Audit Reports

-A A +A
skip-to-content

FAA Has Not Effectively Overseen Southwest Airlines’ Systems for Managing Safety Risks

Self-initiated
Project ID: 
AV2020019
What We Looked At
On March 9, 2015, the Federal Aviation Administration (FAA) established requirements for air carriers to implement a formal, top down approach to identifying and managing safety risks, known as safety management systems (SMS). However, recent events have raised concerns about FAA’s safety oversight, particularly for Southwest Airlines, one of the largest passenger air carriers in the United States. In early 2018, our office received a hotline complaint regarding FAA’s oversight of Southwest Airlines and a number of operational issues at the carrier. Then, in April 2018, Southwest Airlines Flight 1380 suffered an engine failure that resulted in the first U.S. passenger fatality in over 9 years. We initiated an audit to assess FAA’s oversight of Southwest Airlines’ systems for managing risk.
 
What We Found
Our review identified a number of concerns regarding FAA’s safety oversight of Southwest Airlines. First, Southwest Airlines continues to fly aircraft with unresolved safety concerns. For example, FAA learned in 2018 that the carrier regularly and frequently communicated incorrect aircraft weight and balance data to its pilots—a violation of FAA regulations and an important safety issue. Southwest Airlines also operates aircraft in an unknown airworthiness state, including more than 150,000 flights on previously owned aircraft that did not meet U.S. aviation standards—putting 17.2 million passengers at risk. In both cases, the carrier continues operating aircraft without ensuring compliance with regulations because FAA accepted the air carrier’s justification that the issues identified were low safety risks. Second, FAA inspectors do not evaluate air carrier risk assessments or safety culture as part of their oversight of Southwest Airlines’ SMS. This is because FAA has not provided inspectors with guidance on how to review risk assessments or how to evaluate and oversee a carrier’s safety culture. As a result, FAA cannot provide assurance that the carrier operates at the highest degree of safety in the public’s interest, as required by law.
 
Our Recommendations
FAA concurred with all 11 of our recommendations to improve its oversight of Southwest Airlines’ systems for managing risk and provided appropriate planned actions and completion dates.

Recommendations

Open

Closed

No. 1 to FAA

Ensure Southwest Airlines complies with regulatory requirements to provide accurate weight and balance information to pilots, or grant an exemption that justifies the non-compliance being in the public interest.

No. 2 to FAA

Retrain inspectors at the local oversight office for Southwest Airlines on the purpose and proper use of the Voluntary Disclosure Reporting Program.

No. 3 to FAA

Train managers and inspectors of the local oversight office on their roles and responsibilities to work with Southwest Airlines for root cause analysis.

No. 4 to FAA

Enhance management controls to ensure designated airworthiness representatives comply with established procedures to verify that aircraft conform to U.S. airworthiness standards.

No. 5 to FAA

Develop a management control to ensure that designated airworthiness representatives verify the completeness and accuracy of maintenance records, and do not rely on air carrier provided summary data to make airworthiness determinations.

No. 6 to FAA

Complete a compliance review of other certificates issued by the designated airworthiness representatives used by Southwest Airlines.

No. 7 to FAA

Ensure Southwest Airlines complies with regulatory requirements that the 88 previously owned aircraft conform to U.S. aviation standards.

No. 8 to FAA

Train inspectors on FAA's process to provide feedback on designated airworthiness representatives when corrective actions are needed, and provide inspectors access to the system used to provide feedback.

No. 9 to FAA

Develop and implement a management control to ensure air carriers and inspectors do not use Safety Management Systems as a substitute for regulatory compliance.

No. 10 to FAA

Develop and implement guidance on how to evaluate air carrier safety risk assessments to ensure the carrier has performed a comprehensive analysis, identified root causes, and established appropriate corrective actions.

No. 11 to FAA

Develop and implement inspector guidance on how to evaluate air carrier safety culture and how it should be factored into oversight decisions.