Committee investigation report: aviation safety oversight

tags
Regulatory Capture Boeing

Notes

I. Executive Summary

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Chairman Wicker sent seven letters, which included thirty specific requests for information to the FAA. To date more than half of the requested information remains unanswered or incomplete.

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committee staff were permitted to interview less than half of the employees requested.

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FAA senior managers have not been held accountable for failure

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repeated findings of deficiencies over several decades.

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FAA continues to retaliate against whistleblowers

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failed to produce relevant documents requested by Chairman Wicker as required by the U.S. Constitution

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FAA repeatedly permitted Southwest Airlines to continue operating dozens of aircraft in an unknown airworthiness condition

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Boeing inappropriately influenced FAA human factor simulator testing of pilot reaction times

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FAA senior leaders may have obstructed

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II. Overview

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weeks after the second of two tragic crashes of Boeing 737 MAX aircraft, Committee staff began receiving information from whistleblowers

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fifty-seven whistleblowers.

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“FAA’s official responses to Congress appear to have been misleading

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evidence corroborated and firmly supports the vast majority of whistleblower allegations.

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Investigation

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Training

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Training content and quality have diminished over time.

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Southwest Airlines

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persistent oversight concerns regarding Southwest Airlines.

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Southwest purchased eighty-eight aircraft from foreign manufactures and put them into service after issuing airworthiness certificates that were predicated on deficient information.

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FAA managers failed to support the frontline inspectors and enforce regulations, clearly favoring the airline.

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Oversight

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FAA inspectors found non-compliant safety issues and attempted to hold operators accountable. FAA managers often refused to support compliance or enforcement actions, and in some cases they appeared to retaliate against inspectors for doing so.

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safety concerns were communicated and documented prior to several fatal crashes.

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Perceived Favoritism of Operators by Management

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FAA management favors operators and does not support frontline inspectors

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communications between FAA managers and operators which clearly supported the perception of “coziness.”

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managers overruled inspectors on issues that were clear violations of regulations. When inspectors pushed back, they were investigated and in some cases reassigned.

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former FAA senior managers who left the agency to work in the private sector and directly interact with prior FAA supervisors and subordinates in their new positions.

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Aviation Safety Action Program

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dozens of cases submitted by whistleblowers that were clearly not admissible to the ASAP program. Despite their articulation of exclusionary criteria, FAA inspectors including ASAP managers, were pressured and coerced by FAA managers to accept the events into ASAP.

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operators have intentionally misled the FAA and obscured relevant information

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Often times, the operator was the source of the complaints prompting investigation, and in others, they demanded FAA management remove the inspector.

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The 737 MAX

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factors such as insufficient training and coziness could have contributed to the troubled certification.

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Boeing’s assumed reaction time of four seconds is unrealistic and found actual pilot reaction times were as much as four times the assumed time.

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at least one official FAA recertification test event was improperly influenced by Boeing.

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Audit and Evaluation

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AAE does not necessarily conduct independent, objective, or impartial investigations and evaluations.

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AAE often also fails to independently investigate waste, fraud, abuse, or mismanagement.

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While it is common for such a report to be received thirty to sixty days after its due date, one year late is inexcusable.

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Legislation

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IV. Findings

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Senior managers in FAA Flight Standards may lack technical knowledge and experience to effectively lead aviation safety regulatory oversight programs.

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no one interviewed could confirm whether the work stoppage asserted by then Acting Administrator Elwell actually took place.

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FAA continues to retaliate against whistleblowers

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FAA conduct of investigations appear to be inconsistent, lack objectivity and diligence while providing opportunity for abuse and retaliation.

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During 737 MAX recertification testing, a Boeing employee inappropriately influenced FAA human factor simulator testing

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FAA Aircraft Certification Office (ACO) test pilots were complicit in skewing human factor simulator testing

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DOT OGC improperly redacted information in produced documents,

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FAA senior leaders may have obstructed

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Operators intentionally file Aviation Safety Action Program (ASAP) reports which do not meet the requirements of the ASAP program.

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FAA management is complicit in accepting ASAP events which are not eligible

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FAA management is reluctant in many cases to listen to inspectors and support requested compliance and enforcement actions.

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FAA senior managers have not been held accountable for failure to develop and deliver adequate training in Flight Standards despite repeated findings of deficiencies over several decades.

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FAA repeatedly permitted Southwest Airlines to continue operating dozens of aircraft in an unknown airworthiness condition for several years.

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Southwest Airlines successfully exerts improper influence on the FAA

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FAA appears to select managers in the Southwest Airlines Certificate Management Office (CMO) who lack reasonable experience and do not provide effective regulatory compliance or enforcement.

