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IMPROVI NG Al RCRAFT SAF ETY FAA Certification of Commercial Passenger Aircraft Committee on FAA Airworthiness Certification Procedures Assembly of Engineering National Research Council NATIONAL ACADEMY OF SCIENCES WASHINGTON, D.C. 1980

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The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advis- ing the federal government. The Council operates in accordance with general policies determined by the Academy under the authority of its Congressional charter of 1863, which established the Academy as a private, non- profit, self-governing membership corporation. The Coun- cil has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineer- ing communities. It is administered jointly by both Academies and the Institute of Medicine. The Academy of Engineering and the Institute of Medicine were estab- lished in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Library of Congress Catalog Card Number 80-82605 International Standard Book Number 0-309-03091-9 Available from: Office of Publications National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America

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NATIONAL RESEARCH COU NCIL OFFICE OF THE CHAIRMAN 2101 CONSTITUTION AVENUE WAS H I N GTO N1, D. C . 2 0418 The Honorable Neil Goldschmidt Secretary of Transportation Washington, D.C. Dear Mr. Secretary: June 24, 1980 I have the honor to transmit the report entitled Improving Aircraft Safety: FAA Certification of Com- mercial Passenger Aircraft, prepared by the Committee on FAA Airworthiness Certification Procedures of the National Research Council's Assembly of Engineering and supported by Contract DTOS59-80-C-00028 with the Department. The report deals with one example of a genre of problems new to our age, i.e., the ability of govern- ment to minimize the risk to the public from a large, complex, sophisticated technological enterprise that contributes great public benefit attended by a very low probability of a major accident--in this case, the policies and procedures of the FAA for assuring the airworthiness of jet transport aircraft. Early in its report, the committee makes the following observation: "Aircraft safety demands a 'forgiving' design that is tolerant of failure, care- ful production that is of the highest quality, and excellent maintenance that gives painstaking attention to detail throughout the life of the airplane. The

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The Honorable Neil Goldschmidt June 24, 1980 Page 2 rare fatal accident that involves airframe or equipment is almost without exception the result of a failure of at least two, and occasionally all three, of these factors. n How to establish a reliable system of scien- tific and technological vigilance that polices without a garrison, that establishes technical standards while respecting creativity, innovations, and competition, that protects human life and the environment at costs that do not bar public enjoyment of the benefits is the challenge to FAA as it is to several other regula- tory agencies. The committee's task was complicated by the finding of significant deficiencies in a system that, never- theless, has operated with a good safety record. In- deed, it may not be overstatement to suggest that, had we been evaluating the regulation of a different tech- nology, aircraft safety could appropriately have been employed as a standard of excellence for comparison. How, then, can we impress a sense of urgency on recom- mendations for improving a good system, yet avoid alarming needlessly both passengers and purchasers of airplanes? One conclusion is evident: the technical sophistication of the responsible organization must not merely stand pat; it must keep pace with the ad- vancing state of the art, or risk falling dangerously behind and, hence, insufficient to its task. Concern for the latter eventuality is a major message of this report. The past safety record of the domestic airlines, (35 deaths per million landings in 1979), and the worldwide acceptance of U.S.-built airplanes, confirm that our nation's system for assurance of airworthi- ness has operated quite well. The committee finds,

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The Honorable Neil Goldschmidt June 24, 1980 Page 3 however, that this system can and should be better still, and warns against the perils of a complacency that it has detected. Noting that the past safety record is not necessarily a good predictor of future success, the committee calls into question the in- creasing technical domination of the agency by the industry it regulates and urges the FAA, as soon as possible, to centralize and upgrade the technical proficiency of its staff into a corps of rule-making and design certification engineers, and also to upgrade the skills and techniques of its force of production and maintenance inspectors. The committee's view of its findings as well as its recommendations will, perhaps, best be appreciated as a struggle toward an ideal. The barriers to attain- ment are, however, generic to government, particularly to regulatory agencies, rather than unique to the FAA, e.g., the conditions and rewards of government service as compared to those in the private sector. To achieve the recommended staffing quality and pattern and to maintain high morale and a sense of creative accost plishment in a well-established regulatory agency will require a substantial effort to those ends. But, only thus can the FAA be expected to maintain an appropriate relationship to the regulated industry, to assure a future safety record at least as good as that of the last decade, and thus to warrant some measure of shielding from the winds of political change. It should be appreciated that this report presents a limited approach to the entire scope of considera- tions relative to the FAA. By agreement, for example, aircraft engines, aircraft of foreign manufacture, and

