Records: Southwest Airlines flew 'unsafe' planes
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Why is it you almost never see a Southwest pilot do a walk around? How does the FAA allow them to only do a walk around with a change in the cockpit crew and leave the others to the rampers who are "trained" to spot defects?
The airplane could go for six or more landings without a pilot on the outside to look for problems.
The airplane could go for six or more landings without a pilot on the outside to look for problems.
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http://www.star-telegram.com/news/story/527869.html
Posted on Thu, Mar. 13, 2008
Southwest Airlines finds cracks in 4 grounded planes
BY: TREBOR BANSTETTER
[email protected]\
Southwest Airlines discovered fuselage cracks on four of the airplanes that it grounded for inspections Wednesday, the airline said today.
The Dallas-based carrier took 38 Boeing 737 planes out of service to check for cracks in the exterior above and below passenger windows. It also checked five planes that were already parked for maintenance, and one plane that had recently been retired from the fleet.
A spokeswoman said that 34 of the planes passed the inspections and were returned to service today.
"Four were held for surface repairs, and we expect to have them back in service by the weekend," said spokeswoman Brandy King.
Southwest parked the jets in the wake of a congressional investigation into its airplane inspections. The FAA proposed a record $10.2 million fine last week against the carrier for failing to ground dozens of jets last year after it discovered they had not been examined for potentially dangerous fuselage cracks.
Congress is also investigating whether some FAA officials allowed the airlines to keep the planes in service for up to 10 days despite the inspection lapse.
The airline said Tuesday that it suspended three of its employees in the wake of an internal investigation, and is auditing its inspection records. That review unocovered an additional inspection lapse, which prompted Wednesday’s decision to ground the planes.
Posted on Thu, Mar. 13, 2008
Southwest Airlines finds cracks in 4 grounded planes
BY: TREBOR BANSTETTER
[email protected]\
Southwest Airlines discovered fuselage cracks on four of the airplanes that it grounded for inspections Wednesday, the airline said today.
The Dallas-based carrier took 38 Boeing 737 planes out of service to check for cracks in the exterior above and below passenger windows. It also checked five planes that were already parked for maintenance, and one plane that had recently been retired from the fleet.
A spokeswoman said that 34 of the planes passed the inspections and were returned to service today.
"Four were held for surface repairs, and we expect to have them back in service by the weekend," said spokeswoman Brandy King.
Southwest parked the jets in the wake of a congressional investigation into its airplane inspections. The FAA proposed a record $10.2 million fine last week against the carrier for failing to ground dozens of jets last year after it discovered they had not been examined for potentially dangerous fuselage cracks.
Congress is also investigating whether some FAA officials allowed the airlines to keep the planes in service for up to 10 days despite the inspection lapse.
The airline said Tuesday that it suspended three of its employees in the wake of an internal investigation, and is auditing its inspection records. That review unocovered an additional inspection lapse, which prompted Wednesday’s decision to ground the planes.
"Congress is also investigating whether some FAA officials allowed the airlines to keep the planes in service for up to 10 days despite the inspection lapse."
how can they interfere? extensions for AD compliance or maintenance or waivers are legally issued by the FAA all the time--- the FAA IS the law
will congress posse change something or is this just hand waving along the same vein as the steroid/ baseball nonsense ?
how can they interfere? extensions for AD compliance or maintenance or waivers are legally issued by the FAA all the time--- the FAA IS the law
will congress posse change something or is this just hand waving along the same vein as the steroid/ baseball nonsense ?
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From AVweb today
Southwest Airlines FAA Oversight Blowback
Fallout from the recent Southwest Airlines maintenance oversight fiasco that led to the airline's temporary grounding of 40 aircraft has resurrected accusations that the FAA is getting too cozy with the airlines. The FAA is quick to point out that the aircraft it oversees help compose one of the safest aviation systems in the world. Critics contend that the airlines the FAA is meant to regulate are too often referred to by the agency as customers, indicating an inappropriate relationship maintained by the regulating agency. For Southwest, reports suggest that the FAA inspector assigned to the airline knew of but did not report the shortcomings that ultimately prompted the agency to levy a record $10.2 million fine against the airline, and later led the airline to ground scores of aircraft. It may be the contradictions inherent in that series of events that have now led congressional investigators to call on airline and FAA employees with knowledge of substandard oversight practices to contact them. But it's not that simple. Today, some airline maintenance is performed overseas without oversight of any full-time FAA certified mechanics.
And so, the Transportation Committee is expected to include discussion of those practices during hearings regarding Southwest's maintenance concerns on April 3. Congress may also address regulating the way inspectors are assigned to airlines -- paying closer attention to exactly how the relationship is fostered.
Southwest Airlines FAA Oversight Blowback
Fallout from the recent Southwest Airlines maintenance oversight fiasco that led to the airline's temporary grounding of 40 aircraft has resurrected accusations that the FAA is getting too cozy with the airlines. The FAA is quick to point out that the aircraft it oversees help compose one of the safest aviation systems in the world. Critics contend that the airlines the FAA is meant to regulate are too often referred to by the agency as customers, indicating an inappropriate relationship maintained by the regulating agency. For Southwest, reports suggest that the FAA inspector assigned to the airline knew of but did not report the shortcomings that ultimately prompted the agency to levy a record $10.2 million fine against the airline, and later led the airline to ground scores of aircraft. It may be the contradictions inherent in that series of events that have now led congressional investigators to call on airline and FAA employees with knowledge of substandard oversight practices to contact them. But it's not that simple. Today, some airline maintenance is performed overseas without oversight of any full-time FAA certified mechanics.
And so, the Transportation Committee is expected to include discussion of those practices during hearings regarding Southwest's maintenance concerns on April 3. Congress may also address regulating the way inspectors are assigned to airlines -- paying closer attention to exactly how the relationship is fostered.
What I now find interesting is almost a year later after the whole fleet had been “inspected” now we have these four that don’t pass
I suspect that what didn't pass was more like that the normal cracking progressed to outside of limits and now has to be repaired. You don't throw away cracked airplanes you repair them when the cracks begin to link up or thereabouts.
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Read the CVA transcript from both flights
Everything was just normal... Next thing you know they were heading to their deaths. The primary cause was that no one realised that this control system was a single point of failure. Even by following proper maintenance (at the time) it was not enough to prevent the wear and tear on the jack screw. The deal was simple: The FAA will not force a systems redesign so long as the airplanes get extra inspections. The inspection intervals were made very short.