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FAA managers undermine Aviation Safety Inspectors and in some cases retaliate against them

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V. Introduction

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DOT OGC staff has refused to provide the information, stating it is not their responsibility to provide detailed accounting for their document productions.

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The level of cooperation by the FAA and DOT has been unacceptable and at times has bordered on obstructive.

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A. The Federal Aviation Administration

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B. History of Safety Concerns in the FAA

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Government Accountability Office

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Fundamental concerns about the quality of oversight, many of which are rooted in the inadequate level of training for key safety oversight positions within the FAA, go back as far as 1989.

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approximately half of FAA’s safety inspectors think that they have the technical knowledge required to effectively do their jobs.

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Department of Transportation Office of Inspector General

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Southwest notified the FAA of the violation the day after it was discovered, but the FAA allowed the airline to continue operating the affected aircraft

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in total, the aircraft flew in violation of the AD for up to nine months, carrying over six million passengers. When inspectors finally inspected the aircraft, they found significant, dangerous fuselage cracks on five of the planes.

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FAA had an “overly collaborative” relationship with Southwest Airlines

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ATOS marked a shift away from inspection-based safety systems toward data-driven ones.

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multiple missed ATOS inspections had allowed AD compliance issues to go undetected for years,

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weaknesses in FAA’s processes for internal reviews and in its protections for whistleblowers.

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National Transportation Safety Board

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reminding the FAA that, instead of the carrier’s responsibility, it is the FAA’s responsibility to identify systemic safety problems at a carrier and to ensure that these problems are resolved. The recommendation was closed in 2009 and classified as an “unacceptable response” from the FAA.

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C. Whistleblowers

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Culture of Retaliation

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FAA Security warned her that the FAA was displeased with her findings. Three months later, Diefenderfer was forcibly reassigned to another office. After complaining to the U.S. Office of Special Counsel (OSC), an investigative team was sent to the Seattle FSDO. Upon the completion of that investigation, Diefenderfer was reinstated

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Alaska Airlines Flight 261 crashed into the Pacific Ocean about 2.7 miles north of Anacapa Island, California, killing eighty-eight people.

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Maintenance deficiencies including fraudulent documents were among the safety concerns disclosed by Ms. Diefenderfer. Committee Investigators understand Ms. Diefenderfer successfully negotiated a large settlement agreement with the FAA as a result of her complaint before the Merit Systems Protection Board.

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there were a number of serious maintenance violations occurring at Southwest Airlines, and that the FAA, in effect, looked the other way.

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FAA Hotline complaint, later attributed to a Southwest Airlines employee, which resulted in a whistleblower being removed from his oversight duties

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D. FAA Aviation Safety and Whistleblower Investigation Office

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many FAA employees, including managers and human resource officials, do not clearly understand what constitutes whistleblowing or how to properly treat employees that make protected disclosures.

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one of AAE’s own investigators admitted to a colleague that they had been going after whistleblowers and boasted about how many had been fired as a result.

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Finding: The Aviation Safety and Whistleblower Investigation Office enacted as part of the 2012 FAA Modernization and Reform Act was not fully implemented and remains insufficient.

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VI. Committee Investigation

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B. Concerns Surrounding the FAA’s Responses

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FAA responses to Committee inquiries often conflicted with allegations supported by evidence from whistleblowers, FAA internal communications, and findings of the DOT OIG and the Office of Special Counsel (OSC).

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Assertions made in letters by then Acting Administrator Elwell were contradicted by internal FAA reports of investigation he included with his response.

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OSC found that of the twenty-two ASIs identified in the whistleblower complaint, sixteen of them had not completed required formal training classes.

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These findings are very serious and could have far-ranging ramifications regarding the type ratings of hundreds of certificate holders. Because it involves AEG ASI’s, the proverbial “tip of the pyramid” for pilot qualification and certification, every type rating issued by an unqualified ASI potentially creates another potentially unqualified pilot, including other ASIs, and the most senior pilots and check pilots at FAA-certificated operators.

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FAA staff interviews revealed inconsistencies on how or if this directive was communicated. One manager stated that he directed the work stoppage and it was his idea.

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no confirmation of any work stoppage has been provided to the Committee.

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representations by the FAA were, in fact, misleading at the very least. Whistleblowers contend actions by FAA senior officials were designed to cover up their incompetence.

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FAA Conduct of Investigations

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National Transportation Safety Board Investigations

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when Boeing ran the flight test in which they tested the MCAS, they did not have any other alarms or alerts going off that could have theoretically been going off in a situation that led to an MCAS activation.

