Committee Investigation Report--Aviation Safety Oversight
Prepared by US Senate Commerce Committee Majority Staff, December, 2020 (excerpts)
… The Committee investigated circumstances surrounding several cargo, charter, and private aviation fatal accidents. Many of these tragedies occurred in Hawai’i. Several deficiencies discovered in FAA commercial airline oversight were also present in this environment. In multiple cases reviewed by Committee investigators, FAA inspectors found non-compliant safety issues and attempted to hold operators accountable. FAA managers often refused to support compliance or enforcement actions, and in some cases they appeared to retaliate against inspectors for doing so. Tragically, these safety concerns were communicated and documented prior to several fatal crashes. In one case, an FAA ASI investigated a fatal accident killing all eleven people on board. The ASI discovered significant maintenance concerns and discrepancies. The ASI included the concerns in his/her findings and requested the immediate revocation of the license of the mechanic responsible for the aircraft’s maintenance. The request was sent to FAA legal counsel for review. Ultimately, the license revocation was not supported and the mechanic was recertified two days after a second fatal crash that killed two. A subsequent investigation revealed the same mechanic had performed maintenance on both airplanes, and that he had previously been found to have submitted false paperwork. An NTSB investigation into the crash is ongoing….
…FAA improperly allowed a Part 135 Helicopter company in Hawai’i to operate under Part 91….
On March 11, 2020, after the Committee received whistleblower disclosures of misconduct by the FAA in Hawai’i, Chairman Wicker sent a letter to FAA Administrator Dickson requesting information and documentation related to the whistleblower claims.49 That same day, Chairman Wicker sent a second letter to FAA Administrator Dickson urging him to personally ensure that the FAA whistleblower in Hawai’i, Joseph Monfort, was not retaliated against….
Committee Investigative Referrals On January 31, 2020, the Committee released a fact sheet detailing whistleblower allegations of misconduct at the FAA FSDO in Honolulu, Hawai’i. 90 As part of its investigation, the Committee referred information to the DOT OIG for investigation. The Committee recently received additional information related to the airworthiness of the airplane involved in the skydiving flight fatal accident that killed 11 in Hawai’i in June 2019. This information has been shared to supplement the previous referral. The DOT OIG’s investigation is ongoing. Committee staff will continue to make such referrals as additional information is received and developed….
D. Allegations of Misconduct at the Honolulu Flight Standards District Office
In June 2019, Committee investigators received information from a whistleblower alleging misconduct by FAA managers at the Flight Standards District Office (FSDO) in Honolulu, Hawai’i. This initial whistleblower, an FAA employee, alleged that FAA managers too frequently overrode the recommendations of inspectors, hampering the ability of inspectors to conduct effective oversight. The whistleblower also alleged that at least one manager issued improper check ride certifications. The whistleblower indicated that this knowledge was indirect but well known by local employees and representatives of the Professional Airway System Specialist (PASS) union.
On July 31, 2019, Chairman Wicker sent a letter to then Acting FAA Administrator Elwell requesting documents that included information specific to allegations of misconduct in Hawai’i.164 On September 5, 2019, Committee staff provided the FAA a prioritized request for certain items included in the July letter. This prioritized request again included information regarding a specific aviation company in Hawai’i. The Committee has requested documents related to whistleblower allegations of whistleblower retaliation and misconduct at the Honolulu FSDO on July 31, September 5, and December 18, 2019, and has yet to receive many of the specific documents requested.165
A second FAA employee whistleblower contacted the Committee in December 2019, with allegations of misconduct at the same FAA office. The whistleblower, Joseph Monfort, expressly agreed to be publicly identified. Mr. Monfort provided several protected disclosures to the Committee and filed a whistleblower retaliation complaint with the Office of Special Counsel. Mr. Monfort served twenty years in the United States Army and retired as a warrant officer helicopter pilot. In 2009, he began his career with the FAA, and works as a principal operations inspector in Hawai’i.
