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Welcome to the June edition of the Aviation Watchdog Report. From everyone at The Foundation for Aviation Safety we send our heartfelt condolences to the families and friends of those lost in the tragic Air India Flight 171 crash. We realize this could have been our families or friends. It is a very sad reminder of the importance of aviation safety and how vulnerable the system can be. We are hopeful that a thorough and timely investigation will reveal the causes and that appropriate actions are immediately taken. We are also hopeful U.S. authorities—specifically, Boeing, the FAA, and the NTSB will be forthcoming and not withhold critically relevant information from accident investigators like we saw in the two Boeing 737 MAX disasters.
In this month’s newsletter each story involves a “compare and contrast” theme. This is not just a nostalgic journey about how things used to be, but a look at history with a safety perspective. The aviation industry has evolved far beyond what the Wright brothers could have ever imagined in their wildest dreams. Accident rates are a fraction of what they once were. But are we still making progress? Has a complacency set in as the aviation industry pursues profit over safety? Has government oversight become nothing more than a paper tiger? Read on as we dig into these questions by reviewing recent data, examine the evolution of some key decisions by the FAA and Congress, and reflect on a tragedy that could happen again.
A lot of people have been expressing concern over recent aviation mishaps. The mainstream media is always asking the standard question, “Is it safe to fly?” In response all we hear is that aviation is the safest way to travel. This is often supported by the statistics, but the Foundation is dedicated to looking further into the industry and has a more honest appraisal.
Aviation safety depends upon a vast team across many disciplines. This includes everyone from pilots and flight attendants to air traffic controllers, mechanics, dispatchers, line personnel, and many more. Redundant systems, quality assurance checks, consistent training, experience levels, and discipline all play into how safe the system really is. When this system works perfectly it is very safe. We have learned through extensive operations over many decades how to operate with a safety margin included. In most cases this allows for the singular human failure to occur without a disastrous outcome.
Therein lies the insidious threat to aviation safety. The critical safety margin has been eroded over the years. Complacency has crept into the industry along with a sense of invulnerability. Yes, until recently the U.S. hadn’t had a major airline crash since 2009. That is the good news, and unfortunately, the news that major industry players focus on. Just like the stock market, relying on past performance is no guarantee of future success. The industry has rested on its laurels so long that the safety margin is slipping away.
It has always been challenging to quantify how safe any endeavor truly is. The goal is zero incidents; this we can all agree upon. But how do we know that we are truly operating safely and not just lucky? We must look at how operations are carried out each day and look for the warning signs. Are steps taken to save time and money or are they taken to make the system safer? It is the Foundation’s opinion that the former is the reality today. Here are a few examples of how the safety margin has been eroded over the years.
• In recent years Boeing has removed thousands of quality assurance inspections during the manufacture of new aircraft including each 737 MAX. This speeds up production but is a clear reduction in the safety margin. The Alaska Airlines flight 1282 door plug blowout may have been prevented had more inspections taken place. This manufacturing error was not an isolated incident. Several other 737-9 MAX airplanes at both Alaska Airlines and United Airlines were also found to have incorrectly installed bolts and other issues in post-accident inspections. If the Alaska accident was caused by manufacturing employees failing to follow removal procedures, what are the root causes of these other manufacturing defects found on other Boeing airplanes?
• The National Transportation Safety Board (NTSB) was always heralded as the world’s foremost aviation accident investigation body. Although not a regulatory body, the NTSB has always claimed to be steadfast in finding root causes and making aggressive recommendations for corrective action. Given this, when did the NTSB start withholding documents that could be pertinent in a fatal airline crash? The Foundation provided several Boeing and FAA official documents to the NTSB last July related to the 737 MAX ET302 crash. The NTSB is obligated by international law and accident investigation standards to provide this relevant evidence to all the parties to the two MAX accident investigations--even though the accident investigations have been closed. These documents contain significant information that should be thoroughly investigated. In addition to helping explain the MAX accidents, further investigation could help explain manufacturing related electrical/electronic systems defects and other chronic production/quality control issues going on with Boeing airplanes. This information also points to a deliberate cover-up because these documents were not shared by Boeing or the FAA during the multi-year accident and criminal investigations. Why is NTSB Chair Jennifer Homendy refusing to share this vital evidence with her international peers and law enforcement? A disgraceful change in culture has taken hold over the last 10-15 years compromising industry safety and risking international trust.