I must agree that one of the safest airlines is now being punished even though there were no accidents related to this issue. The problem here is that a systems redesign is truly warranted to avoid the SPOF. However, this cost would be astronomical and would probably just ground the aircraft.
This is why the FAA is jumping up and down. By SWA delaying the inspections then a design defect becomes apparent. They are controlling the design defect by the use of inspections; therefore, this moves the classification of these inspections to critical.
it's a pay me now or pay me later scenario. SWA and the airline industry have decided to withhold dealing with a costly design change in exchange for spreading this expense over the remaining life of the aircraft through short interval inspections. A deal is a deal. SWA broke the deal and now they must pay. The $10 Million is just to get their attention and it most certainly did.
I must agree that one of the safest airlines is now being punished even though there were no accidents related to this issue. The problem here is that a systems redesign is truly warranted to avoid the SPOF. However, this cost would be astronomical and would probably just ground the aircraft.
This is why the FAA is jumping up and down. By SWA delaying the inspections then a design defect becomes apparent. They are controlling the design defect by the use of inspections; therefore, this moves the classification of these inspections to critical.
it's a pay me now or pay me later scenario. SWA and the airline industry have decided to withhold dealing with a costly design change in exchange for spreading this expense over the remaining life of the aircraft through short interval inspections. A deal is a deal. SWA broke the deal and now they must pay. The $10 Million is just to get their attention and it most certainly did.
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Some question Federal Aviation Administration's oversight strategy
Southwest incident exposed flaws with approach that relies on airlines, critics say
Nearly 12 years after the tragic ValuJet crash that forced regulators to reinvent their approach to airline safety, the Federal Aviation Administration faces new questions about whether its method of policing the airlines is working.
The FAA spent the past week answering for a regional supervisor's decision to allow Southwest Airlines to keep flying jets that needed crucial safety inspections.
Southwest has turned contrite in recent days, with apologies to customers and a pledge to follow the letter of the law.
But inspectors say they've also faced opposition to getting tough with other airlines, an allegation echoed by a congressional committee that insists the FAA has gotten cozy with carriers. The FAA has taken a partnership approach to regulation, in which the agency relies on the airlines to self-disclose safety risks and de-emphasizes hands-on inspections.
"We're depending way too much on the airlines," said Linda Goodrich, regional vice president of the Professional Aviation Safety Specialists, the inspectors' union.
"There's a point at which you get diminishing returns," she said. "From our perspective, that's where we're at."
In North Texas, for instance, inspectors chafed four years ago when the FAA decided to settle about 60 regulatory violations with American Airlines for $2.5 million, about $5 million less than the book value of the penalties. More recently, FAA inspectors overseeing Southwest and Northwest airlines said they were removed from their jobs after trying to investigate serious maintenance problems at the carriers, allegations mostly supported by independent investigators.
1996 crash
The FAA began moving away from its confrontational, cop-on-the-beat approach to policing the airlines after the 1996 ValuJet crash in Florida that killed 110 people.
Even then, the FAA took blame for going easy on airlines in order to promote commercial aviation.
The FAA was faulted for poor oversight of ValuJet, an airline that grew quickly and farmed out almost all of its maintenance. The agency admitted that it didn't have enough inspectors to monitor the airline. It later prohibited the shipment of oxygen generators in cargo holds, where a fire started that brought down the plane.
"In a system as large as ours, you can't inspect every individual part or flight or airplane," said Andrew Steinberg, a former U.S. assistant secretary of transportation who left the agency this year.
"Clearly you need some spot-checking, like there are traffic cops on the highways," he said. "But the basic framework for safety is to make sure the airlines' programs are in place to ensure safety."
The post-ValuJet era introduced big changes.
FAA inspectors now file fewer "enforcements," as investigations bearing sanctions are known. Instead, they're supposed to focus on the most serious risks - ones that cause accidents - by analyzing data provided by the airlines.
The airlines are encouraged to self-report regulatory violations. By doing so, the companies can avoid fines. But they also learn lessons that prevent accidents, FAA officials said.
Peggy Gilligan, the FAA's deputy associate administrator for aviation safety, said the approach strikes a balance between enforcement and information sharing, because "we have learned over the years that you can't enforce perfect safety."
The equilibrium allows the FAA to "learn lessons before we see risk manifest itself as incidents or accidents," Ms. Gilligan said this week.
Even critics say that new approach, known as the Air Transportation Oversight System, makes sense.
With ValuJet, a start-up airline that grew quickly, "it was impossible to get a handle on the enormous amount of stuff going on," Ms. Goodrich said. "We had no way to prioritize the risk."
Troubles linger
And yet, as the Southwest case showed, the newer approach isn't flawless.
The FAA's maintenance oversight was also an issue in 2006, when a small airliner crashed into a shipping channel near Miami, killing 20. The operator, Chalk's Ocean Airways, repeatedly fixed a fuel leak but missed the structural weakness that caused a wing to fall off.
After the crash, the National Transportation Safety Board recommended the FAA verify that maintenance programs of commercial airlines include criteria to identify systemic problems.
In a letter to the NTSB, the FAA replied that it shared the concerns about "systemic deficiencies in maintenance program oversight" and was developing new instructions for inspectors. An FAA spokeswoman said the FAA's concerns were limited to minor operators such as Chalk's, which used very old seaplanes.
Last year, the U.S. Department of Transportation's inspector general investigated the complaints of an FAA inspector with oversight responsibility for Northwest Airlines.
The inspector general's investigation largely backed up the inspector's claim that Northwest's mechanics weren't properly trained and that efforts to sanction the carrier were thwarted by FAA managers.
In North Texas, inspectors said supervisors have soft-pedaled investigations and reduced fines to an amount that didn't pinch airlines with annual revenues in the billions. Inspectors in the FAA's Southwest oversight office complained for three years about flaws in the airline's system for following federal safety regulations known as airworthiness directives, according to federal records.
Last year, Southwest disclosed to the FAA that 46 jets missed airworthiness inspections, but it didn't immediately ground them; an FAA supervisor appears to have known Southwest didn't stop flying after indicating that it would.
Inspectors in the office overseeing American Airlines have made similar complaints about their efforts to police American, according to two inspectors who spoke on condition of anonymity because they aren't authorized to talk to the media.
The FAA supervisor in Irving who oversaw Southwest's maintenance, and gave tacit permission to keep flying the jets, previously had the same duty for American Eagle.
