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From the FAA Website:
“The Next Generation Air Transportation System (NextGen) is a large-scale FAA initiative to modernize the U.S. National Airspace System (NAS).”
“Through NextGen, the FAA has revamped air traffic control infrastructure for communications, navigation, surveillance, automation, and information management to increase the safety, efficiency, capacity, predictability, flexibility, and resiliency of U.S. aviation. NextGen’s scope includes airport infrastructure improvements, new air traffic technologies and procedures, and safety and security enhancements.”
“Through research and collaboration, NextGen is defining new standards and further advancing our global leadership in aviation. The FAA fosters international cooperation in evolving enhanced aviation technologies to improve airspace system safety and mobility around the world.”
Sounds great right? The only problem is the FAA’s NextGen modernization effort began over two decades ago, with more than $14 billion already invested. But what do we have to show for it other than misrepresented FAA claims? As calls grow for additional funding, critical questions remain unanswered: Can we trust DOT and FAA leaders to finally deliver on their promises this time? What safeguards must be in place to ensure a nationwide implementation within the next three to four years?
In this issue of The Aviation Watchdog Report, we dig into these pressing questions surrounding the future of air traffic control. We also explore air quality concerns, offer practical tips for emergency evacuations, and celebrate a special milestone: one of our team members has just graduated with a degree in aerospace engineering from the University of Virginia.
Recent incidents involving smoke and fumes in commercial aircraft have brought renewed attention to air quality in airline transportation. An LRD activation by the MAX LEAP 1B engine (see the Foundation January 27, 2025 letter to the NTSB) is one way that cabin or cockpit air supplies can become toxic within a few seconds. The Foundation calls on the FAA to immediately act on this serious safety issue. The LRD design flaw isn’t just about air quality--an airplane could easily be lost from such an event. What’s also concerning is the industry has known for many decades that cabin air quality can be harmful to crew members and passengers and done very little to address the problem. Pilots and flight attendants are at greatest risk of injuries due to their frequent exposure.
For decades aircraft manufacturers and air carriers have largely ignored or downplayed the issue claiming acute “fume events” are extremely rare and that harmful chemical levels are too low to be concerned about chronic exposure.
Of primary concern is the design of most aircraft environmental control systems. Highly compressed air is taken from the engine (bleed air) and fed to the air conditioning system. This unfiltered bleed air is cooled and mixed with recirculated cabin air. The recirculated air is fed through HEPA filters, but the bleed air is not. Should a seal or bearing fail or a system be over-serviced, super-heated oil or hydraulic fluid can enter the air conditioning system. Toxic chemicals could be mixed with the air supplied to either the cockpit or the passenger cabin. A notable exception to this is the “no-bleed architecture” design of the Boeing 787. Electric compressors supply the air required for environmental control.
A query of the FAA Service Difficulty Report (SDR) database reveals that problems with air conditioning, air distribution systems, and pressurization (JASC codes 2100, 2120, 2121) are occurring frequently on the most popular airliners: the Airbus and Boeing derivatives. In 2024 there were nearly 1,000 SDR’s for these issues. While most of these maintenance issues did not lead to acute fume events it reveals the vulnerability of the aircraft systems and could indicate a reduction in routine maintenance activities. The FAA estimates the occurrence of fume events is extremely rare with a rate no higher than 33 per one million flights. An LA Times’ analysis of NASA safety reports alone (voluntary reporting) counted 362 fume events in 2018 and 2019, and nearly 400 crew members or passengers who received medical attention and four dozen pilots who were described as impaired to the point of being unable to perform their duties.
Other estimates put fume events as high as 200 per million flights, roughly 20 per day worldwide. Even if the conservative estimate is accepted as accurate, it represents nearly four events per day worldwide.
Fume events can lead to catastrophic health problems. JetBlue Captain Andrew Myers was seriously injured on January 17, 2017 during an engine run up test at the Portland Oregon International Airport. The airplane filled with haze and a strong odor. Myers evacuated and fell down coughing in the jetway. Subsequently, he needed a cane to walk, suffered tremors, and had memory issues. In 2018 the FAA revoked his medical certificate with a diagnosis of toxic encephalopathy. This is a prime example of what is now called aerotoxic syndrome.