• The air traffic control system in this country was at one time a shining example to the world. It now seems to be a laughingstock as we learn about the current use of paper strips, floppy disks, and outdated radar and communication systems. The FAA has had over 20 years to make infrastructure improvements with the NextGen initiative, yet has failed to do so despite spending billions of dollars.
There are many more failures, some are highlighted in this edition of The Aviation Watchdog. As you read these accounts it will be a lot harder to fall back on the platitude “flying is the safest mode of transportation.” Remember that safety isn’t an absolute, it is a moving target that can easily be influenced by expediency, greed, or neglect. This is especially true in aviation where a misstep can lead to hundreds of lost lives. Everyone in the system, all those mentioned above, must work together in a transparent and honest effort to act in the safest manner possible.
There is obvious inherent risk in aviation; we all know each flight can go wrong very quickly. Managing this risk is not easy, but it is imperative. Maintaining the safety margin accounts for a host of shortcomings, but there is a limit. When the margin is decreased through whatever means we risk more disasters like those we’ve recently experienced. There are no accidents, only predictable outcomes. When warning signs are ignored, when profit trumps established procedure, or when people are pushed too far by fatigue, stress, or both, we all know what will happen. We just don’t know exactly when or how bad it will be.
The Air India crash is the first total hull loss for the 787 since entering commercial service in October 2011. Unlike the production of multiple 737 versions over the years, the Dreamliner is a substantially new design. It isn’t just a bigger 737. Any comparison of the two would be an apples to oranges situation (except for Boeing’s corporate-wide engineering and manufacturing policies and processes). So, what is so unique about the Boeing 787?
The driving motivation for the 787 design was efficiency. In the competitive world of commercial air travel the airlines are looking for every advantage. It’s all about passenger seat miles, revenue miles, and reduced maintenance costs. Fuel cost is typically the highest expense for any airline so an airplane design that focuses on these efficiencies is very attractive. Additionally, to live up to the Dreamliner moniker the aircraft had to include a comfortable passenger experience. Here are the 787 highlights:
• The aircraft is largely a carbon composite structure. Aluminum skin protects only the leading wing edges and the engine nacelles. This saves significant weight.
• Engines with higher bypass ratios and higher-pressure ratio compressors mean more efficient fuel burn. The forecast was for a reduced fuel burn per seat of 20%.
• Fly-by-wire control surfaces eliminate cables and decrease weight.
• This is largely an electronically controlled airplane with six generators, several electric hydraulic pumps, and a ram air turbine. Boeing claims the more efficient power generation and distribution resulted in 20 miles less wiring than the 767.
• No-bleed architecture includes electrically powered air conditioning packs eliminating engine bleed air thereby increasing engine efficiency and improving air quality in the cabin. The wing anti-ice system is also electrically powered.
• The pressurization system limits cabin altitude to 6,000 feet. This compares favorably to other designs such as the 777 that have an 8,000-foot maximum. This improves passenger comfort.
The 787 airplane has been plagued with production issues and delays. The first flight of the 787 was scheduled for August 2007. What followed were years of delays due to incomplete software, supply chain problems, and traveled work. Traveled work means manufacturing work that is supposed to be completed in one area of the factory called a “flow day”, but due to manufacturing problems the jobs are delayed and completed later. Traveled work frequently results in cascading problems because factory workers cannot complete their jobs if prior jobs are not finished on-time.
On July 8, 2007, a prototype 787 lacking several major operating systems was rolled out of Boeing’s Everett, Washington factory. The aircraft continued to experience multiple delays, until its maiden flight on December 15, 2009, more than two years behind schedule. It was another two years before the airplane was certified. The first airplane was delivered to All Nippon Airways.
Although the 787 has operated for nearly 15 years without a major accident, there are still significant issues with manufacturing quality control and ongoing operational issues.
Airworthiness Directives (ADs) are defined by the FAA as unsafe conditions. The list of 787 ADs include:
• Multiple AD’s for water leaking into Electrical Equipment (EE) bays from lavatory plumbing and fixtures.
• Intermittent transponder failures.
• Seat track splices and floor beam side-of-body fittings constructed of the wrong metal alloy.
• Misalignment of the horizontal stabilizer pivot pin lockring in the final assembly process.
• Excessive gaps and pull-ups in the assembly of the forward pressure bulkhead.