Between 1997 and 2002, FAA inspectors documented more than 60 enforcement cases against American and American Eagle, according to FAA records obtained by The Dallas Morning News.
Some reports addressed violations such as blocking emergency equipment with baggage. Others were for more serious violations, like deferring the repair of engine cracks and using tape to fix part of a plane's horizontal stabilizer.
The cases dragged on for so long that, all together, they would have cost $7.5 million for American Airlines, American Eagle and Reno Air, an airline acquired by American. But the FAA supervisor noted that American Eagle had made numerous safety improvements.
And Thomas E. Stuckey, the FAA's regional division manager for flight standards, noted that American had experienced "significant financial losses" and recommended a lower penalty - between $3.4 million and $3.8 million, according to a memorandum Mr. Stuckey wrote to an FAA director.
The FAA agreed to settle the case in 2004 for about $2.5 million, a decision that irked inspectors who thought it didn't sufficiently penalize American. The airline paid the fine but admitted no fault.
Mr. Steinberg, who was then the FAA's chief counsel, agreed to the $2.5 million settlement. Such "global settlements" became less common as the agency moved to resolve enforcement cases more promptly, he said.
"They were done mostly for administrative convenience," said Mr. Steinberg, who worked for American Airlines in the 1990s. "They do probably lower the penalty amount, but I think that it's hard to know whether in aggregate it ends up collecting less money."
Incentive to comply
The Government Accountability Office, in a report issued in September 2006, said that reducing sanctions for reasons unrelated to the merits of the case didn't help improve compliance.
"If violators expect sanctions to be reduced, they may have less incentive to comply with regulations," the GAO wrote. "In effect, it becomes more difficult to achieve the goal of preventing future violations."
Ms. Goodrich said many inspectors have been frustrated that their enforcement cases have led to settlements and lesser penalties, such as written warnings.
"Why should you bother if it's a paper game that's going on?" Ms. Goodrich said. "A wink and a nod that says, 'Don't worry. We'll take care of it later.' "
Ron Ricks, a Southwest executive vice president, said the airline's recent lapses shouldn't be used to indict the oversight system. The newer approach has allowed airlines and the FAA to focus on fixing problems instead of assigning blame, he said.
Under the old system, airlines were less willing to admit problems because they knew they would be punished, he said.
"The safety professionals at Southwest Airlines ... fervently believe that the partnership approach to safety works better than the old system - the old, adversarial cop-on-the-beat system," said Mr. Ricks, who oversees law, airports and public affairs.
Southwest hasn't talked about its strategy to reduce its $10.2 million fine, which caught the carrier by surprise. The FAA announced the penalty a week before a scheduled congressional hearing about FAA oversight. The hearing was postponed until April 3.
Southwest is going through an "informal conference" with the FAA, in which both sides talk about how to resolve the problems, Mr. Ricks said.
But to judge from a recent meeting in Washington, getting the FAA to reduce the fine this time may be tough.
"The FAA was stern," Mr. Ricks said. "The FAA was firm."
Southwest incident exposed flaws with approach that relies on airlines, critics say
Nearly 12 years after the tragic ValuJet crash that forced regulators to reinvent their approach to airline safety, the Federal Aviation Administration faces new questions about whether its method of policing the airlines is working.
The FAA spent the past week answering for a regional supervisor's decision to allow Southwest Airlines to keep flying jets that needed crucial safety inspections.
Southwest has turned contrite in recent days, with apologies to customers and a pledge to follow the letter of the law.
But inspectors say they've also faced opposition to getting tough with other airlines, an allegation echoed by a congressional committee that insists the FAA has gotten cozy with carriers. The FAA has taken a partnership approach to regulation, in which the agency relies on the airlines to self-disclose safety risks and de-emphasizes hands-on inspections.
"We're depending way too much on the airlines," said Linda Goodrich, regional vice president of the Professional Aviation Safety Specialists, the inspectors' union.
"There's a point at which you get diminishing returns," she said. "From our perspective, that's where we're at."
In North Texas, for instance, inspectors chafed four years ago when the FAA decided to settle about 60 regulatory violations with American Airlines for $2.5 million, about $5 million less than the book value of the penalties. More recently, FAA inspectors overseeing Southwest and Northwest airlines said they were removed from their jobs after trying to investigate serious maintenance problems at the carriers, allegations mostly supported by independent investigators.
1996 crash
The FAA began moving away from its confrontational, cop-on-the-beat approach to policing the airlines after the 1996 ValuJet crash in Florida that killed 110 people.
Even then, the FAA took blame for going easy on airlines in order to promote commercial aviation.
The FAA was faulted for poor oversight of ValuJet, an airline that grew quickly and farmed out almost all of its maintenance. The agency admitted that it didn't have enough inspectors to monitor the airline. It later prohibited the shipment of oxygen generators in cargo holds, where a fire started that brought down the plane.
"In a system as large as ours, you can't inspect every individual part or flight or airplane," said Andrew Steinberg, a former U.S. assistant secretary of transportation who left the agency this year.
"Clearly you need some spot-checking, like there are traffic cops on the highways," he said. "But the basic framework for safety is to make sure the airlines' programs are in place to ensure safety."
The post-ValuJet era introduced big changes.
FAA inspectors now file fewer "enforcements," as investigations bearing sanctions are known. Instead, they're supposed to focus on the most serious risks - ones that cause accidents - by analyzing data provided by the airlines.
The airlines are encouraged to self-report regulatory violations. By doing so, the companies can avoid fines. But they also learn lessons that prevent accidents, FAA officials said.
Peggy Gilligan, the FAA's deputy associate administrator for aviation safety, said the approach strikes a balance between enforcement and information sharing, because "we have learned over the years that you can't enforce perfect safety."
The equilibrium allows the FAA to "learn lessons before we see risk manifest itself as incidents or accidents," Ms. Gilligan said this week.
Even critics say that new approach, known as the Air Transportation Oversight System, makes sense.
With ValuJet, a start-up airline that grew quickly, "it was impossible to get a handle on the enormous amount of stuff going on," Ms. Goodrich said. "We had no way to prioritize the risk."
Troubles linger
And yet, as the Southwest case showed, the newer approach isn't flawless.
The FAA's maintenance oversight was also an issue in 2006, when a small airliner crashed into a shipping channel near Miami, killing 20. The operator, Chalk's Ocean Airways, repeatedly fixed a fuel leak but missed the structural weakness that caused a wing to fall off.
