July 2025 EDITION
Aviation Watchdog Report
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Editor, Randy Klatt
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Introduction

Welcome to the July edition of the Aviation Watchdog Report. Global focus on aviation safety has intensified following the release of the Air India 171 Preliminary Investigation Report. This issue provides the Foundation’s analysis of the report’s contents and, critically, highlights what remains unaddressed. The Cover Story examines the disturbing influence of financial incentives on adherence to safety fundamentals. Additional articles discuss the intended function of Safety Management Systems and underscore the significance of flight crew duty periods and mandated rest requirements. Lastly, don’t miss the latest edition of Warning Bells. I hope you find these stories as interesting and thought-provoking as I do.

Ed Pierson
Executive Director

Cover Story: Is Safety Taking a Back Seat to Financial Gains?

In 1986, Wall Street investor Ivan Boesky gave the commencement address at the UC Berkeley School of Business Administration. His speech included, “Greed is all right, by the way. I want you to know that. I think greed is healthy. You can be greedy and still feel good about yourself.” This speech was the inspiration for the movie Wall Street starring Michael Douglas as the notorious Gordon Gekko. Boesky, once highly successful, was convicted of filing false trading records in 1987, paid a $100 million fine for insider trading, and received a three-year prison sentence. Maybe greed isn’t good after all.

Financial decisions amongst aircraft manufacturers, airlines, and even federal agencies often overshadow critical safety issues. Shareholder profits, passenger seat mile calculations, and fuel conservation are all top-of-mind for airlines. Manufacturers are concerned with labor costs, efficient supply chains, and production schedules. Federal agencies like the FAA or NTSB are seemingly under continual budget constraints.

At first glance this makes sense. After all, aviation is a massive industry and the mighty dollar is vital for continued operations, infrastructure investment, and future expansion. But at some point, these pressures can influence decisions that put employees and the flying public at risk. Examples of this are often so blatant as to be shocking.

The manufacturing issues within the Boeing factories are well known at this point. As one former Boeing employee told the Foundation, “Schedule is king.” Driving employees to complete work within aggressive time constraints is a clear example of unsafe work practices. Mandatory overtime is commonplace if jobs are not completed on schedule. This leads to rushed work and an increased potential for manufacturing errors. Combine this with the elimination of thousands of quality assurance inspections and it becomes clear why Alaska Airlines Flight 1282 suffered a door plug blowout. The desire for profit created the culture that resulted in a near disaster and certainly eliminated any profit in the near term.

As reported in Flying Magazine, on March 20, 2024, the Boeing CFO at the time, Brian West, told a Bank of America Global Industrials Conference in London, "For years, we prioritized the movement of the airplane through the factory over getting it done right, and that’s got to change." While there is consensus that change is necessary, it remains to be seen whether Boeing has effectively improved its manufacturing processes. Key considerations include whether the company is now prioritizing safety over profitability, addressing employee feedback, and implementing effective solutions on the factory floor. Successful progress in these areas could enable Boeing to meet production targets and deliver safer aircraft.

The question of whether commercial aircraft can be safely operated by a single pilot remains a subject of ongoing analysis within the aviation industry. Airlines seek to lower labor expenses, while manufacturers are interested in advancing and marketing new technologies. As highlighted in this NASA study, this issue has been under examination for several years. Although theoretical models have increasingly aligned with practical realities, pilots continue to play a vital role in ensuring airline safety. The presence of a two-pilot crew provides an additional layer of oversight, which can be critical for safe operations.

In 2021, ICAO (International Civil Aviation Organization) funded the European Union Aviation Safety Agency (EASA) to conduct the Extended Minimum Crew Operations – Single Pilot Operations (eMCO-SiPO) project. The overarching goal was to determine if current technology could allow fewer pilots in the cockpits of commercial aircraft. eMCO would allow single-pilot operations while in the cruise phase of flight while SiPO would allow end-to-end single piloted options.

Fortunately, this recently released study has determined that current technology and cockpit configurations do not support a sufficient level of safety and EASA has suspended progress on authorizing single-piloted operations for commercial aircraft.

