbitt told me, “We've done a lot of research. We're reminding people. We're seeing a lot of compliance. . . . And we're continuing to collect data.” He added that these data are “mixed.” Meanwhile, I flew on dozens of flights to research this book, and in some cabins I counted three, four, or even more lap kids.

The Arguments Against Securing Infants

I've written about this issue extensively, and each time I do I'm subjected to a higher than usual amount of nasty (and uninformed) blog comments. It strikes me how often readers respond in the vein of “If it's so dangerous, why do the airlines and the FAA allow it?” Why indeed.

But there's no shame in being unaware of the dangers. Even NTSB chairman Hersman advises, “I was one of those parents who flew with a child on my lap. Then I came to the Safety Board and I learned. . . . People look to the government for laws and guidance.” Hersman points out that compliance with state child restraint laws in automobiles exceeds 95 percent, even where adult compliance lags.

After my last column for USAToday.com I wrote a follow-up responding to the standard arguments against mandating child restraints. In addition to diversion, there are four other claims that surface time and again.

The “Superman” Argument

It's all about the g-forces, and no one this side of the planet Krypton can argue with physics. The most loving parent or caregiver in the world can't hold on to even the lightest infant in an aircraft traveling at four-fifths the speed of sound. What's more, the weight of the adult can crush a baby held either inside or outside the adult's seat belt. This is the argument that isn't an argument; anyone who claims a child is safer in their arms is dead wrong.

The “We're All Gonna Die Anyway” Argument

Why worry about child restraint systems? Or air bags? Or even seat belts? If anything goes wrong on an airline flight, it's all or nothing—and no one will walk away. This old and tired argument has always been wrong, but in recent years it's become
very
wrong. Also, CRSs prevent injuries and deaths under conditions that pose much less serious threats to adults, such as severe turbulence.

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