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The Honorable Neil Goldschmidt June 24, 1980 Page 4 the consequences of the dual responsibility of the agency--to promote civil aviation as well as to assure its safety--were all outside the scope of this study and may warrant equivalent attention in the near future. Allow me to take this opportunity to convey the great appreciation of our institution to George Low for his incisive leadership of this difficult and sen- sitive task, to the entire committee for their dili- gence, zeal, high competence, and spirited public ser- vice, and to our staff for their valiant efforts to assure that the committee would complete its assign- ment on schedule yet in good conscience that all aspects of the airworthiness system relevant to their limited charge had been adequately appraised. Mr. Secretary, the National Research Council is pleased to make this report available to the Depart- ment of Transportation, the Federal Aviation Adminis- tration, the Congress, and to all Americans who share pride in and concern for aviation, a distinctively American enterprise. So Philip Handler Chairman, National Research Council President, National Academy of Sciences

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NATIONAL RESEARCH COUNCIL ASSEMBLY OF ENGINEERING 2101 Constitution Avenue Washington, D. C. 20418 COMMITTEE ON FAA AIRWORTHINESS CERTIFICATION PROCEDURES Dr. Philip Handler Chairman National Research Council Washington, D.C. Dear Dr. Handler: June 24, 1980 202/389-6677 It is my privilege to submit for transmittal to the Secretary of Transportation the report of the Committee on FAA Airworthiness Certification Procedures. Our assignment, at the request of the Secretary, was to undertake a six-month assessment of the adequacy of the Federal Aviation Administration's policies and procedures for certifying the airworthiness of commer- cial transport aircraft. Airworthiness is the aspect of air safety related to the design, manufacture, and maintenance of airplanes and does not embrace such other key safety matters as airlines and flight crew opera- tions or air traffic control, which are also within the province of the FAA. Public and official concern following the fatal accident of an American Airlines' DC-10 at Chicago's O'Hare Airport on May 25, 1979, surely precipitated the Secretary's call for our study. But it should be stressed that our charge was to review the overall cer- tification activity of the agency and not at all to review either the details of that or any other specific accident or the several reports of groups that examined in great detail the causes and circumstances of the Chicago crash. Our study involved questions about the efficacy of the nation's system for assuring both the traveling pub- lic and domestic and foreign purchasers that American- built aircraft continue to warrant their world-wide

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Dr. Philip Handler June 24, 1980 Page 2 reputation for safety, durability, and reliability. Since many of the committee's recommendations address what we find to be shortcomings in FAA practices and capabilities, it is important to remind the reader that this report is intended to help make a very good system even better. Indeed, the nation's commercial air travel system is the standard of the world for safety, dependability, and comfort. Throughout our deliberations, each member of the committee has been impressed by the scope and complexity of the activities under its review, the importance of a safe aviation system to our nation's economy and life style, and the enormous burden of responsibility placed on the FAA to regulate the aviation industry in the public interest. The elements comprising airworthiness are strongly interdependent, and our recommendations reflect this interdependence. Good people are needed, and they require workable regulations and current information, continued education and motivation, effective organiza- tion and leadership. Only when all of these are in Place can the FAA be most effective. Therefore, we hope that the Secretary of Transportation and the Adminis- trator of the FAA will implement our recommendations together as a package and not select one area over another for change. The issues addressed in our study are related to other aspects of air transportation safety that remained outside the scope of our examination or that we could not examine in the time available. Both Secretary Neil Goldschmidt and Deputy Secretary William J. Beckham invited us to identify additional issues worthy of more extensive and detailed examination. As it happens, a number of issues at the periphery of our review did arise with sufficient repetitiveness to suggest that they may indeed warrant closer scrutiny--namely: _ . . . . , . . ~ While our study was limited to what some have called the safest component of the aviation triad, the airplane itself, the other two elements--the national aviation system (air- ports, airways, and air traffic control) and . -

