How the FAA missed an opportunity to save a life
Engine blowout that killed mother of 2 mirrored an incident 19 months earlier on same model plane
The woman in 14A was settled into her window seat, buckled in for the flight home. Moments later, with a sudden burst of violence at 32,000 feet, the window was gone.
Fan blade No. 13 had broken off inside the left engine, hurling shrapnel against the side of the plane. Her window disappeared out over the eastern Pennsylvania countryside, and Jennifer Riordan’s upper body was sucked halfway through the opening left behind.
During the 17 wrenching minutes that followed on that April morning last Riordan year, pilots struggled to
guide the hobbled plane to an emergency landing and passengers fought to save the mother of two from Albuquerque, leaving a legacy of heroism in an incident that travelers around the world may have taken as a nightmarish, if seemingly random, accident.
In fact, federal regulators and the companies that built and flew Riordan’s plane knew from experience that such a scenario was possible. Nineteen months earlier, in August
2016, a fan blade had broken off in the same model engine on the same model Southwest plane over Mississippi.
The engine blowout damaged the plane in that case as well, but the passenger cabin “was not penetrated,” investigators said. The pilot was able to make an emergency landing and no one was hurt.
The Federal Aviation Administration began crafting a proposal for more inspections after the first engine failure. But it did not order those inspections until after the failure repeated itself on Riordan’s flight.
The FAA’S halting response troubled some inside the agency who say it fit a pattern of giving too much deference to industry — including airplane manufacturers and their suppliers, airlines and others. The issue has taken on added urgency following the crashes of two Boeing 737 Max jets in Indonesia and Ethiopia that killed 346 people.
In a statement, the FAA said it “promotes a strong safety culture across the industry” and had acted in “an expedient manner” following the initial Southwest incident.
“The actions taken by the FAA were consistent with our established and proven risk-based processes,” the agency said.
The National Transportation Safety Board last month raised concerns about the design of the Boeing Next- Generation 737 planes at issue in the Southwest incidents, noting that the broken fan blade on Riordan’s flight destroyed part of a structure that houses the engine known as a fan cowl. A metal latching mechanism that was part of that structure flew out and smashed against the plane, causing Riordan’s window “to depart,” the NTSB said.
As FAA officials have sought to offer reassurances about the rigor of agency oversight in the months since the 737 Max crashes, they have repeatedly said that over the past decade U.S. airlines have carried 7 billion passengers around the country with just one fatality.
Riordan was that one in 7 billion.
Cascade of sound, terror
Jennifer Riordan was 10 minutes late to her own wedding, something her husband, Michael, still jokes about.
But there was no way she was going to be waylaid at New York’s Laguardia Airport after a business trip. She wanted to be back with her family.
As Riordan, 43, nestled in for the ride, two recent medical school grads sitting in the next row prepared to return home from their New York honeymoon. A pair of Texas grandparents settled in after their first visit to Manhattan.
This account is based on a review of hundreds of pages of documents from the crash investigation, NTSB interviews with pilots and passengers, U.S. and European regulatory filings, interviews with regulators and people close to Riordan, and a video stream of her memorial.
As the Boeing Next- Generation 737 climbed out of Queens before 11 a.m., a request went out from the cockpit to the flight attendants in the back: “Whenever you guys are both up here, would you just give me a ring and just throw me some peanuts?”
First officer Darren Ellisor guided the plane toward cruising altitude, headed for Dallas and Riordan’s connecting flight.
Then, at 11:03 a.m., a cascade of sound, vibration and terror.
Andrew Needum, a firefighter from Celina, Tex., heard a pop, then screams. William Crowley, a Southwest employee hitching a ride in a jump seat, heard what sounded like a marble crashing into glass, then a din so loud people struggled to hear each other. After what sounded like an explosion, school nurse Peggy Phillips watched a flight attendant nearly get knocked down as the plane shuddered.
