From the outset it became evident that finding published information on these incidents was going to be a daunting task. Searches of the National

Transcription

1 To: International Brotherhood of Teamsters Airline Division, members of Congress, the Federal Aviation Administration and general public From: Chris Moore, the Aviation Mechanics Coalition, Inc. Date: April 2015 Re: Allegiant Air Updated Air Returns and Diversions due to Maintenance-related Issues September 2014 Through March 2015 SUMMARY Allegiant Air is an FAA-certificated, Ultra Low Cost carrier based in Enterprise, Nevada. The Carrier operates a fleet of 70 Aircraft with an average age of 22.2 years. The MD-80 fleet, having 54 aircraft, comprises 75% of the fleet and has an average age of 24 years. The Carrier employs approximately 1,800 people including roughly 230 mechanics with an average seniority of 4.0 years; however 55% of the group has less than 4 years and 35% have less than 2 years of experience with the airline. Allegiant Air is run by CEO Maurice Gallagher, and up until October 1 st ; President Andrew Levy. Both can trace their roots back to another low cost carrier, ValuJet, and were in place when ValuJet Flight 592 crashed into the Florida Everglades due to a cargo compartment fire caused by errors committed by contract maintenance employees. The Aviation Mechanics Coalition, Inc. (TAMC) promotes the common interest of FAA-licensed aviation mechanics working in the United States aviation industry. In this regard, it promotes industry-wide safety rules and regulations affecting aviation maintenance and monitors aviation safety-related trends in the industry. TAMC also seeks to foster a better working environment for aviation industry mechanics and to identify and help eliminate obstacles and work-related disincentives leading to the erosion and dissipation of the aviation maintenance profession. Among other projects and operations undertaken by TAMC are: (1) the promotion and support of industry-wide safety rules and regulations through legislative and regulatory activity; (2) the performance of safety-related best-practices audits to measure airline maintenance safety compliance to ensure that maintenance professionals' working environments are safe; (3) the promotion and support of industry-wide health and retirement security standards for maintenance professionals to better ensure stable, long-term employment within the aviation maintenance profession; and (4) legislative, regulatory and media outreach to expose the hazards of outsourced aviation maintenance to the flying public and to prevent the loss of aviation maintenance professionals' jobs and work opportunities to low-wage, under-regulated and unsafe foreign maintenance operations. (5) Develop education programs specific to attracting and retaining workers to the industry. (6) Provide continued education programs for the advancement of Aviation Safety. In February 2014, the TAMC was approached by pilots from Allegiant Air who were concerned by the number of air returns and diversions due to fixable maintenance-related issues. It should be noted that Allegiant has an aircraft utilization of roughly 5.5 hours per day, which is less than half the industry average. The TAMC, after considering the number and reasons for the maintenance issues, agreed to launch an investigation.

2 From the outset it became evident that finding published information on these incidents was going to be a daunting task. Searches of the National Transportation Safety Board and Federal Aviation Administration databases, which rely on local news reports, revealed no reports of declared emergencies for engine and hydraulic failures at Allegiant Air. Allegiant is not required to report Department of Transportation delay and cancellation information because the company falls below the 1% threshold of the total domestic scheduled-service passenger revenue. As a consequence of this rule, the TAMC must rely on the pilots reporting back when they experienced an air return, gate return, aborted take-off or other maintenance related incident. The TAMC cannot conclude that the below maintenance issues were the only air returns, gate returns low speed aborts, and diversions during the time period, as the company does not report such incidents to the FAA. We find it disconcerting that an airline with such a small fleet has experienced such a large number of schedule disruptions due to mechanical issues. This trend, which we first documented in 2014, continues unabated into the first quarter of What follows is a snap shot of September 2014 through March of Definitions: AR= Air Return Aircraft is inflight and the crew determines that for safety purposes, they must return to the airport of departure. DV= Diversion The crew determines for the safety of the flight, that they must land at the nearest suitable airport along the route of flight. GR= Gate Return After the flight has left the gate and prior to takeoff, a condition develops that requires a return to the gate for maintenance. LSA= Low Speed Abort Prior to V1 (the speed at which a safe abort cannot be made and the aircraft must takeoff), an event occurs that requires the crew to abort the takeoff run a very high risk event. Flight A/C # A/C Type Departure. Destination Diverted to. Status Date AAY 220 KBLI KLAS KBLI AR 9/4/2014 Event: Primary Stabilizer Trim Failure Primary Trim Failure leads to loss of Pitch Control by the flight crew. The crash of Alaska Airlines 261 was due to Stabilizer Trim Failure caused by inadequate lubrication. Failure to accomplish this required task has been cited in several mechanics calls to the Maintenance hotline. AAY950 N871GA MD83 KPGD KYSY KPDG AR 9/4/2014

