September 2025 EDITION
Aviation Watchdog Report
ENTER NEWSLETTER
Editor, Randy Klatt
Go to Newsletter Archive

Introduction

In this issue of the Aviation Watchdog, you’ll find stories featuring serious lapses in leadership and transparency across the industry. This includes accident investigations that take far too long and are susceptible to bias and influence to chaotic ground evacuations caused by passengers failing to follow flight attendant instructions. When leadership fails the vacuum is quickly filled by those who can conceal, mislead, or lie for personal or corporate gain. The aviation industry is in dire need of strong leadership and transparency across all sectors. Without it the safety margin will continue to shrink. Thank you for reading; I hope you find the information useful and thought provoking.

Ed Pierson
Executive Director

Strong Leadership in Aviation Safety - It’s Crucial to Success

William M Allen
Boeing’s longest-serving President with tenure from September 1, 1945, until April 29, 1968.

Named one of the Great American Business Leaders of the 20th Century.

On the night he became CEO, he wrote down resolutions for himself in his diary:

Be considerate of my associates' views

Don't talk too much, let others talk

Make a sincere effort to understand labor's viewpoint

Perhaps more than any other industry, aviation is built upon the trust and confidence of all entities. The typical airline passenger is forced to trust that the aircraft they are boarding is well designed, manufactured, and maintained. But we also put our faith in the crew, baggage handlers, dispatchers, and ground crews. Then the bigger picture- is the national airspace system fully operational and can it safely handle 45,000 flights each day in the U.S? Big questions that many people just don’t ask. It’s hard to be confident in the aviation system when the media coverage is filled with bad news. Recent crashes including JeJu, Delta Connection, the PSA-Blackhawk midair collision, and Air India are extremely distressing to say the least. What is needed to restore the confidence of the flying public?

The answer is simple yet complex at the same time. With strong leadership comes stability, honesty, transparency, and the resulting confidence of those who use commercial air transportation. What we’ve seen over the last few years is far from ideal and in some cases unacceptable and even illegal. Leaders standing up and accepting responsibility for the mistakes and working tirelessly to fix the problems would restore the safety margin that the industry has worked so hard to achieve but has thrown away in recent years.  

The Boeing Company saga has been difficult to watch and extremely painful for those who are directly affected by the tragic events. It’s clear that the pursuit of profit overcame all other concerns leading up to the two 737MAX crashes in 2018 and 2019. What was missing was strong and effective leadership. When we look at leaders we expect to see honesty, integrity, selflessness, attention to detail, and clear communication. What we should not see is deceit, coverups, fraud, and heartless disregard for human life. This lack of leadership led to a faulty aircraft design and rushed manufacturing. That in turn led to two crashes, 347 lives lost, billions of dollars in lost revenue, and an incalculable reputational loss.

These events also led to a 20-month grounding of the MAX and a recertification of the aircraft. One could rightfully assume that this humiliating process would bring significant change for the better. Certainly, all MAX defects and design flaws would have been solved during those 20 months, and the current fleet would be as safe as any commercial aircraft.

Well, not so fast. Look no further than the Foundation’s 737 MAX Design and Manufacturing Problems Table. More than 30 safety issues including the Load Reduction Device, non-compliant crew alerting system, loose or missing hardware (Alaska 1282 door plug blowout is one example), insufficient bonding and grounding, and Spirit AeroSystems fuselage quality control problems.  

But leadership problems are not unique to Boeing. The current accident investigation of Air India flight 171 has lacked all the elements of solid leadership. Very little communication combined with a substandard preliminary investigation report has led to speculation and finger pointing. This investigation has all the hallmarks of a corporate media department tactical approach. Investigators are supposed to be independent of other government agencies, political pressures, and financial interests. They simply follow the facts as they are discovered and produce documentation that is clear and as definitive as humanly possible. Instead, there are months of inadequate communication and a preliminary report that raised more questions than answers. The only entities that benefit from withholding information and/or misleading information are those who have a financial interest in the outcome.

The JeJu 2216 investigation is another example of woefully inadequate leadership, transparency, and concise communication. Details of what was to be a “technical update” to the investigation was briefed to family members and the media. However, it appeared to family members as well as union representatives that the South Korean ARAIB was casting blame on the pilots for shutting down the wrong engine after the bird strike without a thorough release of all the facts. The briefing had to be cut short as the ARAIB speakers were being shouted down by victim family members.  

