Interview: Nick Sabatini

While you were there, what was your impression of the relationship between the FAA and the entities it set out to regulate?

That's a great question, because there was a significant transition from the time when I first joined the FAA. There was a relationship which was not conducive to producing the best possible result for the public. It was a relationship where certificated entities would be very reluctant to talk to the FAA and talk about what they were seeing in terms of what needed to be addressed. So things were underground, so to speak.

In fact, I recall -- and many of my colleagues had the same experience -- walking in to, say, an aviation hangar, and there would be signs there, "Don't talk to the FAA," because they believed if they told you anything, you would use it against them.

Is that the way it worked, too? Was the FAA very much in an enforcement posture?

Absolutely. So it's important to understand, since this has certainly been an issue for some, the FAA will always be the regulator and will always take the appropriate action for people who do not comply with the regulations.

But what's important to understand about the relationship with industry and the regulator, the FAA, is that we best serve the public when you have a relationship where industry can come forward and say, "This is what we're seeing, and this is what we believe needs to be addressed," and working together, you can come to solutions. That is how we have gotten to this phenomenal safety record.

So, coming into it [in 1978] and viewing it pretty fresh off your NYPD policing career, were you able to make some analogies to being the cop on the beat and being the FAA inspector in that hangar, where they're saying, "Don't talk to the FAA"?

It's very different when you're on the street and there is a crime committed. Then you take the appropriate action, a summary arrest, whatever the case may be. But here we're dealing with people who are not criminals. They want to comply with the rules. They may not have, unwittingly perhaps. If it's intentional, then we treat that way.

So the evolution has been one where you want to encourage people who are voluntarily and willingly complying with regulations, but when there are mistakes made, slips, lapses, whatever, errors of some kind, you don't want them to bury that. You want to understand not only what happened but why it happened. If you understand why something happened, then we're on the road to addressing the root cause. We can solve what caused that event to have occurred.

So, to use the simple analogy, were you suggesting things be a little more good cop than tough cop?

I think it's a balance. If the entity or the individual is deliberately violating regulations, then absolutely apply the maximum that the rules allow. But to best serve the public, it is important to work together so that we can understand why things are happening and address that root cause.

To have this conversation, you really have got to go back and look at the context of where we are.

When you consider, from the August 2006 [Comair] accident, a tragic accident in Lexington, Ky., to that [Continental Flight 3407] accident in February 2009 -- in those intervening years, the United States air transportation system transported 2 billion people, maybe a little bit more. That is the equivalent of having transported the population of the United States more than six times without putting a scratch on anybody.

That's the context and the background against which you need to have to have a conversation about where we're going as an aviation industry, as an air transportation system. It is the safest form of transportation.

We're at a place and time where accidents are rare and they are random. We no longer see common-cause accidents. Accidents that we do see, as rare as they are, have their own set of unique circumstances, so we need to move to prognostics. We want to prevent accidents from ever happening. The reality is risk is always greater than zero. We need to learn what those unknown risks are out there.

Who is best positioned to know what risks they see every day? It's people who are operating the system and have their hands on the system every single day. That's the balance that has to occur.

You want it such that they are complying with the regulations. And then what they see in the course of daily operations is shared, because we want to collect that data, analyze that data, identify the precursors, areas of vulnerability and apply interventions. That's the future.

Back to the cop analogy. This is the difference between making an arrest after a homicide and doing some kind of crime prevention activity, talking to sources, whatever the case may be.

This is a great point that you're making there. The New York City Police Department adopted under Mayor [Rudy] Giuliani basically the essence of the broken-window theory.

Now, they're a public safety organization as we are. They have turned that city into one of the safest cities in the world. They went to analysis of data to identify what are those early precursors that would indicate or suggest the potential for rising crime in the neighborhood. In New York City, it happens to be graffiti, and once they know that, they can apply the appropriate interventions.

It's the same thing with us. We're in the public safety business. What are the early warnings? What are the precursors that are out there but they are not clearly visible, not known? There are unknown risks out there, and how do you identify them? ... You have the people who are operating the system voluntarily provide you with the data that they see and together conduct the analysis and identify areas of vulnerability and apply interventions.

So what's the aviation equivalent of graffiti and broken windows?

It's that the future's going to be about not large trends but small data points.

The Comair accident in Lexington, Ky., caused the agency to do some analysis on why a wrong runway departure -- they conducted a study, reviewed 5.4 million records and identified that a certain number of airports have certain characteristics that cause potential confusion.