Mr. Monfort alleges that some managers in the Hawai’i FAA office have an inappropriately close relationship with Novictor Aviation, a helicopter tour operator in Hawai’i. According to Mr. Monfort, these FAA managers have granted multiple policy deviations for Novictor. The Committee notes that three Novictor crashes have occurred in the last two years, one of which resulted in three deaths.166
Operation of small non-commercial aircraft, excluding on-demand charter flights or air tours, is governed by Part 91 of title 14 of the Code of Federal Regulations (CFR). Part 91 is generally less restrictive when it comes to safety requirements. Certain exceptions for some commercial operators allow them to operate under Part 91 instead of the more stringent safety standards found in Part 135, which generally applies to on-demand charter flights and air tours. The NTSB has a long history of concerns about the safety of Part 91 air tour operations and has recently recommended eliminating the exemption that allows certain air tours to operate under Part 91.167
On November 2, 2018, local FAA management revoked Novictor Helicopter’s Letter of Authorization to operate under FAA Regulation Part 91, citing the company’s accident history and lack of verifiable safety measures, according to Mr. Monfort. As a result, Novictor was required to operate under Part 135. On November 20, 2018, Mr. Monfort’s Front Line Manager (FLM) at the FAA, Darett Kanayama, granted check airman authority to the owner and operator of Novictor, Nicole Vandelaar. In 2017, Ms. Vandelaar had been prohibited from receiving Part 135 check airman authority by the Manager of the Regional Flight Standards Division. Mr. Monfort alleges this prohibition was due to a lack of qualifications, including the 14 CFR Part 119.71 requirement that Directors of Operations have three years of managerial experience within the last six years.168
As a principal operations inspector, Mr. Monfort was assigned to conduct oversight of Novictor Helicopters. On April 29, 2019, a tour helicopter operated by Novictor crashed on a residential street in Kailua, on the island of O’ahu, killing all three aboard.169 Mr. Monfort began an investigation into the crash, which revealed that Ms. Vandelaar had improperly received her check airman certification from Mr. Kanayama. According to Mr. Monfort, Ms. Vandelaar was improperly certified to administer check rides on behalf of the FAA, but subsequently gave a check ride to the pilot involved in the April 29th crash ten days before the accident. Mr. Monfort proceeded to revoke Ms. Vandelaar’s check airman authorization by letter on May 3, 2019. Later that day, Mr. Monfort was removed from the investigation by his Assistant Manager, Michael Heenan. Mr. Monfort’s workload was cited as the reason for his removal. Documents reviewed by Committee staff corroborate these claims by Mr. Monfort.
In a previous incident involving Novictor, Mr. Monfort became aware that a Novictor helicopter had made an emergency landing near Wahiawa, Hawai’i, on September 18, 2018, damaging the aircraft. According to Mr. Monfort, Novictor did not notify the local FAA office, which it was required to do under normal procedure. FAA inspectors only learned of the event when an inspector happened to see the damaged helicopter being transported near the local FAA office with the tail number taped over. A subsequent investigation into the emergency landing found that the accident occurred due to poor maintenance practices and pilot error. The staff who entered these findings into the FAA database that tracks these incidents left the pilot and operator fields blank. According to Mr. Monfort, this is highly unusual and appeared to have been done to obscure attribution of the incident to the pilot and Novictor. As a result, a search of the FAA’s internal accident database for “Novictor” or the pilot’s name does not reveal this incident. Mr. Monfort alleges that this discrepancy in the FAA incident report is evidence of an effort by Novictor and/or FAA employees to divert attribution of this incident away from Novictor.
Mr. Monfort was also assigned to conduct oversight of Safari Aviation, Inc., a helicopter tour operator located on the island of Kaua’i. In September and November 2019, Mr. Monfort requested two travel authorizations to proceed to Kaua’i to inspect Safari Aviation. Both requests were denied by FAA managers, making it almost impossible for Mr. Monfort to perform adequate FAA oversight. On December 26, 2019, a Safari Aviation tour helicopter crashed, killing seven.170 In 2016, Mr. Monfort had initiated a review of Safari’s training program due to deficiencies he noted in a check ride with the pilot involved in the December 26, 2019, crash.