After the crash, the National Transportation Safety Board recommended the FAA verify that maintenance programs of commercial airlines include criteria to identify systemic problems.
In a letter to the NTSB, the FAA replied that it shared the concerns about "systemic deficiencies in maintenance program oversight" and was developing new instructions for inspectors. An FAA spokeswoman said the FAA's concerns were limited to minor operators such as Chalk's, which used very old seaplanes.
Last year, the U.S. Department of Transportation's inspector general investigated the complaints of an FAA inspector with oversight responsibility for Northwest Airlines.
The inspector general's investigation largely backed up the inspector's claim that Northwest's mechanics weren't properly trained and that efforts to sanction the carrier were thwarted by FAA managers.
In North Texas, inspectors said supervisors have soft-pedaled investigations and reduced fines to an amount that didn't pinch airlines with annual revenues in the billions. Inspectors in the FAA's Southwest oversight office complained for three years about flaws in the airline's system for following federal safety regulations known as airworthiness directives, according to federal records.
Last year, Southwest disclosed to the FAA that 46 jets missed airworthiness inspections, but it didn't immediately ground them; an FAA supervisor appears to have known Southwest didn't stop flying after indicating that it would.
Inspectors in the office overseeing American Airlines have made similar complaints about their efforts to police American, according to two inspectors who spoke on condition of anonymity because they aren't authorized to talk to the media.
The FAA supervisor in Irving who oversaw Southwest's maintenance, and gave tacit permission to keep flying the jets, previously had the same duty for American Eagle.
Between 1997 and 2002, FAA inspectors documented more than 60 enforcement cases against American and American Eagle, according to FAA records obtained by The Dallas Morning News.
Some reports addressed violations such as blocking emergency equipment with baggage. Others were for more serious violations, like deferring the repair of engine cracks and using tape to fix part of a plane's horizontal stabilizer.
The cases dragged on for so long that, all together, they would have cost $7.5 million for American Airlines, American Eagle and Reno Air, an airline acquired by American. But the FAA supervisor noted that American Eagle had made numerous safety improvements.
And Thomas E. Stuckey, the FAA's regional division manager for flight standards, noted that American had experienced "significant financial losses" and recommended a lower penalty - between $3.4 million and $3.8 million, according to a memorandum Mr. Stuckey wrote to an FAA director.
The FAA agreed to settle the case in 2004 for about $2.5 million, a decision that irked inspectors who thought it didn't sufficiently penalize American. The airline paid the fine but admitted no fault.
Mr. Steinberg, who was then the FAA's chief counsel, agreed to the $2.5 million settlement. Such "global settlements" became less common as the agency moved to resolve enforcement cases more promptly, he said.
"They were done mostly for administrative convenience," said Mr. Steinberg, who worked for American Airlines in the 1990s. "They do probably lower the penalty amount, but I think that it's hard to know whether in aggregate it ends up collecting less money."
Incentive to comply
The Government Accountability Office, in a report issued in September 2006, said that reducing sanctions for reasons unrelated to the merits of the case didn't help improve compliance.
"If violators expect sanctions to be reduced, they may have less incentive to comply with regulations," the GAO wrote. "In effect, it becomes more difficult to achieve the goal of preventing future violations."
Ms. Goodrich said many inspectors have been frustrated that their enforcement cases have led to settlements and lesser penalties, such as written warnings.
"Why should you bother if it's a paper game that's going on?" Ms. Goodrich said. "A wink and a nod that says, 'Don't worry. We'll take care of it later.' "
Ron Ricks, a Southwest executive vice president, said the airline's recent lapses shouldn't be used to indict the oversight system. The newer approach has allowed airlines and the FAA to focus on fixing problems instead of assigning blame, he said.
Under the old system, airlines were less willing to admit problems because they knew they would be punished, he said.
"The safety professionals at Southwest Airlines ... fervently believe that the partnership approach to safety works better than the old system - the old, adversarial cop-on-the-beat system," said Mr. Ricks, who oversees law, airports and public affairs.
Southwest hasn't talked about its strategy to reduce its $10.2 million fine, which caught the carrier by surprise. The FAA announced the penalty a week before a scheduled congressional hearing about FAA oversight. The hearing was postponed until April 3.
Southwest is going through an "informal conference" with the FAA, in which both sides talk about how to resolve the problems, Mr. Ricks said.
But to judge from a recent meeting in Washington, getting the FAA to reduce the fine this time may be tough.
"The FAA was stern," Mr. Ricks said. "The FAA was firm."
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....mea culpa ??
"FAA to Check Maintenance Records at All US Airlines After Southwest Missed Safety Inspections"
. . .
"
After a drumbeat of bad publicity lasting more than a week, Southwest confirmed Monday that it was suspending plans to outsource some of its maintenance work to a contractor in El Salvador.
The Business Travel Coalition, a group representing corporate travel customers, said U.S. airlines outsourcing of maintenance costs rose from 26 percent in 1997 to 64 percent in 2006. The group called for more FAA oversight of repair facilities both in the United States and in foreign countries, with the cost of inspections borne by airlines that outsource maintenance work.
"
. . .
http://biz.yahoo.com/ap/080318/faa_i...ions.html?.v=3
. . .
"
After a drumbeat of bad publicity lasting more than a week, Southwest confirmed Monday that it was suspending plans to outsource some of its maintenance work to a contractor in El Salvador.
The Business Travel Coalition, a group representing corporate travel customers, said U.S. airlines outsourcing of maintenance costs rose from 26 percent in 1997 to 64 percent in 2006. The group called for more FAA oversight of repair facilities both in the United States and in foreign countries, with the cost of inspections borne by airlines that outsource maintenance work.
"
. . .
http://biz.yahoo.com/ap/080318/faa_i...ions.html?.v=3
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AD Overruns - in general
I have been in the industry (UK) for over thirty years – in the maintenance field – and have occasionally been involved in dealing with AD overruns after they have occurred.
The overruns that I have seen have usually occurred through either the interpretation of the AD or the actioning of the AD once interpreted.
When an AD is issued it needs to be interpreted – ADs can be very complex as they are usually written to cover the whole world fleet. There will often be many variables to consider such as Aircraft build date (serial number), Aircraft Series, Aircraft Flight Hours/Cycles, and Modification status (for each Airframe).