The investigation structure is problematic when considering who has access to the Investigator in Charge (IIC). Manufacturers, airlines, and unions are all routinely granted accredited representative status. Their knowledge and insight can be crucial to determining the accident causes; however, they all have inherent interests involving finances, stakeholders, and professional reputation. Without a determined investigatory body taking charge of the facts and the communication plan all credibility can be lost very quickly.

The Foundation for Aviation Safety is dedicated to informing the public about critical issues involving aviation safety. This includes holding our government officials and governing bodies accountable. Honest and thorough accident investigations are vital to solve the problems found and correct them in a timely manner. Leaders in those organizations must rise to the top and do their jobs to prevent further disasters.

Incident Transparency

Aircraft Emergencies and Diverts - More Transparency is Needed

The Foundation for Aviation Safety tracks emergencies and incidents around the world daily. In doing so it’s possible to see trends across airlines, aircraft models, and geography. However, this is a challenging task as specific information about these events is difficult to come by. The media is always eager to cover high profile emergencies and accidents but does a poor job of covering incidents and declared emergencies that land safely.

Airlines are reluctant to comment on any incidents. The usual statement includes only that the plane had a “technical issue”, the flight landed safely, and an apology for any inconvenience. Although most incidents are minor in nature and may not require detailed reporting, the absence of any detailed description of the event is tantamount to covering up what is really happening. Airlines are putting reputation and profits over disclosing the facts surrounding emergencies.

If a flight is forced to divert from their original destination something significant occurred on the aircraft. This may have nothing to do with the aircraft; it could be an issue with an unruly passenger or a medical emergency, for example. Such incidents are common, and these diversions are efforts designed to help maintain passenger safety. Generally, these diverts are reported by the airline with sufficient detail for the public to understand what happened. However, an aircraft malfunction is another story.

Often airlines do not issue any statement about an aircraft emergency. When a flight squawks the emergency transponder code 7700 it is an important event that deserves an explanation. Simply reporting this as a technical issue is insufficient. What sort of problem was it? Engine, avionics, pressurization, electrical, or hydraulic malfunctions serious enough to declare an emergency certainly should be publicly reported. Not doing so does accomplish one airline goal-- to downplay emergencies yet maintain the illusion of transparency by admitting an event occurred. But it also covers up the facts and prevents any detailed tracking of aircraft malfunctions and the resulting safety impact.

Aviation websites such as Aviation Herald occasionally report more details than were previously known about incidents. ATC recordings of the radio transmissions can be a reliable source of information. It can also come from passengers posting on social media or other news sources but rarely comes from the airline. The lack of detailed information is, in fact, a message stating “nothing to see here.”  But we all know there are recurring aircraft system malfunctions that should be made public. The more information the public has access to, the safer everyone will be. Hiding the details about in-flight emergencies does not promote aviation safety. Reputation should not be formed by the public affairs spin but by operational performance, safety record, and honest reporting.

Emergency Evacuation

Ground Evacuations Revisited

The July 26 emergency evacuation of American Airlines flight 3023 in Denver was yet another reminder that an emergency can happen at any time and passengers must be ready to act swiftly and appropriately. In this incident there was only one reported minor injury; however, there are many lessons to be learned from what occurred. The root causes of this dangerous brake fire incident must be identified and immediately resolved. There have been numerous reports of chronic problems with the brakes on 737 MAX airplanes. For example, cracks in brake clips. Boeing and the FAA know this is another serious defect that remains unresolved.

In the May edition of the Aviation Watchdog, we covered this topic with the story, “Emergency Evacuation- Are you Prepared?” If you haven’t read that article, we urge you to do so now. During a ground evacuation time is of the essence and each person on board must be prepared and able to act quickly to save lives.