During these episodes, Mr. Monfort repeatedly appealed to his office’s senior managers to have his direct manager’s decisions overturned. Mr. Monfort alleges that as a result, he received two separate suspensions that amount to whistleblower retaliation. Mr. Monfort has filed a whistleblower retaliation complaint with the Office of Special Counsel.
On December 18, 2019, after not receiving any documents in response to previous requests about FAA aviation safety in Hawai’i, Committee staff submitted an inquiry to counsel for the U.S. Department of Transportation (DOT) about the production status of the documents prioritized on September 5, 2019. The agency indicated the request was in process. Committee staff emphasized the importance of the specific Hawai’i request and further focused the request by providing an FAA enforcement file number that had been provided by Mr. Monfort. Eight days later, while Committee staff awaited the production of these documents, the December 26th Safari Aviation crash occurred, killing seven.
On January 17, 2020, Committee staff received a tranche of documents in response to the previous and prioritized requests. Of the 157 pages received, only five were substantively related to the prioritized topic of Hawai’i. These five pages identified several relevant attachments that were not provided to the Committee. This document production did not provide all documents related to the specific FAA enforcement case file requested on December 18, 2019.
On January 22, 2020, Committee staff learned that an FAA Special Agent reinterviewed Mr. Monfort regarding a previously investigated matter from 2018 in which he alleged deficiencies in a Part 135 operator’s training program. Additionally, Mr. Monfort was notified that he would be interviewed by FAA and DOT attorneys in February 2020, regarding a fatal helicopter accident he investigated in October 2017. Mr. Monfort reports increasing pressure by his FAA managers to revise findings of his Novictor investigations.
As a result of the Committee’s thorough investigation and review of available documents, on January 24, 2020, Chairman Wicker requested that the Inspector General for the Department of Transportation conduct a thorough investigation into these allegations of regulatory violations and whistleblower retaliation.171
Parachute Jump Plane
Since releasing its first fact sheet, the Committee continued to receive concerning information from FAA whistleblowers regarding the Honolulu FSDO.172 On June 21, 2019, an aircraft serving as a parachute jump plane crashed shortly after taking off from Dillingham Airport, Mokulēʻia, Hawai’i, killing eleven. The Committee has reviewed documentation citing a mechanic’s failure to perform the manufacturer’s recommended maintenance as a possible contributing factor to a loss of control immediately after takeoff. At the time, an FAA inspector recommended an emergency revocation of the mechanic’s FAA certificate. This recommendation was submitted in November 2019.
On February 22, 2020, a second aircraft experienced a loss of control immediately after taking off from Dillingham Airport, crashing and killing two.173 According to information provided by whistleblowers, an initial inspection revealed that vital cables had broken and exhibited excessive and abnormal wear. Maintenance records revealed a “100-hour inspection” was last performed on September 19, 2019, by the same mechanic associated with the accident that occurred on June 21, 2019. Although the mechanic certified “checking all cables and control pulleys as required,” FAA whistleblowers contend that the mechanic could not have reasonably failed to notice the level of wear and tear of the vital cables. They also contend that the wear could not have occurred in the timeframe between the last maintenance and the crash.
On February 24, 2020, two days after the second fatal crash, and approximately three months after the FAA inspector recommended the emergency revocation, the FAA issued the mechanic a letter of re-certification, rather than revocation, allowing the mechanic to retain his/her FAA mechanic’s certification. FAA whistleblowers allege this is an example of FAA management’s unwillingness to listen to inspectors and support requested enforcement actions.
On February 20, 2020, FAA whistleblowers expressed concern to the Committee that the Honolulu FSDO had undertaken a major “file clean-up project” in January that may have intentionally or inadvertently destroyed documents vital to DOT OIG’s investigation into allegations in the Committee’s first fact sheet. The Committee has confirmed that the document clean-up project occurred, but does not know whether it was in any way connected to the OIG investigation.