Airline labor costs and employee manning levels are the only reasons these options are desirable. Automation has certainly come a long way over recent decades and the industry has navigated the transition from three flight crew members to two while still providing an acceptable level of safety. However, moving from two pilots to one is significantly more challenging and wrought with safety concerns. The second pilot is often critical in high workload phases of flight, during difficult weather conditions, or during emergency or abnormal operations. Several examples of this include the Alaska Airlines Flight 1282 door blowout. The first officer has said, “I’m thankful that there were two flight crew members in the flight deck as it enabled us to work as a seamless team in returning to the ground safely.”

In February 2024, Lufthansa flight LH1140's first officer suffered a seizure while alone in the cockpit. Security measures delayed the captain's reentry by 10 minutes, leaving the aircraft temporarily without a pilot and highlighting the safety risks of single-pilot operations.

General aviation aircraft are often single-piloted. However, even in this environment of smaller aircraft the second set of eyes can be extremely valuable. The tragic Cessna Citation S550 crash in San Diego involved a single pilot who made poor decisions throughout the descent and approach. Could a second pilot have been helpful in preventing this crash? We will never know for sure, but it is likely.

Flight attendants are crucial to aviation safety, handling emergency procedures both on the ground and in flight. According to federal regulations, specifically CFR 121.391, at least one flight attendant is required for every 50 passenger seats.

However, American Airlines just received an exemption to decrease the number of flight attendants from eight to seven on their B787-9P, a configuration with an increased number of business class suites. This number is still more than the required minimum but raises safety concerns. The Association of Professional Flight Attendants (APFA), representing 28,000 American inflight crew members, objected to American’s plan. In December 2024, the flight attendant union said that it “is unrealistic and unsafe to expect that seven Flight Attendants can adequately serve and ensure safety under the new configuration of the 787-9P, especially with an increase to 51 private Business Class Suites.” With eight exit doors this reduced staffing requires one flight attendant to be assigned to two widebody exits during an emergency evacuation.

American has stated that this flight attendant decrease provides more flexibility in scheduling and could reduce delays and flight cancellations in the future. Their focus remains on financial and operational goals rather than the safety of the flying public.

Commercial aviation depends on a consistent system-wide approach to incident and accident prevention. Decades of experience have taught us that cutting corners in pursuit of financial gains can lead to disaster. One major incident can be extraordinarily expensive both in dollars and human loss and suffering. Even Ivan Boesky might agree that there is no place for greed in the aviation industry. Recent global accidents highlight the need to prioritize aviation safety.

JULY 2025

Air India Flight 171 Update

The Aircraft Accident Investigation Bureau (AAIB) preliminary report for the June 12 Air India Flight 171 crash was released on July 11. Although the report has been widely interpreted as pointing to intentional or inadvertent pilot actions, there are glaring omissions, and any finger-pointing appears to be premature. The Foundation recognizes a familiar pattern in this report; imply pilot blame, while diverting attention away from other potential aircraft system failures.

The first obvious area to scrutinize is the aircraft electronic/electrical system. The surviving passenger talked about lights flickering, which would suggest that the electrical system should be carefully examined. However, no statements on the electrical system operation were provided in the preliminary report.

In addition, there are recent airworthiness directives (ADs) that identify several electrical issues on the 787. One AD specifically pointed to “uncommanded activation of the fuel shutoff function for an engine” (). Several others document water leaks into the electronics equipment bay (, , and )

Beyond the electrical issues, the FAA issued a Special Airworthiness Information Bulletin (SAIB), warning of fuel control switches which were installed with the locking feature disengaged (mechanical, manufacturing issue). On July 11, in response to the preliminary accident report, FAA issued a Continued Airworthiness Notification for the International Community (CANIC) inexplicably stating that faulty fuel control switches are NOT unsafe. Due to the locking mechanism on the fuel control switch, the cockpit voice recorder (CVR) should have detected the distinctive clicking sound if the pilots operated the switches yet there was no mention of this in the preliminary report. Including the entire CVR transcript would have been very helpful in clearing up much of the ambiguity, especially including the seconds between fuel cutoff and the “mayday” radio transmission.

The scrutiny of maintenance records revealed that the throttle control module was replaced on the accident airplane (VT-ANB) in 2019 and 2023. The preliminary report says the reason for the replacement was not linked to the fuel control switch. What was it linked to?