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Dr. Philip Handler June 24, 1980 Page 3 airline flight operations (flight crews, dispatchers, and meteorological services)--may need to be subjected to similar examination. . Aircraft engines, which were specifically excluded from the committee's charter, are cer- tificated in a manner similar to aircraft. The recommendations of our report should be evalu- ated for their applicability to engines. Deregulation has led to an increase in the number of airports where many airlines operate, placing an added burden on FAA inspectors. Another effect of deregulation is that commuter airlines are carrying more passengers at additional loca- tions. The general implications of airline deregulation for safety need to be examined. In addition, the emerging problems of commuter air- lines and their implications for FAA policies and procedures require study. In connection with the certification of commer- cial transport aircraft, our committee did not have time to conduct a detailed examination of three critical matters: the potential problems of an aging airplane fleet, the adequacy of the FAA's surveillance of subcontractors and sup- pliers, and the FAA certification of aircraft produced outside the United States and used by American carriers. None of these has been assessed adequately; each would benefit from careful and objective study. As a personal note, may I say that this study could not have been undertaken and completed by volunteers within six months without a well-balanced and hard- working committee of experts and a highly skilled and dedicated staff. I am grateful that you have provided me with both. Sincerely, '~,6C,~ ~ ~: George M. Low Chairman

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COMMITTEE ON FAA AIRWORTHINESS CERTIFICATION PROCEDURES GEORGE M. LOW, President, Rensselaer Polytechnic Institute, Troy, New York, Chairman RICHARD B. AULT, Former Vice President, Engineering, Western Airlines, Encino, California EUGENE E. COVERT, Professor of Aeronautics and Astronautics, Massachusetts Institute of Technology, Cambridge, Massachusetts BERNARD C. DOYLE, Former Chief, Investigations Division, National Transportation Safety Board, Bethesda, Maryland LLOYD E. FRISBEE, Former Vice President and General Manager, Engineering and Operations, Lockheed-California Company, Carson City, Nevada AARON J. GELLMAN, President, Gellman Research Associates, Inc., Jenkintown, Pennsylvania RAYMOND C. GERBER, Retired Captain, Pan American Airways, Amityville, New York DAVID C. HAZEN, Professor of Aeronautical Engineering, Princeton University, Princeton, New Jersey DONALD W. MADOLE, Partner, Speiser, Krause and Madole, Attorneys at Law, Washington, D.C. JAMES W. MAR, Hunsaker Professor of Aerospace Education, Massachusetts Institute of Technology, Cambridge, Massachusetts JOHN L. McLUCAS, Executive Vice President, Communica- tions Satellite Corporation, Washington, D.C. MAYNARD L. PENNELL, Former Vice President, Product Development, The Boeing Company, Seattle, Washington ALBERT L. UELTSCHI, President and Chairman, Flight Safety International, Inc., Flushing, New York SUSAN C. PERRY, Executive Secretary MICAH H. NAFTALIN, Special Assistant to the Chairman WILLIAM M. BLAND, Jr., Consultant JOHN H. ENDERS, Consultant ROBERT G. LOEWY, Consultant LAUREEN DALY, Secretary BARBARA DARR, Secretary DELPHINE D. GLAZE, Secretary FRANCES SHAW, Project Assistant xiii

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Preface In December 1979 the National Research Council was requested by the Secretary of Transportation, Neil Goldschmidt, to establish a "blue-ribbon" committee to assess the procedures and practices used by the Federal Aviation Administration (FAA) to assure the safety of commercial passenger aircraft. In making the request, the secretary asked that the study be completed no later than June 30, 1980. For its part, the Research Council accepted the commission, knowing full well that a six- month timetable to examine the complicated issues con- nected with FAA operations would require a knowledgeable committee working to a navigable course. The members of the committee were selected consis- tent with the Research Council's policy of providing expert competence and balanced viewpoints. The chairman, who is now president of Rensselaer Poly- technic Institute, was manager of the Apollo spacecraft program and, later, deputy administrator of the National Aeronautics and Space Administration. Other members of the committee include three academic authorities in aeronautical engineering; three former aircraft and air- line executives with experience in the design, manufac- ture, and maintenance of commercial airplanes; two members who were professional airline captains; an attorney in private practice who specializes in aviation law and regulations; a transportation economist; and two former government officials--one from the FAA, the other from the National Transportation Safety Board. The latter is also an engineer and attorney. Of the three elements that determine safety in com- mercial passenger aviation--the flight crew, the control of traffic, and the quality, or airworthiness, of the machine itself--the committee was charged to focus its attention on the airplane. Its study examined the ways xv