Outside, the plane’s mangled left engine had been destroyed from within. The sheared-off fan blade No. 13 had sent metal pieces from the engine’s outer casing flying, gouging holes in the front of the plane’s wing in addition to blowing out Riordan’s window.
It felt like the plane had been “T-boned by a Mack truck,” one of the pilots would recall later, and the plane rolled hard to the left.
In the cockpit, an altitude warning horn blared through the noise, signaling to the pilots that there had been a sudden loss of pressure. They grabbed oxygen masks.
The first officer gave the controls to captain Tammie Jo Shults, a former Navy fighter pilot. They radioed air traffic control that they needed to make an emergency landing.
On the ground, some authorities didn’t know if the plane had been hit by a bird, a terrorist or a mechanical malfunction.
“Ladies and gentlemen, this is your captain. We’re . . . going into, ah, to Philadelphia . . . ah, remain seated. Thank you,” Shults said.
‘Canary in the coal mine’
Nineteen months earlier, another broken fan blade sent metal fragments flying, ripping a 5-by16-inch hole above the left wing of an Orlando-bound Southwest 737.
FAA officials began investigating. But they decided not to issue an urgent safety order, known as an emergency airworthiness directive, that would immediately require new inspections.
Citing information from the engine’s manufacturer, FAA officials said the engine had been used around the world for nearly 300 million hours over more than two decades with no other fan blade breaking off. They considered the incident an anomaly and concluded that the blades fit in a “low risk” category, according to an FAA account provided to NTSB investigators.
The engine had been built by one of Boeing’s suppliers, CFM International, a joint venture between General Electric and French aerospace firm Safran Aircraft Engines.
The FAA would continue to track efforts by CFM and monitor some inspections started by Southwest, officials said. That information would help the FAA craft a package of new inspection requirements using a formal regulatory process that includes time to consider comments from industry and others, the agency said. A year after the Mississippi fan blade incident, the FAA issued a Notice of Proposed Rulemaking for possible new inspections.
“It appeared that we had time to react and take actions accordingly,” Christopher Spinney, of the FAA’S engine certification office, told NTSB investigators.
But they did not have time, and that fit a broader FAA pattern, investigators say.
In an interview, NTSB Chairman Robert L. Sumwalt III said investigators at the independent safety agency did not find that the FAA acted too slowly, “under the circumstances.” The Mississippi engine failure “was considered a one-off event,” he said.
Still, Sumwalt said, “speed” is “not the word I would use” to describe how the FAA addresses some safety issues.
“I would use ‘ the lack of speed,’ or ‘ the lack of timeliness,’ ” Sumwalt said. “We do know that sometimes the rulemaking process, as well as other things, move slower than we’re comfortable with.”
The FAA’S approach to the two Southwest fan blade failures was a “canary in the coal mine,” said an FAA official, speaking on the condition of anonymity to talk candidly about the agency’s internal operations. Those cases foreshadowed later revelations about the FAA’S decision to certify that the Boeing 737 Max was safe, he said.
A flawed flight-control feature on the Max would end up contributing to two deadly crashes of the jets within five months. Some family members of those killed say the FAA did not do enough after the first Max crash.
“They knew,” said Nadia Milleron, whose daughter Samya Stumo was killed on the later flight in Ethiopia. “They could have done something.”
“It’s another example of an FAA system that seems to be more focused on industry and industry’s needs rather than safety,” the FAA official said.
“It appeared that we had time to react and take actions accordingly.” Christopher Spinney, of the FAA’S engine certification office, describing the regulatory process to NTSB investigators
Federal investigators examine the Southwest Airlines plane that made an emergency landing at Philadelphia International Airport in April 2018 after shrapnel from an engine failure blew out a window, pulling Jennifer Riordan halfway outside the plane.
The airliner on which Jennifer Riordan was a passenger sits on the runway in Philadelphia after its emergency landing. The damage to the plane’s left engine and Riordan’s broken-out window can be seen.