During aircraft certification the FAA requires that all passengers must be able to evacuate the aircraft . Evacuation testing is required to ensure that a full plane can be emptied that quickly. Unfortunately, the tests are conducted in an unrealistic manner. The passengers are volunteers who know ahead of time what to expect, there is no real danger from a fire or other hazard, they are usually younger adults in good physical condition, and they are all wearing practical clothing. This is in stark contrast to what really happens in an emergency when the danger is real and panic can set in very quickly. The American 3023 evacuation took nearly five minutes to complete. Had the fire spread more quickly or entered the cabin there likely would have been many serious injuries or even fatalities.

Federal regulations mandate numerous specifications for aircraft seats. These are generally designed to ensure seats are crashworthy, fire resistant, proper restraints are installed, and the seat placement itself won’t harm occupants. However, specific dimensions and pitch (leg room) are left primarily to the airlines. Over the last 40 years airline seats have been getting narrower. This not only makes for an uncomfortable flight but can make it much more difficult to exit an individual seat or a row of seats.

There are specific aisle widths required by the regulations; however, they are shockingly narrow. The table below shows aisle widths for various aircraft sizes. An aisle on a typical airliner can be as narrow as 15 inches at the floor level. For comparison, the OSHA standard for a building egress route width is 28 inches wide. Simply getting out of your seat and egressing through the airplane aisle is a difficult task. Add a fire and smoke along with elderly people, crying children, and people insisting on carrying their personal belongings and you have a recipe for disaster.  

The most important thing you can do as a passenger is to be prepared for the worst. When you take your seat look around and identify the closest exit. Remember, it may be behind you. Count the number of rows between you and the exit so you can find your way to it in case of poor visibility. Wear comfortable clothing that won’t hinder your movement. Listen to the flight attendant briefing and follow all attendant orders during an evacuation. This is critical safety information that might save your life. This is especially important if you are sitting in an exit row. Additionally, if you are flying on a Boeing 737 variant remember the over-wing exits do not have emergency slides, and you must use the flaps to slide to the ground from the wing.

Lastly, please DO NOT carry out your baggage, purses, backpacks, or other possessions. You are not only risking your own life, but the lives of others around you. Each second you take to grab a bag is a second lost during the evacuation. Focus on getting out of the aircraft quickly and safely. As we covered in the May edition, but worth repeating, here are some FAA recommendations:

• LEAVE YOUR POSSESSIONS BEHIND.
• Stay low.
• Proceed to the nearest front or rear exit - count the rows between your seat and the exits.
• Follow floor lighting to exit.
• Jump feet first onto evacuation slide. Don't sit down to slide. Place arms across your chest, elbows in, and legs and feet together. Remove high-heeled shoes.
• Exit the aircraft and clear the area.
• Remain alert for emergency vehicles.
• NEVER RETURN TO A BURNING AIRCRAFT.

For additional information on seat sizes and legroom on various airlines and aircraft take a look at and . Seat Guru also offers charts covering all seat configurations and amenities offered by airlines worldwide - takes you to their short haul economy chart. Please take your passenger responsibilities seriously; lives do depend upon it.

Podcast Preview

Episode 28: Leadership, Integrity, and Transparency

In this episode of Warning Bells, Foundation for Aviation Safety’s Ed Pierson and Randy Klatt examine how leadership—or the lack of it—shapes aviation accident investigations. Drawing lessons from recent tragedies, including the Air India Flight 171 disaster, they discuss the crucial role of integrity, humility, and accountability in uncovering the truth. The conversation highlights the inherent conflicts of interest when manufacturers and regulators investigate their own products, the dangers of withholding factual information, and why thoughtful and experienced speculation can be both healthy and necessary when official reports are lacking or non-existent.
Collision Avoidance System

TCAS in the News

Collisions between airborne aircraft have been a serious threat since the inception of controlled flight. These collisions have become known as “midair” collisions. According to Merrium Webster, midair is defined as, “a point or region in the air not immediately adjacent to the ground.” Although not adjacent to the ground, midair collisions most commonly occur at low altitudes. They are more common near airports and often involve small aircraft, helicopters, military aircraft, and those flying under visual flight rules where the “see and avoid” doctrine applies. This was the case on May 12, 2021, when a Cirrus SR22 airplane, N416DJ, and a Swearingen SA226TC airplane, N280KL, were substantially damaged when they collided in flight while approaching to land at Centennial Airport (APA), Englewood, Colorado.