3 Event: Engine developing 20% less than required power. AAY526 N415NV MD83 KLAS KLAS AR 9/8/2014 Event: #2 Engine Shutdown due oil loss caused by improper maintenance. AAY318 N878GA MD83 KLAX KSGF KIWA DV 9/8/2014 Event: Automation Issues. AAY 116 N878GA MD83 KIWA KSBN KIWA AR 9/11/2014 Event: Loss of all cockpit Automation, Repeat write up from 9/8/14 (noted above) AAY154 N874GA MD83 KIWA KSCK KLAS DV 9/14/2014 Event: Loud noise coming from Emergency Exit. Repeat Write up on prior leg. This is indicative of a leaking air seal, making it hard to maintain cabin pressure or worse, a misaligned exit window due to damage or improper installation. AAY416 N901NV B757 KLAS KMFE KLAS AR 9/15/2014 Event: Left Bleed Air Trip. Engine bleed air is critical for cabin pressurization and cabin temperature control. AAY1073 N905NV B757 KLAX KHNL KLAX AR 9/15/2014 Event: Left Generator and Center fuel tank boost pump failure. Resultant loss of 50% of electrical capability for flight instruments and systems and restricting the ability to transfer fuel from tank to engines, possibly leading to total loss of engines due to fuel starvation.

4 AA114 N421NV MD83 KIWA KGRI KIWA AR 9/18/2014 Event: Hydraulic Leak. Hydraulics control many critical systems such as Landing Gear and Flight Controls. Loss of the system results in loss of critical flight and landing systems, including landing gear, steering and brakes. AAY960 N879GA MD83 KPDG KFWA KSFB DV 9/18/2014 Event: Smoke in the Cabin. ANY smoke in the cabin is cause for alarm if the source cannot be readily identified and contained. AAY160 N410NV MD83 KIWA KRAP KIWA AR 9/21/2014 Event: Generator Issues (Electrical System) AAY900 N401NV MD83 KFLL KPBG KSFB DV 9/25/2014 Event: Center fuel pump not transferring to engines. This could lead to fuel starvation to the engines resulting in loss of power or inflight shut down forcing an emergency landing or crash. AAY168 N423NV MD83 KIWA KMLI KIWA AR 9/28/2014 Event: Navigation instrumentation and high temperature issues. Loss of instrumentation makes it impossible to determine where the aircraft is and renders impossible the ability to make an instrument approach in marginal weather. AAY486 N417NV MD83 KLAS KLAS AR 10/2/2014 Event: Smoke in the cabin. AAY812 N880NV MD83 KPIE KROA KPIE AR 10/3/2014 Event: Multiple electrical issues. AAY526 N876GA MD83 KLAS KSCK KLAS AR 10/5/2014 Event: Flight Director and Automation Failure. The Flight Director (F/D) is the primary flight and navigation instrument for pilots. Loss of it and automation is a critical failure in clear weather and potentially catastrophic in bad weather or at night.