So, of course, you apply that information, that knowledge, now to designing airports and runways, etc., and taxiways so that we don't have that. That's what has to happen. It's primarily about data. It's understanding what the data is telling you and identifying what needs to be changed and redirected.

And you're not going to get that data if you don't have a good relationship with those operators.

Absolutely not.

Because they don't have to give it to you?

They don't have to. There are, by regulation, certain records that must be provided, but that which is not required by regulation is that which is known to them as they operate in the system.

Tell me about the FAA's historic mission here -- to promote as well as regulate aviation. When you first got there, did you see an inherent contradiction there?

I know that the Congress removed the word "promote." But I will tell you that the language today talks about "encourage."

I never did see that there was a conflict. I could easily compartmentalize. If I'm encouraging you to do better, I'm not encouraging you to necessarily grow your business in terms of promoting aviation.

The "promotion" was promoting aviation safety as we saw it. Most people in the FAA that I know looked at it that way: promoting aviation safety.

So they weren't aviation boosters necessarily.

Not as far as I'm concerned. That's my own personal paradigm. Promotion to me meant the promotion of aviation safety.

You got there right as deregulation [was occurring]. The world changed pretty quickly when you got to the FAA. How did all the additional carriers and the big change in the way we fly affect the way the FAA and you did your business?

A number of things happened at deregulation. About that same time, there was a major rule change for Part 135 -- on-demand charter, that sort of operation -- which significantly raised the standards to be a Part 135.

It was a lot of work, because all those operators who were currently Part 135 operators had to be converted to the new Part 135. That took a number of years.

In addition to that, outside the 135 world, you had all kinds of airlines getting into the business, new players, new operators. It must have been a busy time.

It was. I'm not exactly sure how to answer that question.

I guess what I'm saying is the big question would be, how much did this tax the FAA?

From a safety perspective, nothing changed, other than during that time coincidentally we raised the standards for Part 135.

But not too long afterward in the early 1990s, there was the conversation, because of some events that occurred, that 135 operators who were providing scheduled service with airplanes as large as up to 30 seats, to bring them under Part 121.

We have to be careful on the jargon here. Basically what you're saying is, in the '90s, you had commuters or regionals flying under the rules for charter operations, not airline rules, and there was a series of incidents that occurred there. Take me back to the time and what was going on.

During that time, as I said, there were ... a few accidents that caused the agency to think about having one level of safety. If you're providing scheduled service, then you're going to provide that scheduled service with aircraft sizes of 10 or more seats. Then you're going to have to perform that scheduled service under Federal Aviation Regulation Part 121, which is the regulation that governs airlines that we know today.

And it's interesting to know that there is this term of art that is bandied about in terms of regional air carriers that Federal Regulation 121 makes no such distinction. The regulation that applies to regionals is the same regulation that applies to the major airlines that we see.

So when people say "one level of safety," is that more than a slogan?

No, it's an absolute standard that needs to be met. All of these operators who are providing scheduled service are doing it in accordance with the Federal Aviation Regulation Part 121. That regulation makes no distinction for regionals or majors -- none.

I know you're out of the FAA now, but during your tenure, was there, in fact, one level of safety?

I believe so. Now, it's interesting to note that in the statute that authorizes the FAA, the statute specifically singles out the air carriers. And it goes on to say that air carriers shall operate at the highest levels of safety, which means that you are constantly raising the safety bar. And that is what's important to understand. Everyone is meeting the regulatory standard, and no matter how high you make that standard, it is always the threshold for entry into that service.

What we would do with air carriers -- and again, working together -- is encourage them to introduce programs that collect data: Flight Operations Quality Assurances [FOQA], the flight data recorder on an airplane. And it captures a tremendous amount of data, and you can look at how those airplanes are performing, how they're operating, etc.

There's another program for pilots, flight attendants, mechanics to report what they see, and the FAA affords them protection against use of the information against them.

It is that flow of data to us and, together, analysis of that data that provides us insight into what is going on in the system, so while they always meet the required regulatory standard, it's the learning of what's going on in the system that constantly raises that safety bar, learning about what's happening in the system and applying interventions to prevent a potential accident.

I think that's really a key point, because what you're suggesting here is some airlines -- the big ones -- because they can afford it better and because they see efficiencies out of it, use these programs which capture this data to find out what's going on well before it becomes an incident and certainly a crash. But what you see is with the smaller players, the small regionals, they haven't made those investments over the years, and so when people tell me "one level of safety," I see all that data flow coming out of the majors, and I don't see the same programs by and large by the smaller players. So is it really one level of safety?

I believe it is, for this reason: You characterize the majors and the regionals. Again, I want to emphasize, there's one regulatory standard, which is a very high standard.

