Aircraft Accidents and Voluntary Disclosures

In my youth, when the weather prevented baseball, basketball and bicycles, my friends and I would retire to the garage for a time-consuming board game, e.g. Risk.  We did not have fun-sucking video games back then, but we relied on outmaneuvering our opponents at the speed of a dice roll.  Monopoly often made a debut at these times with its hotels and railroads … and rich Uncle Pennybags.  With, of course, the coveted ‘Get-Out-of-Jail-Free’ card from both the Community Chest and Chance card decks, it allowed the possessor of said card to escape prison time and return to the action of the game.

The Voluntary Disclosure Reporting Program (VDRP), introduced in May 1998, was designed to encourage air carriers, Parts Approval Holders, and other certificate holders to disclose safety or security information voluntarily to the Federal Aviation Administration (FAA) without fear of the information being made public or for incrimination for the information.  The VDRP was a good idea; it allowed the FAA to promote safety by removing the enforcement consequence.  Unfortunately, as is with many good ideas, the privilege gets abused; it is often seen as a ‘Get-Out-of-Jail-Free’ card.

When I worked on the airport ramps, the fear ramp workers had was that if you hit the aircraft, you were fired; I saw it on the regional airports as well as the airline ramps.  But the air certificate holders soon wised up, that ‘accidents’ can happen; even being extra careful, new-hires and seasoned folks tend to dent the fuselage or run into a flight control … stuff happens.  The new mantra became: tell someone about the damage and no one gets fired.  The operator would rather find out before launch than for there to be a problem later, especially with a pressurized airframe.

In the same vein, the FAA wrote the VDRP policy.  Originally approved for air carriers in January 1992 and expanded in May 1998, the purpose of the VDRP was to give industry their own approved program that stresses the importance of safety failure disclosures.  Per FAA Order 8000.89, the VDRP would drive the discloser to implement new programs to reduce the opportunity for reoccurrence without, in turn, being violated and/or the event being made public.  The FAA’s rules for implementing Title 49 United States Code (USC) section 40123 can be found in Title 14 Code of Federal Regulations (CFR) part 193.

The benefit of Voluntary Disclosure Reporting as opposed to the Compliance Philosophy – and this is important – is the VDRP’s requirement to fix the problem.  The FAA has had the means to tie the Compliance Philosophy to enforcement actions into a symbiotic relationship.  This would give the Compliance Philosophy a lasting effect, but, like a poor marksman, the FAA continues to miss the target.

When enforcement continues to be a reaction to safety violations, the lesson to the certificate holder (CH) is lost; they don’t get it; they don’t learn nuthin’.  Why?  Because the certificate holder is not held to repairing the problem.  Does the CH get fined or lose certification privileges?  Yes, but after the check is cashed, the lesson is lost.  The CH makes no plans to prevent reoccurrence of the bad behavior.

The correction is part of the voluntary disclosure report; the comprehensive fix guarantees the certificate holder looks at the broken program and, as part of their penance, comes up with a proactivenot reactive – means to address the problem.  That way, it does not happen again.

The benefits of safety disclosures cannot be expressed enough.  However, in past articles, the point was made that aviation people of all types, from pilots to mechanics to balloonists outnumber the FAA aviation safety inspector (ASI) workforce overseeing them by over one hundred to one.  The air carrier world is worse, number-wise; the ASI to aviation professional ratio is overwhelming, perhaps many hundreds to one.  The number of safety reports that the certificate management office (CMO) ASI has to keep track of; the aircraft maintenance data that must be crunched; the risk analyses information that must be investigated; all this takes up time the CMO ASIs do not have.  To keep track of the various voluntary disclosure reports could be a job within itself; the CMO relies on the air carrier’s integrity.

For example, on April 1st, a major freight airline (hypothetically) loads a wide body airliner using specific pancake scales to weigh the freight, labeled 1 through 5; the airliner departs for its destination: Boston.  After departure, the ramp loadmaster is checking equipment condition and notices that scale number 3 was supposed to be calibrated by March 31st.  Per Title 14 CFR part 135.185 (b) (2) and part 121.135 (b) (21), the air carrier is violating their own weight and balance manual (WBM).  The freight was incorrectly weighed; the weights are inaccurate.

The WBM was written by the air carrier; approved by the FAA.  To clarify, inaccurately weighed freight could result in an airliner’s loss of control, passenger or cargo airliner.  A single engine feeder aircraft could become a lawn dart, while a helicopter, with a critical center of gravity, might become so much shrapnel spread around the ramp.

Per FAA Order 8000.89, the Initial Notification must include: description of the violation (scale out of calibration); verification that noncompliance ceased after discovery (they removed the scale from service); an investigation conducted and a report written in ten working days and what a comprehensive fix will include – the comprehensive fix must be designed to prevent reoccurrence … period.  What will be done to assure that the air carrier will not miss the calibration date again?  And in 99.99% of the cases, this is where it ends.  The planets align and the Earth rotates on its axis again.

There are other types of disclosures an air carrier must report: pilot altitude deviations, repair station audit evaluations, inflight engine shutdowns, flight diversions, incidents/accidents and so on.

The point was made about air carriers having superior numbers for the FAA CMO’s ASIs to keep an eye on.  This promotes an environment within the air carriers to let things slide while the ASIs are preoccupied, to water down the urgency of, e.g. an uncalibrated scale until the FAA arrives on the field … then file a voluntary disclosure report as a ‘Get-Out-of-Jail-Free’ card.  It is how the game is played.

When I worked for the FAA’s Flight Standards Division, I often enrouted; this means I flew with the flight crew and observed firsthand the loading and unloading conducted on each ramp the plane departed or landed at.  It was a great surveillance tool because the air carrier never saw me coming.  My specialty was cargo, which includes passenger luggage loading; it is my strong point, my history and I know how to play the game.  If, while conducting surveillance, I came up on scale number 3 (that went out of calibration on March 31st) but now the date I’m on the ramp is April 20th; the air carrier’s VDRP could become a violation issue, especially if the comprehensive fix did not correct the problem.  Attempts to file a Voluntary Disclosure then are futile; the air carrier knew about the problem and ignored the consequences, putting safety in jeopardy.  But it only works if the air carrier is caught in the act.

There is more detail to the VDRP than what is mentioned here; these are the basic points of how the VDRP works, why the VDRP works and why the VDRP needs to be taken seriously.  Furthermore, there are certainly no defenses of the behaviorist psychologist – not FAA regulator – direction of the FAA’s Compliance Philosophy.  Failures to, not just discover safety problems, but correct them, end up in real accidents with real people dying.  There are no second rolls of the dice, no ‘Get-Out-of-Jail-Free’ cards, no do-overs.  And there are no excuses for not playing the game … by the rules.

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