5 AAY696 N216NV A320 KSFB KTYS KSFB AR 10/7/2014 Event: Loss of all three communications radios. This results in loss of all radio contact with Air Traffic Control and the potential for Homeland Security to assume an aircraft has been hijacked. AAY620 N424NV MD83 KSFB KCVG KSFB AR 10/10/2014 Event: Right Landing Gear Unsafe Light Indicates that the Landing Gear has not either extended or retracted correctly, leading to a possible gear collapse on landing. AAY8501 N426NV MD83 KENV KFOE KENV AR 10/13/2014 Event: Tail Compartment High Temperature Warning A very critical situation indicating a possible Bleed Air leak from the engines leading to possible structural or systems failures. AAY680 N424NV MD83 KSFB KMLI KSFB AR 10/16/2014 Event: Right Landing Gear Unsafe Light Repeat write up for the same issue days earlier. See above AAY428 N421NV MD83 KLAS KMOT KLAS AR 10/18/2014 Event: Secondary Trim System Failure AAY168 N301NV A319 KIAW KMIL KIAW AR 10/19/2014 Event: Lavatories and Potable water systems inoperative AAY580 N906NV B757 KLAS KBLI KLAS AR 10/23/2014 Event: Compressor Stall with observed flames and High EGT. Requires engine power to be reduced to idle, resulting in single engine operation. AAY182 N302NV A319 KIAW KGRR KIAW AR 10/23/2014 Event: Various MX Issues AAY404 N403NV MD83 KIAW KRFD GR 10/31/2014 Event: Engine compressor stalling after start. Engine cannot develop power in this condition.

6 AAY638 N893GA MD83 KSFB KUSA KSFB LSA 11/2/2014 Event: Right engine oil quantity went to zero. Engine must be pulled back to idle of shut down resulting in single engine operation, requiring declaring an inflight emergency to ATC, descending to a lower altitude due to reduced cabin pressurization capability and the disruption of other aircraft routing in the same area. AAY302 N902NV B757 KHNL KLAS KHNL LSA 11/3/2014 Event: Captain s Airspeed Indicator Failed Various Flights. A/C N407NV 8 repeat write ups on Auto-Spoiler System. Handle fails to retract. Spoilers deploy on landing to inhibit aerodynamic lift and transfer weight from the wings to the landing gear for efficient and safe braking and ground control. On some aircraft they also inhibit or activate systems, so failure to properly re-stow may impact other critical systems. AAY132 N421NV MD81 KIAW KLAS LSA 1/2/2015 Event: Right Engine EPR Gauge inoperative on Take Off roll. EPR is the primary indication that the engine is making the power required. EPR (Engine Pressure Ratio) is the primary manner for determining engine output and critical to ensure the engine does not overspeed, which could result in an overtemperature event or failure. AAY2210 N872GA MD83 KBLI KPSP KBLI AR 1/3/2015 Event: Stabilizer Trim not working. Possible loss of pitch control. Extremely dangerous situation that can lead to a total loss of control of the aircraft. A similar failure event happened to Alaska Air 261 leading to a crash. A simulation with the cockpit and ATC audio is here: AAY 842 N215NV A320 KPIE KSYR GR 1/4/2015 Event: ELAC #2 Failure. (Elevator Aileron Control Computer) This computer controls the amount of pressure applied to the flight controls based on airspeed. Too little pressure at low speed can lead to a loss of control and at high speed can lead to an inflight breakup of the aircraft.