Yet another area to be investigated is a software issue that occurred on an ANA 787, leading to an uncommanded shutdown of both engines after landing. ()

At this stage of investigation, there are no recommended actions to B787-8 and/or GE GEnx-1B engine operators and manufacturers. Airlines and regulators should, at the very least, inspect the locking mechanisms for the fuel control switches, inspect the electronics equipment bay for evidence of water leaks, and demand a complete report of possible electrical, electronic (avionics), and software failure scenarios of the fuel control system.

There is urgency here, and the tired old phrase, “wait for the final report” is unacceptable.

FAA REQUIREMENTS

Understanding Safety Management Systems and FAA Requirements for Airlines and Aircraft Manufacturers

Safety Management Systems (SMS)
Safety Policy and Objectives
Safety Risk Management
Safety Assurance
Safety Promotion

Aviation safety has always been a cornerstone of the air transportation industry. As technology advances and the skies grow ever more crowded, the need for systematic approaches to managing risks and promoting safety has become increasingly important. In recent months there have been several major accidents including the mid-air collision at DCA, the CRJ-900 crash in Toronto, and the Air India 787 crash. Safety systems failed in these accidents, and it is time that operators and manufacturers review their safety programs for effectiveness as well as compliance.

The Federal Aviation Administration (FAA) has established clear requirements and guidelines for Safety Management Systems (SMS) implementation. Although these organizations have had safety programs in place for decades, SMS codifies the system, is extremely comprehensive, and mandates compliance.

A SMS is a structured, systematic approach to managing safety risks in an organization. It provides a framework that integrates safety into the organization’s daily operations, ensuring that safety is not an afterthought but a central aspect of decision-making, culture, and performance.

SMS is defined by the International Civil Aviation Organization (ICAO) as "a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies, and procedures." SMS is typically built around four key components:

·      Safety Policy and Objectives: This establishes senior management’s commitment to safety, outlines the organization’s safety objectives, and defines the roles, responsibilities, and accountabilities for safety within the organization.

·      Safety Risk Management: This is the process of identifying hazards, analyzing and assessing associated risks, and implementing controls to mitigate those risks.

·      Safety Assurance: This component ensures that the SMS is functioning as intended through performance monitoring, audits, evaluations, and the ongoing assessment of safety risk controls.

·      Safety Promotion: This involves training, communication, and continuous improvement, ensuring that a positive safety culture is fostered throughout the organization.

Rather than waiting for accidents or incidents to occur, organizations with SMS seek to identify and address potential safety issues before they escalate. This approach should lead to a reduction in accidents, an improved safety culture, consistent regulatory compliance, and efficient resource allocation for safety initiatives.

The FAA’s adoption of SMS requirements aligns with , which calls for member states to implement SMS in their aviation sectors. In 2015, the FAA published its final rule requiring Part 121 certificate holders (scheduled airlines) to implement SMS. Since then, the FAA has been expanding SMS requirements to other sectors, including Part , aircraft manufacturers, maintenance organizations, and airports.

The primary regulatory framework for SMS for airlines is found in , which applies to all Part 121 certificate holders operating in the United States. The key FAA requirements are as follows:

·      Establishment of an SMS: Airlines must develop and maintain an SMS that is appropriate to the size, nature, and complexity of their operations.

·      Accountable Executive: Each airline must designate an accountable executive responsible for the implementation and oversight of the SMS, including the authority to allocate necessary resources.

·      Documentation and Recordkeeping: Airlines are required to document all aspects of their SMS, including policies, procedures, hazard reports, risk assessments, performance monitoring, and corrective actions.

·      Employee Participation and Safety Reporting Systems: Employees must be involved in safety reporting and encouraged to participate in the organization’s safety efforts without fear of reprisal.

·      Risk Assessment and Mitigation: Identified hazards must be assessed for risk and, where necessary, mitigation strategies must be developed, implemented, and tracked for effectiveness.

·      Training and Communication: Training programs must be provided to ensure all staff understand their safety responsibilities, and safety information must be communicated throughout the organization.