The variables will determine when the initial inspections/modifications will take place and further ongoing repeat inspections (which are often not the same frequency as the initial). This will need to be determined for each and every Airframe in your fleet which will likely not be all the same series or standard. Additionally there are often modifications which can be performed in part(s) or in full to either vary the inspection frequency or to terminate it.
Once an assessment of your particular fleet has been made, this data needs to be inputted into your maintenance control system (usually a computer system) where the system will flag up impeding inspections/modifications which can be planned to be performed at the appropriate downtime.
The interpretation and data input process needs to be very robust to prevent mistakes being made, with constant audits to ensure compliance. However, mistakes do get made (Swiss Cheese – Human Factors) and occasional overruns do occur. I doubt whether there is an Airline flying (with a sizeable fleet) which has never experienced an AD overrun.
It gets even more complex when an Airline takes on Aircraft from another operator (rather than new aircraft) where the new Operator not only has to make sure that the technical records data transfer is taken across accurately, but also that the previous operator had actually interpreted the ADs correctly in the first place!
But what do you do if you find an overrun – ground the affected Aircraft? The certificate of Airworthiness has been invalidated but this does not mean that the Aircraft(s) is un-airworthy (legally yes, but actually not necessarily). As an example if you were mandated to look for a crack at 6000 flight hours and you perform it at 7000 hours due to a data input error – and you find no crack – was the Aircraft un-airworthy during the overrun?
I have seen it where a large European carrier of which I am familiar, experienced an AD overrun due to an error in the records where a risk assessment was conducted between the Airline, MRO, OEM and the Airworthiness Authority – in this case the Aircraft were allowed to continue in operation for a period of time as they were considered to be still Airworthy despite not being in compliance with the AD.
The easy answer is to ground Aircraft but that may not necessarily be in the best interest of all parties – while there is obviously the finger pointing about it being a commercial decision, you also need to consider the Passengers (both safety and travel disruption) Airline operational disruption (confidence in the Airline), confidence in the Aircraft type itself (OEM), and confidence in Airworthiness oversight.
There are numerous ADs per Aircraft type and they can be incredibly complex– an overrun should not dam the whole Airline or industry where an honest mistake has been made, especially where a risk assessment has been performed coupled with an assessment of the implications of a finding, and an expeditious recovery plan put in place. I am not familiar with the SW case but I suspect they performed a risk assessment with the full blessing of the OEM.
bizdev
The overruns that I have seen have usually occurred through either the interpretation of the AD or the actioning of the AD once interpreted.
When an AD is issued it needs to be interpreted – ADs can be very complex as they are usually written to cover the whole world fleet. There will often be many variables to consider such as Aircraft build date (serial number), Aircraft Series, Aircraft Flight Hours/Cycles, and Modification status (for each Airframe).
The variables will determine when the initial inspections/modifications will take place and further ongoing repeat inspections (which are often not the same frequency as the initial). This will need to be determined for each and every Airframe in your fleet which will likely not be all the same series or standard. Additionally there are often modifications which can be performed in part(s) or in full to either vary the inspection frequency or to terminate it.
Once an assessment of your particular fleet has been made, this data needs to be inputted into your maintenance control system (usually a computer system) where the system will flag up impeding inspections/modifications which can be planned to be performed at the appropriate downtime.
The interpretation and data input process needs to be very robust to prevent mistakes being made, with constant audits to ensure compliance. However, mistakes do get made (Swiss Cheese – Human Factors) and occasional overruns do occur. I doubt whether there is an Airline flying (with a sizeable fleet) which has never experienced an AD overrun.
It gets even more complex when an Airline takes on Aircraft from another operator (rather than new aircraft) where the new Operator not only has to make sure that the technical records data transfer is taken across accurately, but also that the previous operator had actually interpreted the ADs correctly in the first place!
But what do you do if you find an overrun – ground the affected Aircraft? The certificate of Airworthiness has been invalidated but this does not mean that the Aircraft(s) is un-airworthy (legally yes, but actually not necessarily). As an example if you were mandated to look for a crack at 6000 flight hours and you perform it at 7000 hours due to a data input error – and you find no crack – was the Aircraft un-airworthy during the overrun?
I have seen it where a large European carrier of which I am familiar, experienced an AD overrun due to an error in the records where a risk assessment was conducted between the Airline, MRO, OEM and the Airworthiness Authority – in this case the Aircraft were allowed to continue in operation for a period of time as they were considered to be still Airworthy despite not being in compliance with the AD.
The easy answer is to ground Aircraft but that may not necessarily be in the best interest of all parties – while there is obviously the finger pointing about it being a commercial decision, you also need to consider the Passengers (both safety and travel disruption) Airline operational disruption (confidence in the Airline), confidence in the Aircraft type itself (OEM), and confidence in Airworthiness oversight.
There are numerous ADs per Aircraft type and they can be incredibly complex– an overrun should not dam the whole Airline or industry where an honest mistake has been made, especially where a risk assessment has been performed coupled with an assessment of the implications of a finding, and an expeditious recovery plan put in place. I am not familiar with the SW case but I suspect they performed a risk assessment with the full blessing of the OEM.
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Bizdev:-
True enough.
In the commercial arena, the other aspect which tends to hold much sway in the decision making process are the financial aspects i.e. what is the cheapest option. All too often rather than terminate an AD by compliance with an SB (the OEM choice), operators are happy to carry out repetitive inspections. That is their choice and in the tough world of heritage operators Vs LC who can blame any one of them?
However, if they do not have the infrastructure to track this course of action they are leaving themselves open to potential AD over runs. Quite often human factor problems are built in (swiss cheese as you refer to) by taking this course of action.
True enough.
In the commercial arena, the other aspect which tends to hold much sway in the decision making process are the financial aspects i.e. what is the cheapest option. All too often rather than terminate an AD by compliance with an SB (the OEM choice), operators are happy to carry out repetitive inspections. That is their choice and in the tough world of heritage operators Vs LC who can blame any one of them?
However, if they do not have the infrastructure to track this course of action they are leaving themselves open to potential AD over runs. Quite often human factor problems are built in (swiss cheese as you refer to) by taking this course of action.
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bizdev;
If that is your honest interpretation of ADs and the system, this is exactly why there is a problem. Justification for pax/schedules or whatever are a beancounters point of view, not the head of a maintenance department who is committed to fleet maintenance rather than mamagement trying to tell him how to run his job.