In June 2019, Southwest Airlines flight 3455 was evacuated and the pilot was removed in a wheelchair due to noxious fumes making him feel dizzy and lightheaded. When passengers asked what happened, Southwest reportedly blamed the rotten smell on a traveler's jackfruit.
On December 23, 2024, Swiss Air flight 1885, an Airbus A-220, filled with smoke. After an emergency landing, five crew members received medical attention and three crew and 12 passengers were admitted to a hospital. Tragically, a 23-year-old flight attendant died from his injuries a week later. His death is potentially linked to portable breathing equipment (PBE) he donned; the cause of death has been listed as oxygen deprivation. This fatality is a direct result of the toxic fumes in the aircraft.
Aircraft manufacturers and government regulators have taken little action to address fume events or implement changes to improve air quality. Over the last 40 years a series of studies have been mandated by Congress and/or contracted by the DOT or FAA starting in 1983 with congressional hearings. Studies by the National Academy of Sciences (NAS) and the National Institute for Occupational Safety and Health (NIOSH) have been conducted; however, sample sizes were low, and some focused more on airborne components such as bacteria or fungi rather than bleed air contaminants. A 1994 NIOSH study characterized the results as “in general, contaminant levels were low compared to existing standards.”
In 2004, the FAA established a National Center of Excellence (COE) for Airliner Cabin Environment Research which in 2007 was renamed the National Air Transportation COE for Research in the Intermodal Transport Environment (ACERite). This effort brought industry, academic, and government organizations together to conduct cabin air quality research projects over the following decade. The resulting resource page can be found here. According to the FAA Cabin Air Quality webpage, this research revealed “the existing design standards have ensured an acceptable cabin environment during normal operations,” and “the environmental control systems used in commercial transport category airplanes, when properly operated and maintained, provide an environment that is equivalent to or better than that of other forms of commercial transport.”
However, specifics about bleed air contaminants were not mentioned. Neither were engine oil additives like tricresyl phosphate (TCP) or tricresylortho phosphate (TOCP). The permissible exposure limit (PEL) for TOCP is only 0.1mg/m3, a miniscule amount. What exactly is “an acceptable cabin environment?” Lastly, how does the air quality change if systems are not “properly operated and maintained?” Fume events often occur due to worn, leaking, or failed seals and gaskets. Clearly not every component is properly maintained across the entire aviation industry.
In 2015 the FAA issued a document entitled, Aircraft Cabin Bleed Air Contaminants: A Review Final Report. The abstract includes this statement:
Included in Public Law 112-95 is the directive to “assess bleed air quality on the full range of commercial aircraft operating in the United States.” Carrying out such a mandate requires adequate funding to support required research.
In other words, despite legal mandates, the FAA did not conduct extensive air quality testing, identify potential health risks, or recommend corrective actions. In 2015 they were simply washing their hands of the issue by blaming funding constraints. The FAA acts like they are the only government agency that must manage technology project funding in phases across multi-year budget cycles. The agency takes no responsibility for the mismanagement of funds despite several DOT IG audits indicating otherwise.
Contrary to the above, (quoted in a December 2020 LA Times article) Boeing’s own expert at the time had a different opinion regarding air quality testing cost and practicality. Auburn University professor emeritus Ruel Overfelt said in a deposition that sensor technology that could be adopted for planes “could probably be bought off the shelf” and had been available for “more than 10 years.”
As a result of the 2018 FAA Reauthorization Act the FAA was once again required to evaluate cabin air quality. Per the Act:
“Section 326(d) directs the FAA to submit to the appropriate committees of Congress a report on the feasibility, efficacy, and cost-effectiveness of certification and installation of systems to evaluate bleed air quality.”