The FAA has extended SMS requirements to aircraft manufacturers, particularly those holding a Production Certificate, with the aim of embedding safety principles into the design, production, and continued airworthiness of aircraft. Like airlines, manufacturers are required to establish an SMS that includes the fundamentals listed above. But it must also include hazard analysis in design and production, safety performance monitoring, and supplier and subcontractor management.

While the framework for SMS is widely accepted, practical implementation poses challenges, including resource allocation, fostering a safety culture, and integrating SMS with existing systems. Securing top management commitment and engagement is the first step, but this cannot be simply talking the talk. The program must be consistent and collaborative from the top to the bottom within an organization.

The FAA mandates SMS implementation but struggles to monitor compliance. What has occurred in the Boeing factories that resulted in two crashes and a door plug blowout are clear example of safety failures in both the manufacturing process and regulatory oversight.

Safety Management Systems represent a proactive, comprehensive, and data-driven approach to managing safety in aviation. By establishing SMS requirements for both airlines and aircraft manufacturers, the FAA aims to embed a culture of safety that permeates every aspect of aviation operations, from design and manufacturing to flight operations and maintenance. However, continued operational safety must be organic within aircraft manufacturers and operators. Claiming to have a comprehensive system in place does not make it so.

Podcast Preview

Episode 27: Why Transparency Matters – Aviation Investigations, Accountability, and Safety

Join host Ed, Joe, and Randy as they sit down with Juan Browne—airline captain, Air Force veteran, and the voice behind the Blancolirio aviation channel—for an unfiltered conversation about transparency in aviation investigations, healthy speculation, and why the aviation community deserves timely access to factual data.
Rest Requirements

Crew Duty and Rest Requirements

Earlier this month became a marathon journey around South America as it attempted to complete its flight from Frankfurt to Buenos Aires. The 20-hour trip included two diverts, a mayday for crew fatigue and fuel concerns, and ultimately flight cancellation.

Declaring an emergency for crew fatigue is an unusual occurrence, but one that shines a light on the issue. Extended flights are physically and mentally demanding for all crew members aboard long-haul flights. The crew had timed out and considering the insidious nature and detrimental effects of fatigue it was likely a very good decision.

Flight crew time limitations and rest requirements are governed by of the FARs. These include 1,000 total flight time hours per year, 100 hours per month, 30 hours in any seven consecutive days, and 8 hours required between rest periods.

The regulation continues with an incredibly detailed paragraph addressing the 24 hours preceding a duty day. Specifically:

(b) Except as provided in paragraph (c) of this section, no certificate holder conducting domestic operations may schedule a flight crewmember and no flight crewmember may accept an assignment for flight time during the 24 consecutive hours preceding the scheduled completion of any flight segment without a scheduled rest period during that 24 hours of at least the following:

(1) 9 consecutive hours of rest for less than 8 hours of scheduled flight time.

(2) 10 consecutive hours of rest for 8 or more but less than 9 hours of scheduled flight time.

(3) 11 consecutive hours of rest for 9 or more hours of scheduled flight time.

As mentioned, there are exceptions to these restrictions as you would expect for any government regulations. Click on to see the exceptions provided in paragraph C.

Similarly, flight attendants are subject to a set of duty time and rest requirements in 14CFR 121.467. Generally, flight attendants are limited to a 14-hour duty day followed by 10 hours of rest. This is for domestic and flag operations. A carrier can assign longer duty days if it also assigns additional flight attendants to the flights to provide ample break time. A scheduled duty day of 20 hours is legal for international flights if the carrier includes three additional flight attendants beyond the required minimum.

The rules ensure crew members get enough rest to maintain their physical and mental health, especially given the demands of long flights, changing time zones, and high responsibility. Flight delays or cancellations due to crew "timing out" prioritize safety, ensuring that crew are alert and well-rested rather than overworked.

The Foundation for Aviation Safety calls for extending rest requirements beyond pilots and flight attendants to all aviation professionals vital to airplane safety—including maintenance workers, manufacturing employees, air traffic controllers, flight dispatchers, and ground crews.

CLOSING

Closing Thoughts

Thank you for reading the Aviation Watchdog Report. Your continued support for the Foundation and interest in aviation safety is vital to making the industry safer for everyone.

The Foundation for Aviation Safety Team

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