That attitude makes you the enabler as much as management.
carholme
If that is your honest interpretation of ADs and the system, this is exactly why there is a problem. Justification for pax/schedules or whatever are a beancounters point of view, not the head of a maintenance department who is committed to fleet maintenance rather than mamagement trying to tell him how to run his job.
That attitude makes you the enabler as much as management.
carholme
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Monkey Wrench
You make a good point regarding repeat inspections versus a terminating modification. This is especially true when airlines know they are going to be handing back aircraft to the lessor in the near future - why go through the expense - just let the maintenance organisation keep making the inspection!!!!!
bizdev
You make a good point regarding repeat inspections versus a terminating modification. This is especially true when airlines know they are going to be handing back aircraft to the lessor in the near future - why go through the expense - just let the maintenance organisation keep making the inspection!!!!!
bizdev
I agree with Bizdev above.
The objective of continued airworthiness is not to tell an airline how to run a business, The objective is to acheive a level of safety that can be demonstrated. Risk analysis is a valid method of demonstration and in my opinion as valid if not more so than the original words written in an AD for showing compliance.
I do agree that bean counters do not own a priority stake in this. Whatever action is proposed must meet the intent of bringing the product back into compliance with "acceptable risk"
The objective of continued airworthiness is not to tell an airline how to run a business, The objective is to acheive a level of safety that can be demonstrated. Risk analysis is a valid method of demonstration and in my opinion as valid if not more so than the original words written in an AD for showing compliance.
I do agree that bean counters do not own a priority stake in this. Whatever action is proposed must meet the intent of bringing the product back into compliance with "acceptable risk"
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Received the following this morning. I guess some folk will be working hard over the Easter break....
QUOTE
NOTICE: N 8900.36
U.S. DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION
National Policy
Effective Date: 03/13/08
Cancellation Date: 06/30/08
SUBJ: Special Emphasis Validation of Airworthiness Directives Oversight
1. Purpose of This Notice. This notice directs an audit of Title 14 Code of Federal Regulations (14 CFR) part 121 air carrier compliance with Airworthiness Directives (AD). The audit is necessary to validate our system for overseeing air carrier management of ADs.
2. Audience. The primary audience for this notice is Flight Standards District Office or certificate management office principal maintenance inspectors (PMI) and principal avionics inspectors (PAI) responsible for the approval/review and surveillance of air carrier AD management programs. The secondary audience includes Flight Standards branches and divisions in the regions and in headquarters.
3. Where You Can Find This Notice. Inspectors can access this notice through the Flight Standards Information Management System (FSIMS) at http://fsims.avs.faa.gov. Operators and the public can find this notice at http://fsims.faa.gov.
4. Background. Current events involving one air carrier's noncompliance with ADs make it necessary to validate our system for overseeing air carrier management of this regulatory requirement.
a. In December 2007, all Federal Aviation Administration (FAA) Certificate Management Teams (CMTs) for 14 CFR part 121 air carriers completed their transition to the Air Transportation Oversight System (ATOS)-a systems-based approach to ensuring air carrier compliance with regulations. ATOS requires systematic, risk-based surveillance of all of the processes that an air carrier uses to comply with regulations and deliver its product. ATOS structures air carrier processes into 97 elements. Inspectors use detailed data collection tools to assess the design and performance of the processes represented by each element. Inspectors use Safety Attribute Inspections (SAIs) to collect data for design assessments and Element Performance Inspections (EPIs) for performance assessments. The SAI and EPI for element 1.3.6, Airworthiness Directive Management, provide specific references to regulations and FAA policy and guidance for an air carrier's management of compliance with ADs.
b. Element 1.3.6 is extremely complex. Multiple ADs affect every aircraft used in air transportation. Literally inspecting each of these aircraft for compliance with all ADs affecting it far exceeds FAA resources. Therefore, ATOS emphasizes the importance of an air carrier's responsibility to have a process that effectively manages the regulatory requirement to comply with ADs.
c. ATOS requires a performance assessment of element 1.3.6 every six months. Many recently transitioned CMT have not yet completed an assessment of element 1.3.6. For this reason, as well as the highly publicized noncompliance of one air carrier, this special emphasis audit is necessary to validate our system of oversight.
5. Action. PMIs and PAIs shall determine their assigned air carriers' compliance with ADs by auditing a sample of ADs applicable to their air carriers' fleets, in conjunction with a retargeted performance assessment of element 1.3.6. The audit consists of two phases. Phase 1 of the audit shall sample 10 ADs for each of the air carriers' fleets, including AD-2002-07-08 and AD-2004-18-06 for the Boeing 737 aircraft, if applicable. Phase 2 of the audit shall sample additional ADs to total 10 percent of the ADs applicable to the air carriers' fleets.
a. PMIs and PAIs shall complete Phase 1 of the audit by March 28, 2008 and Phase 2 as soon as possible but no later than June 30, 2008.
b. The audit shall:
(1) Validate the air carrier's work instructions (e.g., task cards, engineering authorizations, engineering orders, engineering change orders) to accomplish the AD by verifying that the instructions correctly describe the method of compliance contained within the AD and any referenced service information (e.g., service bulletins, service letters) or any related alternative methods of compliance; and
(2) Validate the proper performance of the AD by reviewing the complete work instructions "package" on at least one aircraft.
c. For Phases 1 and 2, PMIs and PAIs shall audit a different aircraft, to the extent practicable, for each AD. This review should also ensure that entries into the AD tracking system were performed correctly. Give emphasis to sampling those ADs which involve required inspections of fuselage, empennage, and wing areas for cracking or similar issues.
d. To initiate Phase 1 of the audit, complete the following steps:
(1) Use ATOS automation to create a Constructed Dynamic Observation Report(s) (ConDOR) for airworthiness element 1.3.6.
(2) In the Local/Regional/National use field enter N8900.36.
(3) In the Requested Completion Date field enter March 28, 2008.
(4) Select EPI question 1.2.
(5) Determine and document data collection requirements in accordance with the instructions above.
(6) Document the results of each AD sampled in the comment field associated with the yes/no response.
e. To initiate Phase 2 of the audit, complete the following steps of the ATOS version 1.2 business process:
(1) Step 2.4, adjust the due date of the next performance assessment of element 1.3.6 to June 30, 2008.
(2) Step 2.6, determine data collection requirements in accordance with the instructions above.