Although the information received by the Committee about these accidents is concerning, the Committee does not conduct aviation accident investigations or determine cause. The Committee’s oversight investigation has focused on whether the FAA is properly enforcing regulations and thereby ensuring the safest aviation system possible. Dozens of FAA whistleblowers contend that it is not. The National Transportation Safety Board (NTSB) is responsible for conducting accident investigations and determining cause. Both of these accidents remain under investigation by the NTSB.174
Since the Committee published its fact sheet on this topic on January 31, 2020, it has corresponded with six members of the Hawaiian helicopter tour community. These individuals, including helicopter tour company employees and former Novictor Aviation Pilots, contacted Committee investigative staff in support of Inspector Monfort’s assertions, uniformly stating their opinions that Mr. Monfort is a strict but fair safety inspector, and that the local helicopter tour community has long held concerns about Novictor Aviation’s operations.
Mr. Monfort alleges that retaliation for his whistleblowing has continued since the Committee published its first fact sheet. He submitted this information to the Office of Special Counsel. Mr. Monfort’s attorney advised the Committee that changes to previously approved accommodations stemming from Mr. Monfort’s disabled veteran status constitute reprisal for Mr. Monfort’s whistleblowing.
On March 11, 2020, Chairman Wicker sent FAA Administrator Dickson a letter making him aware of these allegations and asking that he personally ensure that Mr. Monfort was treated fairly and appropriately. That day, Chairman Wicker also sent Administrator Dickson a letter requesting a number of documents related to the above allegations.175 To date, the Committee has not received a substantive response to this request.
Most recently, in August 2020 the Committee received additional information related to the June 21, 2019, crash that killed eleven in Hawai’i. Documentation reviewed by Committee investigators outlined a complaint filed by a whistleblower following the fatal crash. The complaint describes an incident in 2016 involving the plane in question, the damage it sustained, and the failure of the local FAA office to revoke the plane’s airworthiness certificate. According to the complaint, the plane suffered a large amount of damage while going up in flames, which was understood to be non-repairable.176 Local FAA officials received warnings about the plane’s status and were encouraged to revoke its airworthiness certificate, but did not do so, believing the owner would not attempt to repair the plane. The complaint further states the owner repaired the plane, and flew it to a different FAA jurisdiction, resulting in no follow up oversight.
Initial review of documentation obtained by the Committee indicates that the Flight Standards office investigated this complaint. Committee investigators are unaware if the complaint underwent any criminal or other review by the Department of Transportation Office of Inspector General (DOT OIG) prior to the FAA’s internal investigation. The Committee has requested relevant reports of investigation related to this complaint and will engage the FAA and DOT OIG further.
On October 28, 2020 the NTSB opened a public docket containing factual information collected in support of its investigation into the crash of N256TA.177 The evidence revealed in this docket appears to confirm concerns of a previous whistleblower about the adequacy of the repairs completed on the airplane following an inflight loss of the right hand horizontal stabilizer in 2016. The “Maintenance Record Factual Report” section of the docket includes eight-eight pages of information. The report reveals that parts had been installed the plane that were not approved replacements.178 The Committee’s review of the documents prompt serious questions regarding maintenance of the airplane while it was operated in Hawaii. The docket also revealed the plane required “full aileron trim and some rudder trim in order to fly straight and level”. According to pilots including FAA Inspectors such a setting is indicative of a larger problem and should have been investigated and corrected. The cause of the crash remains unknown and the NTSB is expected to release a final report in 2021.
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Footnote 90: U.S. Senate Committee on Commerce, Science, and Transportation, Fact Sheets: Whistleblower Allegations of Misconduct at the FAA Flight Standards District Office in Honolulu, Hawai’i. January 31, 2020.
VM: Senate committee report criticizes FAA oversight of Novictor Helicopters