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in which the FAA approves the design, fabrication, and production of each new aircraft, as well as the mainte- nance and continuing airworthiness of each airplane. Concentrating on the large passenger aircraft used by the major commercial airlines, the committee's charter excluded from its study the certification of engines, airplanes operated by commuter airlines, businesses, and individuals, as well as aircraft under 12,500 pounds. These are regulated by separate, though similar, proce- dures. Although the committee learned about the airwor- thiness approval procedures in Great Britain and France, it restricted its concerns to understanding the important differences from the FAA process. The committee began its work with three days of public meetings in Washington, D.C., where it heard from the Department of Transportation and the FAA, from industry representatives, and from various aviation interest groups. The participants are listed in Appendix A. It visited production facilities and met with representatives of the three major U.S. manufac- turers--Boeing, McDonnell Douglas, and Lockheed. It spent a day in Seattle with staff members of the FAA's Northwest Regional Office and a day in Los Angeles with representatives of the FAA Western Regional Office. Of the 12 regional offices, these two are responsible for certificating the design and production of large trans- port aircraft built in the United States. The mainte- nance facilities, programs, and interactions with the FAA of Air Florida, United Airlines, and USAir were the subject of visits by members of the committee to the three airlines and with their corresponding FAA inspec- tors. In addition, committee members received briefings from the National Transportation Safety Board (NTSB), from the National Aeronautics and Space Administration tNASA), from the staff of the Government Activities and Transportation Subcommittee of the Committee on Govern- ment Operations, U.S. House of Representatives, and from representatives of the aviation authorities of the governments of Great Britain and France. Failures play a role in examining any system and determining its weaknesses. In the case of aviation, failures can result in fatal accidents. The committee reviewed a number of accidents and incidents that invol- ved malfunctions of aircraft. Some are used in the re- port as examples. Each is referred to usually by title, accompanied by commentary as necessary. For those xvi

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readers who want to know more about two significant accidents caused by the condition of the aircraft, materials drawn from the official reports are provided in Appendix B. The term "airworthiness," as defined by the FAA in briefings for the committee, refers to the safety and physical integrity of an aircraft, including its compo- nent parts and subsystems, its performance capabilities, and its handling characteristics. The practice of award- ing actual certificates for design, production, and air- worthiness has resulted in reference to the system as "certification," and to aircraft as having been "certifi- cated." Because both terms are widely used in practice and in the regulations, they appear throughout this report to describe the FAA's process of assuring the safety of aircraft. Other terms or acronyms used by those familiar with aviation but not known generally are defined when first introduced and also listed in the Glossary. A biblio- graphy, listing reports and other information made available to the committee is also provided. Throughout the study, the committee received unstint- ing cooperation from people in government and industry. In more than one instance, officials and staffs gave up weekends to meet with members of the committee. In par- ticular, FAA staff members replied to committee inqui- ries with documents and briefings on frequent occa- sions-. We are indebted not only to those who took the time to meet with us and make formal presentations, but also to those who helped prepare such material and pro- vided answers to questions, very often on short notice. Although this report was reviewed by individuals representing the National Academy of Sciences' Report Review Committee and the National Research Council's Assembly of Engineering, none of whom took part in the study, the findings and recommendations are those of the committee. . XV11

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Contents INTRODUCTION AND SUMMARY OF RECOMMENDATIONS Type Certification and Rule Making Production and Maintenance Leadership and Advice Concluding Remarks TYPE CERTIFICATION AND RULE MAKING FAA Personnel and Organization Designated Engineering Representatives A New Process for Type Certification The Need for Timely Rule Making Flight After Failure--A Specific Rule The Issue of Public Access PRODUCTION AND MAINTENANCE Quality Assurance in Production Maintenance Surveillance Licensing of Maintenance Personnel Page 1 5 10 13 15 19 20 29 31 33 40 44 49 50 53 58 Reassignment of Personnel 60 xix

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CONTENTS (Continued) The Manufacturer's Continuing Role Information System Damage to Primary Structure LEADERSHIP AND ADVICE A Senior Technical Advisory Committee Aviation Safety Policy Board 61 64 68 73 73 74 Selection of the Administrator and Deputy Administrator 76 Industry Responsibility REFERENCES APPENDICES A. Presentations at Public Meetings, January 21-23, 1980 B. Excerpts From Official Accident Reports Dan-Air Services, B-707, May 1977 American Airlines, DC-10, May 1979 Fatal Accidents Attributed Primarily to Airframe, Powerplant and Systems Failure on Jet Transport Aircraft GLOSSARY BIBLIOGRAPHY xx 76 79 85 87 87 95 101 103 113

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