7 AAY937 N415NV MD82 KTYS KFLL GR 1/4/2015 Event: Unable to start engine. AAY5837 N873GA MD83 KGSO KPIE AR 1/5/2015 Event: Pressurization Issues. Aircraft could not continue. AAY736 N217NV A320 KSFO KBRG KSFO AR 1/8/2015 Event: #1 Engine Fire Loop Loss of the fire warning system can lead to a false fire warning and possible inflight shutdown or an undetected fire that could lead to multiple system failures and loss of the aircraft inflight. AAY560 N404NV MD88 KLAS KMSO GR 1/9/2015 Event: Right Air Conditioning High Temp Light Indicates a possible leak in a bleed air line. Bleed air is very high temperature air that is bled off the engine for pressurization, heating, cooling and wing anti icing systems. A leak in the system exposes critical parts of the aircraft to very high temperature air that can cause component failures or fire if they ignite. AAY673 N879GA MD83 KPSM KSFB LSA 1/9/2015 Event: Left Engine not making power. AAY678 N422NV MD81 KSFB KSGF GR 1/9/2015 Event: Right Hydraulic System Quantity Loss. Loss of system quantity results on the loss of flight controls, landing gear, steering or brakes powered by the system. AAY132 N420NV MD82 KIAW KPVU GR 1/11/2015 Event: Engines won t spool. APU issue. The APU (Auxiliary Power Unit) is used to provide power on the ground or as an inflight backup for systems for the aircraft including electrical, hydraulic and air pressure for engine starting. Insufficient air pressure from the APU makes it impossible to safely start the engines. Attempting a start with low air pressure can lead to an overtemp ( hot start ) or engine fire.

8 AAY978 N877GA MD83 KPDG KHTS LSA 1/11/2015 Event: Spoiler Deploy Message. Spoilers deploy to disturb airflow over the top of the wing, reducing lift. If they deploy inflight this can lead to a loss of control or inability to maintain altitude. AAY816 N901NV B757 KLAS KSGF GR 1/12/2015 Event: #2 Engine Generator Inoperative. This reduces the aircraft s ability to power electrically operated systems and results in higher weather minimum requirements on instrument approaches. AAY222 N416NV MD83 KBLI KLAS GR 1/16/2015 Event: Auto Spoiler will not arm. See related above AAY102 N404NV MD88 KIWA KOGD KLAS DV 1/19/2015 Event: Right Air Conditioner Supply High Temperature Light on. Aircraft could not maintain pressurization on one pack. Air conditioner packs are the individual systems; one per engine that cool, heat and maintain pressurization on the cabin. Loss of one immediately restricts flights to no higher than 25,000 feet to ensure that the flight can make an emergency descent to 10,000 feet it the operating pack fails. High temperature indicates a failure in the system. AAY441 N881GA MD83 KLAS KDLH GR 1/19/2015 Event: Left Engine Slow to Spool with visible smoke. Low spooling (engine rotation) during start indicates a possible low air pressure from the APU or a leak in the bleed duct to the engine. Smoke indicates that the engine speed is too low for the start and the fuel is pooling in lower burner cans and preparing to ignite, causing an engine fire. AAY746 N879GA MD83 KSFB KXNA KSFB AR 1/19/2015 Event: EPR issues. EPR is the primary engine power indication. See related above.

9 AAY892 N893GA MD83 KPIE KYNG KPIE AR 1/19/2015 Event: Smoke in the Cockpit. With all electrical systems and circuit breakers in the cockpit, this is a major emergency. Along with fire, the smoke will make it impossible to see flight instruments and maintain control of the aircraft as witnessed in the crash of the UPS 747 in Dubai. AAY536 N423NV MD81 KLAS KGTF KLAS AR 1/22/2015 Event: Lavatory Smoke Alarm AAY482 N876GA MD83 KLAS KGRR GR 1/23/2015 Event: Right Engine Start Valve Inoperative. Failure of the valve makes it impossible to start the engine if closed, and if open, unable to operate the engine. AAY496 N408NV MD82 KLAS KDSM GR 1/23/2015 Event: Left Engine Vibration and Slow to Spool Indications of possible pending major engine failure due to a bad bearing, shaft, turbine wheel or turbine blade. If this occurs while running, the destructive force can rip into the cabin and sever major flight control systems as in the crash of United 262. See: AAY974 N887GA MD82 KPDG KTOL LSA 1/23/2015 Event: Aft Cargo Door Open indication. AAY858 N891GA MD82 KPIE KCVG LSA 1/25/2015 Event: Aft Air Stair Door open indication. AAY496 N892GA MD83 KLAS KDSM KLAS AR 1/30/2015 Event: Weather Radar Inoperative. Inhibits the ability of the crew to see and avoid serious weather conditions. AAY988 N877GA MD83 KPGD KDSM LSA 2/1/2015 Event: Rudder Limiter Heat inoperative. Rudder load limiter controls the amount of pressure that can be applied to the flight control based on airspeed to prevent overstressing the flight control.