(3) Step 2.7, document data collection requirements in accordance with the instructions above. Include instructions for specific ADs to be sampled and deadlines to save EPI activities to "final" in ATOS automation to comply with Phase 1 and 2 completion dates.
(4) Step 5.1, use the comment field to document the results of each AD sampled.
(5) Step 7.4 or 7.5, complete the performance assessment of element 1.3.6. Include ConDOR data collected in Phase 1.
f. If the audit affirms the performance of element 1.3.6, take no further action.
g. If you cannot affirm performance, follow the ATOS business process to initiate required action, including scheduling a design assessment if systemic issues exists.
h. If the audit finds evidence of noncompliance with ADs, initiate immediate corrective action.
6. Tracking.
a. Document the results of this audit of the air carrier's compliance with sampled ADs in the comment field of the EPI for element 1.3.6, Airworthiness Directive Management. Enter N8900.36 in the Local/Regional/National Use block of the activity screen.
b. If the air carrier did not comply with any of the sampled ADs, take immediate corrective action. Use the ATOS Risk Management Process (RMP), if appropriate.
7. Disposition. This is a special emphasis audit. Therefore, Flight Standards will not incorporate the information in this notice into FSIMS. Direct questions concerning this notice to the Certification and Surveillance Division, AFS-900, at (703) 661-0550.
Original signed by
James J. Ballough
Director, Flight Standards Service
UNQUOTE
QUOTE
NOTICE: N 8900.36
U.S. DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION
National Policy
Effective Date: 03/13/08
Cancellation Date: 06/30/08
SUBJ: Special Emphasis Validation of Airworthiness Directives Oversight
1. Purpose of This Notice. This notice directs an audit of Title 14 Code of Federal Regulations (14 CFR) part 121 air carrier compliance with Airworthiness Directives (AD). The audit is necessary to validate our system for overseeing air carrier management of ADs.
2. Audience. The primary audience for this notice is Flight Standards District Office or certificate management office principal maintenance inspectors (PMI) and principal avionics inspectors (PAI) responsible for the approval/review and surveillance of air carrier AD management programs. The secondary audience includes Flight Standards branches and divisions in the regions and in headquarters.
3. Where You Can Find This Notice. Inspectors can access this notice through the Flight Standards Information Management System (FSIMS) at http://fsims.avs.faa.gov. Operators and the public can find this notice at http://fsims.faa.gov.
4. Background. Current events involving one air carrier's noncompliance with ADs make it necessary to validate our system for overseeing air carrier management of this regulatory requirement.
a. In December 2007, all Federal Aviation Administration (FAA) Certificate Management Teams (CMTs) for 14 CFR part 121 air carriers completed their transition to the Air Transportation Oversight System (ATOS)-a systems-based approach to ensuring air carrier compliance with regulations. ATOS requires systematic, risk-based surveillance of all of the processes that an air carrier uses to comply with regulations and deliver its product. ATOS structures air carrier processes into 97 elements. Inspectors use detailed data collection tools to assess the design and performance of the processes represented by each element. Inspectors use Safety Attribute Inspections (SAIs) to collect data for design assessments and Element Performance Inspections (EPIs) for performance assessments. The SAI and EPI for element 1.3.6, Airworthiness Directive Management, provide specific references to regulations and FAA policy and guidance for an air carrier's management of compliance with ADs.
b. Element 1.3.6 is extremely complex. Multiple ADs affect every aircraft used in air transportation. Literally inspecting each of these aircraft for compliance with all ADs affecting it far exceeds FAA resources. Therefore, ATOS emphasizes the importance of an air carrier's responsibility to have a process that effectively manages the regulatory requirement to comply with ADs.
c. ATOS requires a performance assessment of element 1.3.6 every six months. Many recently transitioned CMT have not yet completed an assessment of element 1.3.6. For this reason, as well as the highly publicized noncompliance of one air carrier, this special emphasis audit is necessary to validate our system of oversight.
5. Action. PMIs and PAIs shall determine their assigned air carriers' compliance with ADs by auditing a sample of ADs applicable to their air carriers' fleets, in conjunction with a retargeted performance assessment of element 1.3.6. The audit consists of two phases. Phase 1 of the audit shall sample 10 ADs for each of the air carriers' fleets, including AD-2002-07-08 and AD-2004-18-06 for the Boeing 737 aircraft, if applicable. Phase 2 of the audit shall sample additional ADs to total 10 percent of the ADs applicable to the air carriers' fleets.
a. PMIs and PAIs shall complete Phase 1 of the audit by March 28, 2008 and Phase 2 as soon as possible but no later than June 30, 2008.
b. The audit shall:
(1) Validate the air carrier's work instructions (e.g., task cards, engineering authorizations, engineering orders, engineering change orders) to accomplish the AD by verifying that the instructions correctly describe the method of compliance contained within the AD and any referenced service information (e.g., service bulletins, service letters) or any related alternative methods of compliance; and
(2) Validate the proper performance of the AD by reviewing the complete work instructions "package" on at least one aircraft.
c. For Phases 1 and 2, PMIs and PAIs shall audit a different aircraft, to the extent practicable, for each AD. This review should also ensure that entries into the AD tracking system were performed correctly. Give emphasis to sampling those ADs which involve required inspections of fuselage, empennage, and wing areas for cracking or similar issues.
d. To initiate Phase 1 of the audit, complete the following steps:
(1) Use ATOS automation to create a Constructed Dynamic Observation Report(s) (ConDOR) for airworthiness element 1.3.6.
(2) In the Local/Regional/National use field enter N8900.36.
(3) In the Requested Completion Date field enter March 28, 2008.
(4) Select EPI question 1.2.
(5) Determine and document data collection requirements in accordance with the instructions above.
(6) Document the results of each AD sampled in the comment field associated with the yes/no response.
e. To initiate Phase 2 of the audit, complete the following steps of the ATOS version 1.2 business process:
(1) Step 2.4, adjust the due date of the next performance assessment of element 1.3.6 to June 30, 2008.
(2) Step 2.6, determine data collection requirements in accordance with the instructions above.
(3) Step 2.7, document data collection requirements in accordance with the instructions above. Include instructions for specific ADs to be sampled and deadlines to save EPI activities to "final" in ATOS automation to comply with Phase 1 and 2 completion dates.
(4) Step 5.1, use the comment field to document the results of each AD sampled.
