John Goglia’s ValueJet Lessons
John Goglia, the NTSB Member who chaired the NTSB hearing on the 1996 ValuJet crash in the Everglades, has written an insightful recollection of that tragedy. His primary take-away is well stated in this quote from his AinOnline article:
“A lot of ValuJet’s problems both before and leading up to the accident involved rapid growth beyond the ability of its infrastructure to handle and oversee that growth…More maintenance problems meant more use of outsourced maintenance providers and required ValuJet to have the infrastructure to support a higher level of oversight of these maintenance providers to ensure compliance with its maintenance manual…And, no matter who actually performs the maintenance, the air carrier is always responsible for the adequacy of that work. In other words, it can outsource the work but not the regulatory responsibility.”
Member Goglia correctly references the FAA’s reliance on Safety Management System as the discipline to focus its oversight resources in tracking an air carrier’s safety performance. Applying the lessons learned from the ValuJet tragedy, each air carrier should be mindful of the human resource impact of increases in operations.
SMS uses data as its risk assessment tool. The Safety Review Board should be mindful of the numbers collected to determine whether the staffing is adequate to meet its regulatory responsibilities. Are the existing systems collecting some or all of these numbers?
- What are the hours worked, particularly overtime, in key positions? Since these numbers translate to paychecks, they are not likely understated.
- What are the positions which should be carefully monitored:
- All line MX personnel
- AI positions
- QC/QA personnel
- Staff assigned to produce and record MX procedures (work cards or the automated equivalent)
- The return to service acceptance inspection personnel,; they may experience surges of time required.
- Stocking and inventory control staff
- MX records teams
- Key points along your airline’s MX quality process.
- Have the measures of hours spent on specific checks increased or decreased compared to past patterns. Fewer hours per C check may indicate greater efficiency, but upon further review may reflect that the staff is being rushed or not paying the same level of care?
- Other considerations which may be relevant to your airline, e.g. with new routes or new stations, what should the Safety Review Board add to its data collection?
- Pilots bear greater scrutiny with expansion. Questions like:
- How rigorous was the pre-hire assessment? Was Personnel able to obtain ALL of the records from previous employers?
- How are the new crewmembers sitting in the right hand seats integrating with the old line captains?
- If the new flights are causing a lot of upgrading of pilots, how thorough was the training? There’s a tendency to assume that a veteran will not have many problems acquiring the knowledge/skills for the new equipment; more sophisticated aircraft tends to have more complex automation. How detailed were the lesson plans?
One of the positive aspects of the FAA working on the Safety Review Board is that the inspectors will gain greater knowledge of these changes and consequently they will be able to better allocate time observing implementation.
Good point, Mr. Goglia. Safety Review Boards—review his suggestions. They are worthy of added emphasis in all times of change.