On one hand, the 787 is a marvel of technology and a very efficient and modern airplane. On the other hand, after 15 years of service it is still plagued by manufacturing defects and poor quality control operations in Boeing factories. Production processes must be corrected, and the actions required by the AD’s must be completed as soon as possible. Airlines are given compliance deadlines to fix ADs. The extraordinarily extended compliance times for many of these AD’s is inconceivable and negligent in our opinion. Airline convenience should not drive the timeline.
As we’ve said many times, the aviation system is dependent upon all entities to do their jobs to provide safe travel for the millions of passengers that board airplanes each day.
In 2005, the FAA implemented the Organization Designation Authorization (ODA) program, fundamentally changing how airplanes are certified in the U.S. Under this regulation, manufacturers like Boeing were granted the authority to certify the design and production of their own aircraft—an essential duty that once belonged solely to the FAA. The FAA justified this shift by claiming it would allow the agency to focus on the most safety-critical issues. Nearly two decades later, it's time to examine whether this hands-off approach has served public safety—or failed it.
Even during ODA's early development, critics raised alarms. One commenter warned that moving from direct technical oversight to a broader "systems" approach would erode FAA’s authority and ultimately compromise safety. That warning has proven to be disturbingly accurate.
The FAA, at the time, even projected that manufacturers might one day select their own certifying engineers without FAA vetting—a prediction that came true with Boeing. This lack of independent oversight became a central issue following the tragic crashes of two Boeing 737 MAX aircraft. In response, Congress took action to reverse some of the ODA program’s most dangerous flaws.
Section 107 of the 2020 Aircraft Certification, Safety, and Accountability Act mandated a return to stronger FAA control. It restored the agency’s role in approving and removing engineers acting on its behalf and required the assignment of FAA safety advisors to monitor manufacturer-designated representatives. It also authorized $3 million per year (from 2021 to 2023) to bolster FAA staffing and oversight capabilities.
Critically, the law also introduced civil penalties for any manufacturer employee who tries to interfere with ODA unit members—through harassment, threats, or other means—and required ODA personnel to report any such interference immediately.
Unfortunately, the FAA’s failures have extended beyond certification and into airline oversight. In 2023, Alaska Airlines filed an unusually high number of Service Difficulty Reports (SDRs) for its new Boeing 737 MAX 9 fleet—averaging 107 reports per month in the first ten months. A Foundation report later suggested pervasive production defects. Instead of pushing for transparency, the FAA appeared to help reduce public reporting: by December, SDRs had mysteriously dropped to just 10.
Then came January 5, 2024. Alaska Airlines Flight 1282 suffered a catastrophic failure when a door plug blew out at 16,000 feet over Portland. It was a shocking, visible consequence of a broken oversight system—and clearly a preventable accident.
The FAA’s job is to regulate, not to enable misconduct or bury bad news. The public deserves an aviation safety agency that acts in the public’s interest—not one that delegates its authority and turns a blind eye when things go wrong.
The American historian and philosopher Will Durant once said, “History is always repeating itself, but each time the price goes up.” This variation on dozens of “history repeating” quotes is particularly applicable to aviation safety in the 21st century as the cost of a major accident is incalculable in both lives and treasure. When an accident occurs, it is vitally important to learn lessons from the tragedy so as not to repeat them.
On July 19, 1989, United Airlines flight 232 crash-landed at the Sioux Gateway Airport in Sioux City, Iowa. There were 296 passengers and crew aboard and 112 lost their lives. The survival of 184 people is miraculous based on the dire conditions the crew encountered. Could such a disaster occur today with a B777 or A330? Let’s take a close look at the root cause of this accident to find some answers.
Flight 232 departed Denver and was cruising at FL370 enroute to Chicago when the number two engine suffered an uncontained failure of the stage one fan rotor disk assembly. Significant damage occurred to the empennage as the fan disk departed the aircraft. This resulted in damage to all three hydraulic systems. With the loss of all hydraulic fluid the aircraft could only be marginally controlled by using asymmetric thrust on the two wing-mounted engines. The coordinated actions taken by the flight crew combined with cabin crew preparation, ATC assistance, good weather, and a well-prepared airport emergency response all contributed to saving a significant number of lives.
