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 Washington Post - - FRONT PAGE - BY MICHAEL LARIS

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.

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