Yeah, but you're suggesting some of them are going above and beyond that, with your encouragement, right?

I would agree. However, that is not to say that they aren't at various stages of evolving to applying those kinds of tools to learning about what's going on in their system. So if it's a smaller Part 121 air carrier, no different than a major, but its resources are less, then they cooperate with others, maybe their own association that they may have that provides them the kind of support for analysis of what they're seeing. So there is a coming together of several smaller air carriers to leverage what they see and leverage resources so that they can benefit.

Now, the FAA also has the collection of this data, and it's not kept silent or secret. It is distributed to the community so that everyone benefits from what is being learned for people operating 737s. This is what we see that is going with 737s in terms of operations or in terms of maintenance; this is what we see with the CRJ-600s; this is what we see with the Embraer. That is shared throughout the system, so even if you may not in fact have your own ASAP [Aviation Safety Action Program] or FOQA program, you benefit from what we learn collectively.

If those data recovery programs are such a great tool for safety, why doesn't the FAA just make a rule that every airline, large or small, have to do it? Why doesn't the FAA make a rule like that?

There is an interesting issue that then unfolds. I believe, and I haven't thought through it enough to really give you a substantive answer, but I would have some concerns about the dynamic that changes. If I require you to report everything, does that really deliver for us what we would want you to be reporting. It's a dynamic, I think, that changes the relation --

So you're suggesting you get more and better data if it's voluntary? Is that what you're saying?

I believe so, because there's the quid pro quo. If you report, you're protected. If you're required to report, I'm not required to protect you unless we then regulate in such a way that says you're required and when you report, nothing will be done or this information won't be used against you.

So it changes the equation of the bargain a little bit.

Yeah, it does. It does. It's not to say it can't be done. It needs to be studied. I wouldn't want to see it become reality unless that's well thought through in terms of what is the impact of requiring you to tell me what you see every day and it's so easy for you to just not report it.

It seems to me that if it's that valuable of a tool, it should be something every airline does, no matter what.

I would say that just about every one of them does it.

Well, maybe now.

Yeah, but, you know, that's the evolution. In 1946 there were approximately 1,500 aviation fatalities, and if we had done nothing and the system did not grow, which it has grown exponentially, it is not unreasonable to believe that we would have had that many, approximately, fatalities every year.

But over time, we have continued to reduce the accident rate to where today accidents are rare and they are random. That was that period of time where strong enforcement and compliance with regulations and the industry evolved over time. They comply. They want to comply. There is a very tiny percentage of people who attempt to cut corners. They are drummed out of the corps, so to speak. When we find those, that type, we take appropriate legal action.

But the vast majority of operators are voluntarily and more than willingly complying. They want to. Why would you want to operate an airline that could potentially be unsafe? What kind of branding is that? Safety is key to gaining public confidence so that people would have confidence to choose your carrier to fly on.

But with the economic pressure that this industry faces, there are lots of little teeny cuts that occur in the real world that when they add up can in fact lead you to an accident scene, right?

I don't agree with that, Miles, for this reason: my personal experience and the people who worked with me during this period of time.

Not too many years ago, we had nine airlines in bankruptcy at the same time, and folks were saying outside of the agency that they're cutting corners because they're in bankruptcy, and therefore they're going to operate unsafely.

We had a focused emphasis on looking at those air carriers and found that they were in complete compliance because we know where to look where you want to cut corners, and we could find no evidence. And we scrutinized very, very carefully, day in and day out, and could not find any evidence that they were cutting corners.

If they were cutting corners, they were cutting corners on the passenger comfort side, where now you have to pay for so many different little items, so they're making it up in other ways. But from a safety perspective, they knew as well as the FAA knew that if ever they had to demonstrate that they were operating safely, this is the time you'd better demonstrate that you're operating safely, and they adhere to that very, very well.

We were talking about that "promotion" vs. "regulatory" rule and what factors into that one -- which ultimately led to the change in the official charter or whatever for the FAA -- was the ValuJet incident [in the Florida Everglades in 1996]. In the case of ValuJet, when you look back on it, it seems as if the FAA was pushing pretty hard to make ValuJet a success. Wasn't that "promotion" that had gone over the top?

Well, I wasn't that close at that time to that particular ValuJet event, so I really can't tell you that it was excessive promotion. Like I said, my belief is promotion, as I saw it, was promotion of the safety equation, not the promotion of the business side of it. That's the way I operated, and that's the way people that I worked with operated.