10 AAY 614 UNKN KSFB KLCK GR 2/1/2015 Event: Right Engine Compressor Stall when throttle is advanced. A compressor stall occurs when airflow across the turbine is disturbed causing a situation similar to an auto engine backfire. This can cause loss of power or damage to the engine which can lead to an inflight shutdown. AAY222 UNKN KBLI KLAS GR 2/2/2015 Event: Right Pack not making pressure. Inhibits the ability to pressurize the aircraft and limits operating altitude. See related above. AAY964 N409NV MD83 KPDG KMLI KSFB DV 2/5/2015 Event: Undisclosed MX issue. AAY806 N425NV MD83 KPIE KSGF LSA 2/5/2015 Event: Uncommanded Slat movement. Very dangerous situation. Slats deploy at low speed to increase wing lift and controllability. Deployment at high speed can overstress the wing leading to a failure of the wing and possible separation from the aircraft. AAY1025 N878GA MD83 KLAX KEUG GR 2/12/2015 Event: Pitot/Stall Heater inoperative. Renders critical flight instruments (airspeed, altimeter) inoperative AAY2842 N893GA MD83 KPIE KSYR KSFB DV 2/14/2015 Event: Center Tank Fuel Tank Boost Pump inoperative. See related above AAY174 N402NV MD88 KIAW KPSC KIAW AR 2/15/2015 Event: Dual EFIS Screen Failure. EFIS (Electronic Flight Instrumentation System) are the primary flight instrument displays. Loss of both means the pilots have no way of determining what the aircraft is doing if they are flying at night or in bad weather. It also makes it impossible to fly an instrument approach. AAY536 N422NV MD81 KLAS KGTF KLAS AR 2/15/2015 Event: Compass Split.

11 AAY846 N223NV A320 KPIE KPIA KSFB DV 2/20/2015 Event: Left Windshield Anti-Ice Failure. Windshield heat is used to keep the windshield from icing in all weather and because it softens the windshield, makes it less susceptible to failure from a bird strike. AAY620 N223NV A320 KSFB KCVG KPIE DV 2/23/2015 Event: Left Windshield Anti-Ice Failure See above. AAY446 UNKN KLAS KMOT KLAS AR 2/23/2015 Event: Nose Landing Gear Vibration. Indication of possible impending wheel bearing failure, strut failure or wheel damage. Should this happen on landing, it could lead to loss of control on the rollout phase. AAY456 N416NV MD83 KLAS KFSD GR 2/23/2015 Event: Auxiliary Pitot Heat Inoperative. See above related. AY132 N301NV A319 KPVU 3/2/15 Event: On landing roll out Captain could not keep aircraft on center line. Aircraft tried to exit the runway and both Captain and First Officer had to apply full Right Rudder to regain control of the Aircraft. Contract MX signed off the Aircraft after some cursory checks and without inspecting the Rudder controls in the tail compartment. Crew refused to fly the aircraft. Extremely dangerous. Indicates an imminent catastrophic failure on the primary rudder control unit that if it occurs inflight, leads to the loss of the aircraft. Had this happened thirty seconds earlier, the result would have been a low altitude rollover and crash as with United 585 and USAir AAY414 N429NV MD82 KLAS KBLI KLAS AR 3/6/2015 Event: Fuel smell in the cabin. Occurring inflight, this is an indication of a serious fuel leak and potential for explosion or fire.