This required another study to determine if air quality can be tested, but no mandate to improve air quality. An initial report was published in December 2020, but it simply established the study participants and reviewed requests for information from aircraft manufacturers. The FAA estimated the study would take 54 months to complete. As of this writing there is no information available on the FAA website regarding this study results although a more exhaustive search revealed this material is available at the DOT National Transportation Library's Repository and Open Science Access Portal (RosaP). The documents were published from May 2022 to April 2025. In some cases, the data continues to be evaluated, and no substantial action has been taken by the FAA. Report details can be found here:
Aircraft Air Quality and Bleed Air Contamination Detection
The U.S. Congress has also failed to act as House bill “Cabin Air Safety Act of 2019” April 10, 2019, (S. 1112/H.R. 2208) failed to become law. The bill required annual training for crews and maintenance personnel, mandatory fume event reporting, a public online database detailing all fume events, and the installation of carbon monoxide detectors in commercial transport aircraft. The bill failed in committee but was reintroduced in 2023 as H.R. 1293 (118th). The bill was supported by ALPA and AFA but was again stalled in committee.
Finally, we reach the Safe Air on Airplanes Act, legislation introduced in congress in May 2024. According to a bill sponsor, Congressman Maxwell Frost of Florida,
“It’s unacceptable and a huge failure of the airline industry that the millions of passengers and crew flying daily are at risk of inhaling dangerous, toxic fumes and chemicals when they step onto an airplane.”
The bill requires filters on bleed air systems within seven years and eliminates bleed air for ventilation in “the coming years.” Likelihood of passage is no better than any previous legislation.
A series of papers have been written by John M. Lind, whose daughter, a flight attendant for a U.S. airline was injured in a fume event in January 2011. Lind’s work has included reports on the History, Root Causes, Engine Maintenance, Toxins identified, Carbon Monoxide, and Atmospheric Gasses. Lind’s comprehensive work as well as that of many others have had little effect on government agencies, manufacturers, or the airlines.
After over 40 years of research, mandated congressional actions, and input from pilots, flight attendants, and passenger groups the time has come for action. The airlines, manufacturers, and the FAA need to stop downplaying these fume incidents, stop dismissing flight crew health concerns, and stop claiming everything is alright. It clearly is not. Recommendations include:
1. Mandating targeted and more frequent maintenance of bleed air and air conditioning systems.
2. Filtering systems within bleed air supplies.
3. Future designs should incorporate no-bleed technology.
4. Installation of permanent air quality monitoring equipment.
5. Extensive studies to collect accurate air quality data to better understand the problem and solutions.
Everyone understands the importance of efficient air traffic control. Nearly three million passengers board commercial airplanes each day with a blind trust that the system is robust and reliable. We also assume the people working the radios and radar screens are well trained, well rested, and are comfortable with the awesome responsibility that comes with the job.
While air traffic controllers (ATCs) are some of the most intelligent and capable people you’ll ever meet, the system within which they work is antiquated, unreliable, stressful, and labor intensive. Chronic personnel shortages plague the system with many major airports, approach control facilities, and enroute centers currently manned at only 60-70% of target staffing levels. According to the FAA Air Traffic Controller Workforce Plan FY 2024-2033 the shortages are widespread and significant.
The personnel shortage has many causes and requires aggressive FAA action to solve in the near term rather than in another decade from now. The training pipeline is long, the dropout rate is as high as 40%, and graduates must work under supervision for years prior to becoming fully certified controllers. The FAA Academy is located on the 133-acre campus of Oklahoma City’s Mike Monroney Aeronautical Center and conducts the 16-week introductory training for ATCs. However, this is only the beginning as OJT, both in classroom and practical, will continue for years. 90% of an ATCs training doesn’t take place at the FAA Academy. In an average year the FAA hires barely enough ATCs to replace those retiring or those who fail to complete training. A mandatory retirement age of 56 along with full retirement available at 50 are also factors. If you’re looking for a career change you need to hustle as the maximum age for application is 30. In FY 2023 FAA hiring and training processes netted only 15 new trainees and FY2024 wasn’t much better with 36 controllers added.
According to the National Air Traffic Controllers Association (NATCA),
“It’s the FAA’s annual hiring targets themselves that are the problem. They are set by FAA Office of Finance and Management, which has no knowledge or expertise on air traffic operations.”
Nearly four decades ago the FAA initiated a plan to streamline ATC training by “off-loading” some portion of the training to colleges or universities. This began the AT-CTI (Air Traffic Collegiate Training Initiative). However, since 1997 this program has only allowed trainees to reduce their stint at the FAA Academy by five weeks. A recent upgrade to this program, the Enhanced AT-CTI, now allows elimination of the FAA Academy attendance if applicants have completed degree programs at accredited colleges and universities. As with most federal programs, real improvement and modernization comes painfully slow.