But in the end, ValuJet was not a safe airline, and it was promoted internally --

Well, I'm not going to review history with you, Miles. The facts will speak for themselves, and anyone can get the record and determine for themselves as to what ValuJet was or was not.

But I want to go back to that transition period and what happened during that one-level-of-safety transition.

The FAA promulgated a rule in 1994 which required those affected to be in full compliance by 1997. It changed significantly the type of airplanes that Part 135 operators were operating at that time and required those people to move into transport category airplanes.

Transport category airplanes are built with many redundancies. They have guaranteed performance in terms of engine failure and what have you, and that's why you saw the proliferation of smaller jets. They are transport category airplanes that came into the system, and they started out with the 30-to-50-seat range and they went in; now, they're operating those jets considered today regionals up to 100 seats and operated by some majors, so that distinction, that term of art of regionals is being blurred.

The point is this: Those jets began to proliferate and came online, but they replaced those airplanes that were less capable than the transport category airplane, and that contributed significantly to the safety of the system.

We were talking about this transition between the two sets of rules. The 135 are charter rules, and 121 [are] airline rules. For a lot of operators, it's a big jump, right, to go from running a charter to running an airliner -- all kinds of different safety requirements, crew. Up and down the board, it's a different way to run a business. How difficult was it to make that transition for a lot of these operators?

Some never made that transition to be successfully certified as a Part 121 air carrier. So those that exist are those that were successful, and those that dropped off -- I don't recall who they are -- some just stayed in the 135 business as on-demand operators.

The point I want to make is that we should not characterize Part 135 as a lesser standard. Captains under 135 are required to demonstrate their proficiency every six months; Part 121 as well -- every six months. First officers every 12 months -- same thing for Part 121.

The major distinction is, as I see it, is the type of aircraft that you're operating. Transport category airplane is the best that we as humans know how to build, and those are required to be operated by 121 operators. Dispatchers, flight following, etc. -- all those things that support that airplane every step of the way along its intended route in 121s.

... Let's talk about Southwest. Going back to this relationship that the FAA tries to create, this sense of creating a dialogue, is that the way you describe it, a dialogue between the regulator and the regulated?

A professional relationship where each member of that relationship understands their responsibilities. There's no reason why, as the regulator, and you're the certificated entity, that we can't have a professional, good, comfortable relationship where we can raise the safety bar together versus adversarial and you don't tell me what I probably ought to know and not knowing, [and] then I can't benefit the public by not knowing.

Something went off the track in the case of Southwest. What happened there? Did they get too cozy?

I don't think they were too cozy. There were strict guidance on how to handle that voluntarily reported incident, and the people receiving the information did not follow the guidance, and as a result, it unfolded the way it did.

But we've learned lessons from that, and we had this -- still do have this -- voluntary reporting system of self-reporting where you discover that you may have not complied with the regulations. We have changed that and strengthened that. Whereas at one time, anyone in the airline could report it to the inspector at the FAA or the local office that has that responsibility, we've changed it to where only certain people in the airline, in the air carrier who are required positions by regulation such as chief pilot, director of maintenance, director of operations, etc., only those people can officially present a self-disclosure to the FAA, and it cannot be accepted by any inspector in the field office. It can only be accepted by the office manager, and there will be periodic reviews of what is being reported in terms of self-disclosures. So that's significantly strengthened that program.

But something went wrong there, and one of the things that went wrong was the people who were trying to do the right thing were not listened to by their superiors. Matter of fact, they were reprimanded.

We also put in place a safety information reporting system. Those people should be listened to, and we have put in place, it's now them, the FAA. But at that time, we put in place a mechanism where you can report anonymously or openly what you see in terms of an inspector or anyone in the FAA wishing to report what is observed and needs to be paid attention to.

So what people who were there say about this is that the atmosphere, a lot of this was fostered by the Customer Service Initiative, which was your baby, right?

Yes, it was. So coming from the field, what we know is that there was a lack of consistency and standardization -- and how best to address that? A decision rendered by an FAA office on the East Coast or the West Coast should be the same. The application of the rule should be the same. The application of guidance and policy should be the same, and that was not how things were working. It was not as good as it ought to be, so you, a citizen of these United States interfacing with your government, should have the right to, when a decision has been rendered regarding an application you may have submitted and you read the regulation and you say, "Well, I should have been issued this," or "It should have gone this other way," you should have the right to appeal that to the supervisor.

So we put in place what was at that time called a Customer Service Initiative. It was never intended in any way to diminish the importance [of] who the real customer is. The real customer is the public of these United States. We never lost sight of that regardless of what anybody says. It is the public who is the customer.