The NTSB investigation determined the fan disk failed due to “the presence of a nitrogen-stabilized hard alpha inclusion.” The titanium alloy used during manufacture was flawed and resulted in fatigue crack development. This defect was created during the final machining and/or shot peening process and was not detected by the inspections conducted by the manufacturer.
As aircraft manufacturing has grown into an international enterprise the supply chain has become long and complicated. Quality control, a key element to aviation safety, becomes more challenging. Unfortunately, situations like the United 232 manufacturing defect are happening today at an alarming pace.
The FAA has issued numerous Airworthiness Directives (AD) involving defective or non-compliant aircraft components in just the last few months. An AD is issued when an unsafe condition is discovered. Unfortunately, it is an extensive list, and we encourage readers to do their own research on regulations.gov, but here are a few examples:
FAA-2024-2721-0005 was prompted by “a manufacturer investigation that revealed certain high-pressure turbine parts in (GE) Model CF6 engines (CF6-80E1A2, CF6-80E1A3, CF6-80E1A4, and CF6-80E1A4/B) were manufactured from powder metal material suspected to contain iron inclusion.” Ironically, the hard alpha inclusion that ultimately led to the United 232 crash was also in a CF-6 engine albeit a much older version.
A similar AD (FAA-2025-0621-0001) includes replacing high pressure turbine parts containing iron inclusions in certain CFM LEAP-1B engines used in the 737 MAX aircraft. Additionally, another AD (FAA-2024-2424-0004) was issued concerning certain low pressure turbine disks made from forgings with nonconforming grain size in LEAP-1A, LEAP-1B, and LEAP-1C engines.
Manufacturing defects are not limited to engine parts. FAA-2025-0749-0001 is a proposed AD prompted by “reports of multiple supplier notices of escapement (NOEs) documenting pressure deck splice fittings that were possibly manufactured with an incorrect titanium alloy material.” Although not a critical engine component the FAA is concerned that these fittings could fail under limit loads thereby compromising aircraft structural integrity.
Another AD (FAA-2024-1301-0012) has been issued related to floor beam side-of-body fittings that have been manufactured with an incorrect material type. This AD is for certain Boeing 787-9 and 787-10 models.
The only good news in this disappointing list of defects is that manufacturers are finding these problems and reporting it to the FAA who in turn issues Airworthiness Directives. Some might say the system is working as it should. However, the process should be better than that. Additionally, the clock is ticking as each day these aircraft continue to fly with seemingly no urgency to complete corrective actions. Often the AD compliance time is several years long. For example, an airline may have two years to inspect the fleet to determine if a faulty part is installed, yet if found the part must be replaced prior to further flight. If the defect is that serious why are the compliance times so lengthy?
The tragic crash of United flight 232 occurred almost 36 years ago yet there are still lessons to be learned from it. There are many elements involved in keeping the flying public safe, some of which are very difficult to control. But maintaining a safe supply chain that leads to building safe airplanes with properly manufactured parts is certainly something we should be able to do with today’s technology. The United 232 NTSB report includes this recommendation:
“Intensify research in the nondestructive inspection field to identify emerging technologies that can serve to simplify, automate, or otherwise improve the reliability of the inspection process. Such research "should encourage the development and implementation of redundant ("second set of eyes") inspection oversight for critical part inspections, such as for engine rotating components.”
When profit trumps all it is often product quality that suffers. But aviation is so unforgiving; these defects are simply not acceptable. They can be missed during both the manufacturing process and in routine maintenance if an effective quality control system isn’t in place. The systematic removal of inspections that Boeing has undergone is a complete rejection of the lessons we should have learned from United 232. Redundant processes and a robust QA system are vital to aviation safety. Manufacturers and airlines must work together to prevent further accidents.
Thank you for reading this edition of The Aviation Watchdog Report.
"Passengers shouldn’t have to rely on whistleblowers to provide the truth. They should be able to get on airplanes and not have to worry about what model it is, whether it was designed and manufactured to the highest of standards, whether the airline is operating and maintaining it properly, or whether government agencies are providing proper oversight. Americans pay billions of dollars for regulatory oversight of the airline industry. That money is currently wasted and drowning in broken promises. Government officials brag about the U.S. aviation system being the gold standard. There is a reason aviation has been historically safe, and that’s because people worked extremely hard for decades making substantial changes. They told the truth, they admitted their mistakes, and they didn’t downplay safety incidents."
~ U.S. Senate Permanent Subcommittee on Investigations, April 17, 2024
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