Not only is the hiring process failing by the numbers, but the system is also failing by not keeping up with technology and automation. Although the FAA Academy boasts that it “offers training on state-of-the-art equipment and techniques,” the real-world scenarios that ATCs face is often a different story despite the fact that the FAA has been developing the NextGen system for over 20 years at a cost of billions of dollars to taxpayers!
Did you know that paper strips are still used to pass aircraft information from one controller to the next despite the FAA attempting to go electronic since 1983? As transportation researcher Bob Poole notes:
On July 17, 2024, the Department of Transportation Office of Inspector General (OIG) issued a report on the slow progress of FAA’s program to equip U.S. airport control towers with electronic flight strips (to replace traditional paper flight strips physically handed from one controller to another). The bad news is that instead of only 89 towers scheduled to receive this improvement by 2028, there will now be only 49 towers equipped by 2029.
This is embarrassing and hardly world class.
In contrast, Canada upgraded their ATC technology over 15 years ago and have been joined by several other countries including the U.K., Australia, and Italy.
Airport Surface Detection Equipment, Model X (ASDE-X) is a system that is designed to assist ATCs in monitoring ground movement and local air traffic to reduce runway incursions or potential midair collisions near the airport. It is currently deployed to 35 major U.S. airports including DCA. The investigation into the January DCA midair collision is partially focused on ATC and the use of this system to warn controllers of imminent collision threats.
Improvements to ground surveillance systems to reduce runway incursions have been slowly implemented. A follow-on system to ASDE-X, ADS-B Airport Surface Surveillance Capability (ASSC), improves situational awareness in all weather. According to the FAA,
“ASSC fuses data to produce a highly accurate display for controllers to show aircraft and ground vehicles on the surface movement area, and on arrival and departure routes.”
Currently ASSC has been deployed to only nine U.S. airports. The busiest airports in New York, Atlanta, Denver, Chicago, Washington DC, Boston, and Los Angeles are not among those nine. With over 1,000 runway incursions occurring each year it is clear - our system is under stress and not working.
The FAA has been horribly slow to implement new technologies and become more efficient. Generally, a disaster must occur before the agency acts. The DCA tragedy is another horrific example of FAA mismanagement. According to CNN the NTSB uncovered 15,214 "loss-of-separation” events between helicopters and airplanes at Reagan National Airport (DCA) between October 2021 and December 2024. These events occurred when aircraft were within one nautical mile of each other and had a vertical separation of less than 400 feet. Additionally, there were 85 “near-miss” events where the aircraft were within 1500 feet horizontally and 200 feet vertically. This begs the question, if the NTSB had access to this data all along, why didn’t they do something to prevent the DCA accident? Isn’t their primary job accident prevention? The entire organizational structure is problematic as well. The FAA not only regulates the air traffic system, but it is also responsible for providing services. In essence they are regulating themselves. It’s time that the DOT force the FAA to immediately implement improvements. The DOT IG should also audit the FAA to determine the root causes of the FAA’s failures to implement the NextGen system.
Recent comments from DOT Secretary Sean Duffy are at least sending the right message.
“If we don’t build a brand-new system, there’s going to be failures and people will lose their lives,” Duffy said.
It is time to take action to overhaul the ATC system, fully staff open positions nationwide, recruit talented young people, and properly fund the FAA to accomplish all this expeditiously. It won’t help to talk about it for the cameras. We’ll only find ourselves in the same position in another decade with more innocent lives lost.
Emergency evacuation of an airliner is not something most people prepare for, yet nearly 3,000,000 passengers embark each day in the U.S. With recent dramatic evacuation events in mind, we should all be ready should such an event occur on your airplane. As the saying goes, “hope for the best, prepare for the worst.”