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VII. Whistleblower Disclosures

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At least one investigator tasked with investigating misconduct and whistleblower retaliation was not sure what constituted a protected disclosure for whistleblowing.

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FAA managers initiated what appeared to be a retaliatory management inquiry against a whistleblower and received support from front line and supervisory human resource personnel

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several lines of business and multiple levels of management believed the whistleblower was not permitted to “go outside” the FAA with a safety disclosure

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senior managers interviewed were openly dismissive

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persistent culture of whistleblower retaliation in the FAA.

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A. Boeing and 737 MAX

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coziness between the FAA and Boeing,

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Boeing intentionally misled FAA certification efforts and downplayed the significance of MCAS.

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why they were only transmitted to DOT the day before, when Boeing had discovered the messages “months ago.”

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“jedi mind trick these people into buying some airplanes.”

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requesting that all reference to MCAS be removed from the Flight Crew Operations Manual and training,

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jedi mind tricking regulators into accepting the training that I got accepted by the FAA

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removing differences table from the 737 MAX FSB report

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These emails show Mark Forkner attempting to get the MCAS system removed from all pilot training as well as the Flight Crew Operations Manual (FCOM) well after he had discovered that the MCAS system was not behaving correctly.

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MCAS Training and Human Factors

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confirmed the existence of MCAS references in early Boeing documentation for FCOM that were later removed.

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FAA senior management was complicit in determining the 737 MAX training certification level prior to any evaluation.

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official directed the result of the 737 MAX training to be no greater than Level B prior to any testing

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Boeing considers this maneuver a memory item and assumes a pilot can recognize and act upon the situation from memory alone in four seconds.

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The three flight crews presented with this scenario responded with reaction times to identify the problem in seven, nine, and eleven seconds. The time to complete the corrective action and correct the situation was forty-nine, fifty-three, and sixty-two seconds.

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Boeing officials were present for the testing and encouraged the test pilots to “remember, get right on that pickle switch” immediately prior to the exercise,

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the FAA ACO test pilot reacted in approximately four seconds in accordance with the assumed reaction time. The AEG pilot reacted in approximately sixteen seconds, or four times longer

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DOT OGC provided no additional explanation as to why the second employee was not permitted to answer the same questions as the first employee.

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Boeing officials inappropriately coached test pilots in the MCAS simulator testing contrary to testing protocol.

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Dissuading FAA Employees from Contributing to OIG 737 MAX Investigation

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Flight Standardization Board

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B. Abuse of the FAA’s Aviation Safety Action Program

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In 2015, the FAA adopted a “Compliance Philosophy,” which relies upon the self-disclosure of errors and focuses on ensuring compliance with regulations instead of immediately taking enforcement actions.

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ASAP allows pilots to report errors without receiving disciplinary enforcement actions

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widespread abuse of the ASAP system, often supported by FAA managers.

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often refuse to hold offending parties accountable to keep relations with the carriers favorable.

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sensors were taped in place for calibration purposes, but maintenance personnel neglected to remove the tape afterwards.

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Compliance Philosophy

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agency ignores laws and regulations, to the detriment of public safety in order to accommodate the compliance philosophy.

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frontline employees are overly aggressive in their application of laws and regulations, as well as excessively confrontational with the carrier.

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ASIs told Committee staff that they have no latitude on this subject. They stated that if an ASI did what these managers suggest is allowable, they could be found to be derelict in their duties.

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The interviews of these managers raise concerns about their knowledge and ability to lead a highly technical regulatory organization.

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The FAA’s Relationship with Regulated Entities

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employees from several airlines claimed ASAP was “sold” to them as a “get out of jail free card.”

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representatives of airlines routinely contact FAA managers when they disagree with the decisions of frontline inspectors

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Elwell and Southwest Airlines senior executives have close personal relationships and communicate frequently.

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perceived relationship Southwest senior executives and Mr. Elwell is well known in the company and has been invoked periodically to get favorable treatment from the local FAA CMO.

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systemic FAA management intervention with FAA Inspectors to favor Southwest Airlines

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C. Atlas Air

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FAA was not well positioned to determine how often pilots have enough experience in air carrier training or flying skills.

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D. Allegations of Misconduct at the Honolulu Flight Standards District Office

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FAA managers too frequently overrode the recommendations of inspectors,

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at least one manager issued improper check ride certifications.

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E. Improper Training and Certification

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F. Ineffective Safety Oversight of Southwest Airlines

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VIII. Conclusion

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FAA policies appear to have reduced effective oversight by abdicating responsibilities to the carriers.

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IX. Recommendations

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