Fortunately, this midair didn’t result in any fatalities. The substantially damaged Swearingen landed safely, and the Cirrus pilot was able to deploy the emergency parachute.

There was a time when midair collisions were commonplace. The big sky little airplane philosophy worked most of the time but when it didn’t it usually meant significant loss of life. Unfortunately, definitive action is often taken only after a major disaster and on June 30, 1956, such . A United Airlines DC-7 and a TWA Super Constellation collided at 21,000 feet over the Grand Canyon. The resulting crashes claimed 128 lives and spurred progress in midair collision avoidance.

Fast forward to the July 25, 2025 near midair collision between a Southwest Airlines 737 and a Hawker Hunter. This close call became front-page news as the Southwest crew took evasive action to avoid a collision. Although the maneuver was not violent it did upset passengers, and two flight attendants suffered minor injuries. A resolution alert from the TCAS required the pilots to make the quick descent. So, what is TCAS and what does it do?

The Traffic Alert and Collision Avoidance System (TCAS) is transponder-based and designed to alert pilots of potential collision threats. TCAS is mandated by ICAO to be installed on all commercial aircraft over 12,600 pounds or authorized to carry more than 19 passengers. The system is independent of air traffic control and requires the use of Mode S transponders. Transponders in properly equipped aircraft continually monitor the nearby airspace by interrogating all transponders within range. Altitude, heading, and speed parameters are used to determine if a collision is imminent. TCAS provides a visual representation of all surrounding aircraft as well as aural warnings if another aircraft becomes a threat for potential collision.

There are two warning levels issued by TCAS. The first is a Traffic Alert (TA). As the name infers, a TA is an alert to the pilot that traffic is nearby and is worthy of the pilot’s attention. Beyond monitoring the location of the other aircraft no action is required of the pilot.

The second warning level is called a Resolution Alert (RA). Unlike the TA, an RA requires pilot action. TCAS has determined that a collision is imminent and will give the pilot aural instructions for immediate action. Examples of this would be a “climb, climb, climb” alert or a “descend, descend, descend” alert. Corresponding alerts are given to both aircraft involved. One aircraft would be alerted to “climb” while the other would be alerted to “descend.” Additional RAs will emphasize the alert. Those include “descend, descend NOW” or “increase climb.”

It's important to note that an RA is a mandatory order; it is not simply a cautionary alert or a recommendation. The pilot is required to follow the TCAS alert until the midair threat is resolved.

Airports pose the most likely scenario for a midair collision. Where multiple aircraft are arriving and departing often simultaneously to/from multiple runways. Although TAs are still active, RAs are inhibited at low altitudes to eliminate false warnings in congested areas. This was illustrated by the tragic midair collision between a PSA CRJ and an Army Blackhawk helicopter at DCA on January 29, 2025. The CRJ received a TA about 19 seconds prior to impact. However, RAs were inhibited, and no action was taken by the CRJ crew as they were focused on landing the aircraft.  The Blackhawk crew reported the CRJ in site and were obligated to ensure separation. However, it’s likely that the crew mistook another aircraft for the CRJ and never saw the CRJ prior to impact.

The rate of midair collisions has decreased significantly over the years; however, there are still between 15-20 collisions per year in the U.S. with 75% of these resulting in fatalities. TCAS is a great addition to the cockpit, but it isn’t an infallible system that eliminates all midair threats. Pilots must remain vigilant with their scans moving from inside to outside continually. See and avoid is still a primary skill that must be mastered, especially since not all aircraft have TCAS.

FAA

FAA Proposes Additional Data Concealment

The Federal Aviation Administration (FAA) is proposing to designate safety and security information, reports, data, and work products provided to the FAA from the U.S. Aviation Safety Team (USAST) and its membership as protected from public disclosure.

According to the public notice, the voluntarily provided information described in the proposed designation “is critical to the FAA’s safety mission because it supports a proactive and collaborative, data-driven strategy to reduce the risk of fatal and non-fatal accidents.”

Let’s review the past seven years and see how “proactive” the industry and FAA have been with their “protected” safety data.