(5) Step 7.4 or 7.5, complete the performance assessment of element 1.3.6. Include ConDOR data collected in Phase 1.
f. If the audit affirms the performance of element 1.3.6, take no further action.
g. If you cannot affirm performance, follow the ATOS business process to initiate required action, including scheduling a design assessment if systemic issues exists.
h. If the audit finds evidence of noncompliance with ADs, initiate immediate corrective action.
6. Tracking.
a. Document the results of this audit of the air carrier's compliance with sampled ADs in the comment field of the EPI for element 1.3.6, Airworthiness Directive Management. Enter N8900.36 in the Local/Regional/National Use block of the activity screen.
b. If the air carrier did not comply with any of the sampled ADs, take immediate corrective action. Use the ATOS Risk Management Process (RMP), if appropriate.
7. Disposition. This is a special emphasis audit. Therefore, Flight Standards will not incorporate the information in this notice into FSIMS. Direct questions concerning this notice to the Certification and Surveillance Division, AFS-900, at (703) 661-0550.
Original signed by
James J. Ballough
Director, Flight Standards Service
UNQUOTE
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I thought the MD80 at alaska airlines had problems because the frequency of inspections had been dropped and the lubricating oil/grease for the jack screw had been changed. all to save money. and approved by the local FAA inspector.
my airline had been flying this type of plane for many years, following exactly the douglas procedures for mx and never had problems with metal shavings or jack screw failures.
my airline had been flying this type of plane for many years, following exactly the douglas procedures for mx and never had problems with metal shavings or jack screw failures.
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sevenstrokeroll;
I agree. "Risk Assessment" as described above is one thing but approval for it is granted on a set of circumtances at a given time. As time roll on and an airline is faced with ever decreasing revenues, the probablility for Risk Assessment abuse prevails and unless that abuse reflects in an incident, accident or regulator inspection/finding, it has the chance of staying hidden for some time. Assessment can be so subjective, whereas the AD is emphatic.
This whole issue and the responses are appearing to be more justification for what everybody knows what is really happening. The fact that it has grown to the level of a major FAA investigation shows that wake up time has come. And not a moment too soon with the pressures being felt with the high cost of fuel, competition, outsourcing of maintenance to cheaper countries and retirement of the baby boomer captains with less and less intake of experience.
carholme
I agree. "Risk Assessment" as described above is one thing but approval for it is granted on a set of circumtances at a given time. As time roll on and an airline is faced with ever decreasing revenues, the probablility for Risk Assessment abuse prevails and unless that abuse reflects in an incident, accident or regulator inspection/finding, it has the chance of staying hidden for some time. Assessment can be so subjective, whereas the AD is emphatic.
This whole issue and the responses are appearing to be more justification for what everybody knows what is really happening. The fact that it has grown to the level of a major FAA investigation shows that wake up time has come. And not a moment too soon with the pressures being felt with the high cost of fuel, competition, outsourcing of maintenance to cheaper countries and retirement of the baby boomer captains with less and less intake of experience.
carholme
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Similar to Ansett Australia B767 groundings?
Reminds one of the Ansett Australia B767s that were grounded in December 2000 and April 2001 because certain fatigue-related inspections had been missed.
To quote the Australian Transport Safety Bureau (ATSB) report,
“There was uncertainty as to the continuing airworthiness status of the aircraft. In December 2000 the concerns related to possible fatigue cracking in the rear fuselage of the aircraft, and in April 2001 the concerns related to possible fatigue cracking of the engine strut fitting on the wing front spar.”
The ATSB report found problems existed in Ansett, the Australian regulator (the Civil Aviation Safety Authority), FAA, Boeing, and the ICAO system for continuing airworthiness assurance.
http://www.atsb.gov.au/publications/..._australia.pdf
Is it likely that the NTSB will investigate the happenings at Southwest?
To quote the Australian Transport Safety Bureau (ATSB) report,
“There was uncertainty as to the continuing airworthiness status of the aircraft. In December 2000 the concerns related to possible fatigue cracking in the rear fuselage of the aircraft, and in April 2001 the concerns related to possible fatigue cracking of the engine strut fitting on the wing front spar.”
The ATSB report found problems existed in Ansett, the Australian regulator (the Civil Aviation Safety Authority), FAA, Boeing, and the ICAO system for continuing airworthiness assurance.
http://www.atsb.gov.au/publications/..._australia.pdf
Is it likely that the NTSB will investigate the happenings at Southwest?
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http://www.oig.dot.gov/StreamFile?fi...ort_Issued.pdf
Looks like there is some investigation happening within DOT, though if the FAA don't have a decent reporting culture how can they expect the airlines to have too?
Press story:
Department of Transportation criticizes FAA reforms | Dallas Morning News | News for Dallas, Texas | Dallas Business News
But in its latest review, the U.S. Department of Transportation inspector general said the agency needs to do more and criticized one major FAA reform – a software system that allows FAA inspectors to directly report concerns to top officials – as unhelpful.
FAA officials had trumpeted the Safety Issues Report System, or SIRS, in March, saying it would give inspectors a way around bosses who didn't agree with their judgments about safety risks.
But the inspector general wrote that the system "merely adds one more process to an already existing internal system that is unequivocally ineffective and possibly even biased against resolving root causes of serious safety lapses."
The FAA said in a statement that it mostly agreed with the report, but it didn't address the criticism of SIRS. The statement stressed that FAA leaders are working to develop an environment that allows employees "to feel fully at ease bringing forth concerns" without "possibility of retribution or retaliation."
Looks like there is some investigation happening within DOT, though if the FAA don't have a decent reporting culture how can they expect the airlines to have too?
Press story:
Department of Transportation criticizes FAA reforms | Dallas Morning News | News for Dallas, Texas | Dallas Business News
But in its latest review, the U.S. Department of Transportation inspector general said the agency needs to do more and criticized one major FAA reform – a software system that allows FAA inspectors to directly report concerns to top officials – as unhelpful.
FAA officials had trumpeted the Safety Issues Report System, or SIRS, in March, saying it would give inspectors a way around bosses who didn't agree with their judgments about safety risks.
But the inspector general wrote that the system "merely adds one more process to an already existing internal system that is unequivocally ineffective and possibly even biased against resolving root causes of serious safety lapses."
The FAA said in a statement that it mostly agreed with the report, but it didn't address the criticism of SIRS. The statement stressed that FAA leaders are working to develop an environment that allows employees "to feel fully at ease bringing forth concerns" without "possibility of retribution or retaliation."