12 Maintenance As part of our initiative to gather data we created a hotline for pilots and mechanics to report maintenance issues. We interviewed a number of mechanics and found concerns similar regardless of which station (airport) they worked. Common concerns were the same. Training is inadequate. One mechanic with many years experience at a European national flag carrier described training as a joke with only Computer Based Training, (CBT) and no classroom for the MD-80 planes which comprise 75% of the Allegiant fleet. Further, the training technology keeps failing, making it very difficult to train. Lack of process to document equipment failures. Persistent technology failures result in mechanics routinely having to work with manual references faxed from Maintenance Control and in some instances with no paperwork at all, only verbal instructions. LAS maintenance went for six months without a working printer, an FAA violation. Not having the paperwork is a F.A.R. (Federal Aviation Regulation) violation. Just Move the Metal culture. Mechanics report a culture of just move the metal and being pressured to get the aircraft to the next station. This has been confirmed by pilot reports of mechanics asking them if they can just take the aircraft as it is. A lack of spare parts and reliable spare parts. In many instances mechanics are required to cannibalize parts from another aircraft because adequate in stock spares are not available. This process, in concert with a lack of reliable technology to cross check the effectivity of the part creates a situation wherein the wrong part can be installed on an aircraft. A good example of the dangers of installing unreliable parts is noted on 10/7/14 when a Communications Panel was replaced on aircraft N216NV, resulting in the failure of all 3 communications radios. Many times mechanics with little or no experience on a difficult task are assigned with minimal or no oversight, only a directive to get the job signed off and the aircraft out. Inadequate tooling or equipment. Mechanics have reported that critical jobs such as stabilizer jack screw lubrication cannot be performed due to lack of training on equipment and unavailability of safety equipment. Conclusions and Recommendations It should be noted that the advanced age of an aircraft in and of itself does not make it unsafe, but aging aircraft do require more maintenance. The lack of experience, parts, tooling and training combined with the age of the fleet is creating a dangerous paradigm that could eventually lead to an accident resulting in serious injury and loss of life. In conversations with some of the pilots it became evident that they are forced to fly aircraft that barely passes acceptable safety standards. This situation creates a troubling norm where the just move the metal culture could be a precursor to a serious accident. Moving forward the TAMC recommends the following: 1) More onsite FAA oversight of the maintenance program until Allegiant can prove that they provide adequate training, tooling, equipment and spares.

13 2) FAA should provide more oversight of the MRO (Maintenance, Repair and Overhaul) facilities performing work for Allegiant. Currently, Allegiant outsources all of its Heavy Airframe MX, Engine Overhaul and Component work. Based on pilot reports, documentation gathered (including some listed above) and the 4-engine inflight engine shutdowns in a 2 week period over the summer, it is clear that serious FAA oversight is called for. 3) The company should invest in required information technology for improved accessibility to required manuals and training. 4) The company should provide instructor lead training and mentoring of new hire mechanics. 5) New hire and low time mechanics should be paired with experienced mechanics when assigned to more difficult technical tasks. 6) The company should provide the proper equipment, in working order, and training on such equipment, required to accomplish maintenance tasks. 7) The company should provide proper safety equipment and training on such items as fall restraint and safety harness systems. 8) The company should review, on an ongoing basis, the quality and reliability of spares and engines as well as maintenance provided by outsourced maintenance. 9) The company should create a strong, effective safety culture by partnering with the mechanics ensuring a safe work environment as well as improved safety for their passengers. We sincerely hope that this report will help Allegiant to recognize the safety shortfalls within their maintenance organization as they are sometimes lost in the shuffle of the day-to-day business of running an airline. Further, we feel that if the airline fails to correct these problems promptly, they run the real risk of having an incident or accident that could result in loss of life.