On October 29, 2018, Lion Air Flight 610 crashed shortly after takeoff, killing 189 people. The cause of the crash was an erroneous flight control input into the Maneuvering Characteristics Augmentation System (MCAS). Investigators pointed to a mis-calibrated angle of attack (AOA) sensor, which was a replacement of the original AOA sensor after a series of electrical malfunctions. Also, in October 2018, though not publicly disclosed, the FAA substantiated Boeing whistleblower complaints of a dysfunctional component center that was supplying incomplete and defective electrical components to the 737 MAX production line. In addition, Boeing executives had internal reports of a 737 MAX “factory in chaos” yet took no corrective action.

However, Boeing secrecy began on the design side of the 737 MAX program. A congressional report highlighted Boeing meeting minutes from June 2013, stating, “If we emphasize MCAS is a new function there may be a greater certification and training impact.”  Boeing hid the flawed MCAS design from experienced FAA engineers who would have quickly identified the design flaw and forced a fix. Instead, the secrecy led to the Lion Air crash.

The concealment continued. Presumably for purely financial reasons, the truth about the flawed design and dysfunctional manufacturing was hidden from public view. Then, on March 10, 2019, Ethiopian flight 302 crashed, killing 157 souls because of another MCAS malfunction with electrical system precursor events.

When the 737 MAX was re-certified and back in service, the design and manufacturing defects continued to appear. A “bad batch” of stabilizer trim motors caused several emergency landings. Faulty electrical bonding and grounding led to additional unsafe conditions and more airplanes being parked until repairs were completed. Serious manufacturing defects led to a multitude of system failures. Ironically, the most “transparent” airline from 2021-2023 was Alaska Airlines. The Foundation released a report in late 2023, showing over 1,200 service difficulty reports on just over 50 MAX airplanes. According to one reporter we spoke with, the airline and the FAA characterized the failures as “routine”.  The reporter also indicated to us that FAA had recommended that Alaska Airlines stop reporting everything to the public and start “protecting” most of the data. The public reports quickly evaporated in December 2023.

Then, as if on cue, the Alaska Airlines door plug blew out on January 5, 2024. Boeing and FAA secrecy didn’t prevent it. In fact, their secrecy enabled it to occur.

Another 737 MAX design defect first appeared in March 2023, when the engine “Load Reduction Device” (LRD) triggered after a Southwest Airlines engine hit a large bird while departing from Havanna, Cuba. The passenger cabin filled with toxic smoke as a result of the LRD activation releasing heated engine oil (smoke) upstream of the bleed air system. Industry and FAA did nothing until a second occurrence on December 20, 2023. This time, the left engine was damaged by a large bird and the toxic smoke poured into the flight deck leading to a harrowing emergency landing in New Orleans. FAA investigators found this LRD design unacceptable but were forced to leak their concerns to the media because of the ongoing “secrecy” practices. It has now been more than two years since the first occurrence, and a design fix seems at least a year away. In this case, the non-disclosure has delayed a fix to this critical safety issue.

A final tragic example took place on January 29, 2025, when 67 people were killed in the collision of American Airlines Flight 5342 and an Army Blackhawk helicopter in Washington D.C. In the three years leading up to the crash, an investigation revealed over 15,000 loss of separation events (1.6% of all operations) and 85 “near-misses” at DCA airport. And yet, the mostly secret data was not acted upon. Adding insult to tragedy, the FAA released their public “hide the data” notice on July 30, 2025, the first day of the NTSB hearing into this crash.

In their public notice, the FAA did not cite a single example where concealment of data led to a safety improvement. We have many, many examples where data was hidden from public view and the result was catastrophic. Let’s stop hiding critical safety information.

The FAA is clearly trying to help the aviation industry conceal critically important safety information from the public, while trying to disguise it as a good thing--voluntary reporting.

The DOT and FAA should be focused on sharing safety data and solving the numerous engineering and manufacturing defects that still exist on Boeing airplanes instead of trying to conceal information from the public. For example, see of serious defects on 737 MAX airplanes that have yet to be resolved despite two fatal crashes that killed hundreds of people and another accident that could have easily resulted in the loss of a third MAX airplane. These defects pose unacceptable safety risks to everyone flying these airplanes.

The Foundation for Aviation Safety vehemently opposes the proposed FAA order.

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

REPORT A SAFETY INCIDENT/ISSUE
Click to report a Passenger or Safety incident / issue you have experienced or encountered