You need look no further than this month’s cover story to understand the circumstances requiring evacuation often include smoke and fumes. Flight crews may initiate an evacuation using the emergency exits at any time they feel it is the safest step to take. Rare or not, when it happens lives do hang in the balance. In fact, in Toronto on February 17th it was passengers who were left hanging upside down after their Delta jet, operated by Endeavor Airlines, impacted the runway, burst into flames, and rolled inverted. An emergency evacuation commenced, and amazingly all 80 people exited the aircraft with 21 injuries reported. Delta Airlines also experienced three smoke/fume incidents in quick succession requiring emergency evacuations in Atlanta. They also had an Airbus 330 engine fire in Orlando on April 25th.
On March 13th an American Airlines 737-800 experienced an engine fire at the gate resulting in an evacuation. Several minor injuries were reported but disaster was avoided in large part due to the outstanding response from the DIA Fire Department.
Then on April 1st an American regional jet operated by PSA also evacuated after landing in Augusta, GA following smoke/haze in the cabin.
So, what should we learn from all of this? First, understand that it does happen more frequently than you think, and you must be mentally and physically prepared to exit an aircraft quickly and safely. This is for your safety as well as the rest of the passengers and crew aboard. Remember, flight attendants will conduct a safety briefing; listen to their instructions. Always note where the two closest exits are located and plan the steps you’ll take should an evacuation become necessary. If you are sitting in an exit row you have an important role to play in an emergency. Take it seriously and understand your responsibilities. Additional FAA Evacuation tips include:
Photos circulating online show passengers doing exactly what they should NOT do. In the Denver incident passengers are clearly seen standing on the wing holding their carry-on bags. This is dangerous for everyone aboard. Also note that the B-737 over-wing exits do not include emergency slides. Passengers are expected to exit the aircraft quickly and turn aft towards the trailing edge of the wing. The flaps are to be lowered and used as an evacuation slide to reach the ground. In this case the flaps were in the up position leading to speculation that the flight crew did not initiate the over wing evacuation. The Denver passengers stood on the wing until ground crews brought portable stairs to the aircraft. This could have been disastrous as the jet fuel is contained in wing tanks… not where passengers should be standing while the aircraft burns.
The next time you fly ensure you are familiar with everything you’ll be expected to do in an emergency. Follow crew directions and live to tell the story after you’ve safely evacuated.
Nikita (call sign Angel) serves as a Flight Operations Analyst for The Foundation for Aviation Safety. Her primary role is monitoring global flight operations and analyzing emergency reports. Nikita has earned a reputation for her outstanding leadership, organizational, communications, and technology skills. She is a terrific individual with an extremely bright future.
We are proud to announce that Nikita has completed her studies at the University of Virginia, majoring in Aerospace Engineering. She plans to pursue a master’s degree in systems engineering. Her UVA studies included examining case studies on major engineering failures, such as the Columbia and Challenger shuttles, the Titan submersible, and the Boeing 737 MAX crashes.
Nikita was inspired to get involved as a volunteer with The Foundation for Aviation Safety shortly after listening to a presentation at UVA given by Ed Pierson.
“My professors instilled in me this sense of duty towards the Common Good–to create and design with end user safety as the utmost priority. At The Foundation, I feel honored to be supporting an altruistic mission and getting to work with such dedicated and talented people, while learning skills outside of my academic background that will help me become a better engineer not only in knowledge, but application.”
In turn, we are very proud of Nikita and appreciative of the difference she makes each and every day to further our mission.
Editor’s note: The Foundation is actively recruiting talented college students for our volunteer staff positions. If you’re a senior or graduate student and your major is engineering, aviation, aeronautics, communications, information technology, meteorology, aviation maintenance, or related fields - consider sending a resume to info@foundationforaviationsafety.org.
Thank you for reading this edition of The Aviation Watchdog Report.
The Foundation for Aviation Safety is joining accident victim family members in calling for DOT Secretary Sean Duffy to create an interagency aviation safety task force. For more information about this task force idea, check out our letter to Secretary Duffy.
If you were in charge, what would you do to improve aviation safety? Please let us know by sending us an email at info@foundationforaviationsafety.org.
Please let us know if your airplane experienced a safety related incident or if you would like to report on another safety related matter. Submit a Safety Report to us anytime.
Until next time, fly safe!
The Foundation for Aviation Safety Team
info@foundationforaviationsafety.org
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