FAA Field and ROOT CAUSE training—change of inspection method is the real issue

FAA Mike Monroney Academy- Flight Safety academy
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Five years ago FAA leadership shifted from “check list” to Root Cause Analysis

Not well received by Field inspectors who knew the old regimen

OIG says it’s lack of training maybe it’s attitude

A Congressionally mandated assessment finds fault with the FAA’s training of its field safety personnel. The Report points to a lack of tools to review the FAA’s review of carrier’s ROOT CAUSE ANALYSIS which is the basis for the SMS Compliance program.

The critique has some validity and the FAA concurred in the IG’s recommendation.  

SMS, Compliance, data-driven oversight, need to identify trends are radically different than the practices which air safety inspectors previously used in  their careers. In the past, these professionals were given detailed guidance that was conducive to a “check list” regimen. These women and men refined the skills to find these problems by scrutinizing the airlines’ paperwork. They had also developed a network of contacts within the certificates to “flag” issues. Careers were made on successful adherence to these old, antiquated investigative techniques.

Mike Monroney Aeronautical CenterOver the past five years, senior management has dictated that the field offices rely on  this new surveillance method. The change rational was based on strong substantive reasons which made irrefutable sense from a headquarters basis. Training for the new analytical tools has been scheduled for all. However, the line inspectors have not warmed up to the change. They may have received indoctrination at the FAA’s Mike Monroney Aeronautical Center, but these students may not be excited about implementing this innovation.

Until the audience accepts that they need to know SMS and root cause analysis, the field staff will continue to fail to apply these new measures of safety and assessment of risk.disinterested students

The OIG Report

The US Department of Transportation Office of Inspector General, upon the request of then-ranking members of the House Committee on Transportation and Infrastructure and its Aviation Subcommittee (now full committee Chair DeFazio and now subcommittee Chair Larsen),examined “ whether FAA ensures that American Airlines implemented effective corrective actions to address the root causes of maintenance problems and FAA’s oversight of American Airlines’ safety management systems (SMS).”OIG Report

At page 8 of the Report, the OIG stated:

FAA concurred with five and partially concurred with two of our seven recommendations to improve FAA’s oversight of American Airlines maintenance programs. We consider recommendations 1, 2, 4, and 6 resolved but open, pending completion of planned actions. However, we are asking FAA for additional information and to reconsider its actions for recommendations

1) Develop and implement root cause analysis training for inspectors more in line with training in the aviation industry.,\..

3) Develop and implement a management control to ensure inspectors require air carriers to provide written root cause analyses and that these analyses do not specifically identify human factors issues as root causes…

6) Develop and implement Safety Management System training for inspectors that is specifically designed to aid inspectors in evaluating air carrier risk assessments


FAA Response

There, Dr. Foushee, Director, Office of Audit and Evaluation, replied—

AAE response


We have reviewed the draft report and offer the following observations:

  • The draft report asserts that the FAA can require an air carrier to provide a written root cause determination. The FAA can request a root cause determination from an air carrier as part of an investigation, but there is no specific statutory or regulatory provision requiring an air carrier to provide such a determination…..
  • The draft report suggests that there is no existing inspection team in place to periodically assess an air carrier’s SMS program. However, the National Certificate Holder Evaluation Program (CHEP) has been in existence since 2005….. The safety attributes directly correlate to the requirements in 14 CFR part 5 for an approved SMS. A CHEP team is required to perform an evaluation when a certificate holder’s risk Appendix. Agency Comments …factors increase. With enhancements, the Agency believes that the CHEP model can satisfy the OIG’s recommendation for a “team inspection approach.”
  • The OIG recommends “root cause analysis training for inspectors” and “Safety Management System training for inspectors that is specifically designed to aid inspectors in evaluating air carrier risk assessments.”

The Agency agrees that training in these areas is vital to the effectiveness of safety oversight, and the FAA intends to address the OIG recommendations for both types of training in parallel. In a December 2019, audit report, the OIG recommended additional root cause analysis training for inspectors, and in May 2021, the Agency provided an update to OIG stating that FAA would complete a competency assessment for aviation safety inspectors and engineers by September 2022. That competency assessment will form the basis for determining any necessary additional root cause analysis and SMS training revisions…

The Washington Post story


IG report questions effectiveness of FAA oversight of American Airlines’ aircraft maintenance program


Among the concerns raised by the DOT’s IG: whether FAA inspectors have the training to effectively do their jobs

AA Maintenance & Engineering Center Tulsa, OK

By Lori Aratani

October 22, 2021, at 8:07 p.m. EDT

A federal watchdog has identified gaps in the Federal Aviation Administration’s oversight of American Airlines, suggesting that federal safety officials who are charged with ensuring the carrier’s airplanes are properly maintained and safe to fly are lacking the training they need to do their jobs.

The report, released Friday by the Transportation Department’s inspector general (OIG), raises questions about the rigor of the FAA’s oversight, noting at least 20 instances in which inspectors closed out cases before American had fixed problems. The IG review also found that FAA rules at the time did not require inspectors to verify whether the airline had fixed issues before cases were declared resolved.

“To further enhance aviation safety, FAA must continue to lead and implement strong oversight controls to help ensure that American Airlines more closely analyzes risks to its operations, adequately identifies root causes of issues, and develops appropriate and effective corrective actions that will prevent reoccurrence of maintenance non-compliances,” the report said.

The IG identified several instances in which it said inspectors failed to push for a thorough analysis of problems. By not requiring American to identify the root cause of issues or by allowing the airline to blame “human error,” the agency missed opportunities to prevent the same problem from reoccurring, the report said.

The report, however, suggested that lack of rigor may not be the fault of inspectors, noting that the agency accepted “insufficient root causes in part because FAA inspectors were not adequately trained on root cause analysis.”

FAA SMS oversight chartIn an emailed statement, the FAA said it “agrees with many of the recommendations in the report and is taking steps to address them.” In its written response included in the IG’s report, the agency said it is “strongly committed to continuous improvement of that record and will continuously implement enhancements to our oversight programs as they are identified.” FAA root cause analysis

However, the FAA also defended its oversight approach, characterizing it as a “risk management-based approach that has sustained an exemplary safety record.”…


The findings were of concern to some lawmakers, including Rep. Peter A. DeFazio, (D-Ore.), chairman of the House Transportation and Infrastructure Committee, who along with Rep. Rick Larsen (D-Wash.), requested the IG’s review.


Today’s report reveals some troubling information regarding American Airlines maintenance and the FAA’s oversight of the airline’s maintenance program,” DeFazio said in a statement…

Under a new system adopted in 2015, the agency has taken a more collaborative approach to oversight, working with air carriers to identify and address problems. However, the IG report noted, nearly six years after the program was put into place, the FAA is still refining its guidance for inspectors.

The report raised concerns about the FAA’s ability to ensure that American accurately characterizes the level of risk posed by certain maintenance issues, noting that while this is the “most challenging part of the risk management process,” it also enables airlines to prioritize which issues to address most quickly…


FAA SMS picture


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