But in a relationship where you're working to raise the safety bar, we wanted to establish consistency and standardization and put in place a mechanism that is still in place today, that allows standardization and consistency to continuously be achieved.

Now, we should have called it the Consistency and Standardization Initiative [CSI]. Why we ever called it Customer Service I have no idea. It just evolved that way, but its intent was about consistency and standardization.

In fact, to further that, the AVS [Aviation Safety] organization, the safety organization, went about the business of achieving ISO [International Organization for Standardization] registration, which is not about regulations but it is a rigorous methodology on how the organization operates internally and how it interfaces in a consistent and standardized manner with the people it is serving in terms of applicants or pilots, mechanics, whatever the case may be.

So the intent was different than what got sent down to the ranks. In other words, you start calling the airlines "customers" -- well, you know, the customer's always right. Not so, right?

That's true. It was never intended to say that the customer's always right. It was a mechanism to say you need to listen to people who have reason to ask questions about a decision that was made. I'm a citizen of these United States; I want my government to be responsive to me. If I have a question about my government, I want to raise that question, and I want someone in authority to tell me why a decision was made that I disagreed with.

And you know what? We require people in the FAA who then review these CSIs to put their decision in writing, and that decision needs to be based on regulation, policy and guidance so that everyone understands why that decision was made. Interestingly enough, most CSIs were not overturned.

How are the airlines the customer?

They're the customer. They're the applicant. They are the entity with whom we interface day to day. Every day you're interfacing with them, and if you want to call them customers, so be it, but not in the sense that they are always right.

What happened is it caused people to believe that the use of the term "customer" meant that the air carrier got its way every time. That is not what it was. Or the individual got his or her way every time. It was designed to allow people a mechanism to have an issue reviewed.

Do you think it confused the troops in the field as to what their mission was?

It may have. I think people that were involved with that issue, some are no longer with the agency.

The Customer Service Initiative, do you regret?

Oh, absolutely not. I think that was a good tool to put in place. I wish we hadn't called it Customer Service. We should have just called it Consistency and Standardization Initiative.

The Southwest story, then, was the Customer Service Initiative gone bad in a sense, wasn't it?

No, I think that it was a totally different issue there, that the air carrier reported a noncompliance, and the person receiving the information did not follow the FAA's guidance on it.

But there was a sense there that the airline could do no wrong here; we're going to make it OK for the airline; the customer's always right.

That may have been the case with an individual.

Right. But I guess what I'm saying is that's an example of how these edicts from on high can get misinterpreted, right?

There are lawyers that interpret everything that we put in writing, so it's the human condition. We put out information. We were very clear about what was intended to do. There was printed material that was available to the industry as well as to FAA inspectors. They knew what it was all about, and if people misinterpret that, then I would say to you that's part of the human condition.

All right. But then, of course, the inspectors who were trying to raise their hand and say, "Wait a minute. This is something pretty serious. We have airplanes falling outside of airworthiness directives -- ADs," they were treated like the villain. What does that say about the FAA?

They should not have been treated as villains. In fact, I will tell you I'm glad they raised their hand, because when it came to our attention, we took the appropriate action.

You're not at the FAA now, but is it fixed? What's happening now, as best you know?

As I said, that was a situation that caused lessons learned. We certainly strengthened the self-reporting system. We put in place a mechanism where FAA employees feel they're not being heard, there's a mechanism to openly or anonymously report whatever you feel you need to have heard. In fact, in recent proposed legislation, the FAA will be required to now have an office specifically looking at those kinds of reports, and I welcome that. ...

No one wants to treat someone who has a safety concern as a villain. How that happened back then, history will look at that and make that decision. But I can tell you, going forward, no one wants to treat those people or wanted to treat those people as villains. When we heard about it, we took the appropriate action.

I guess what worries me as someone who gets on these airplanes is how many of these situations we don't know about. These are people who came forward at tremendous personal risk to their careers, and a lot of pressure is brought to bear upon them to do what they did and take a stand. How much concern do you have that there's more of this going on out there?

I think that was a unique and rare circumstance involving someone who did not follow FAA guidance. I believe that there has been enough publicity about this, internally and externally, to cause people to realize in the agency -- FAA inspectors -- that if they have an issue, they need to come forward. If they want to talk to the senior leadership right there in Washington, you can access them immediately, and that's what we encourage. That's what was encouraged and is encouraged today.

But quite honestly, Miles, I don't think it's widespread. If you go back, and you can avail yourself of this data with the FAA, how many people, once we began to encourage people to come forward -- [there are] very few reports. So if people are not coming forward, what is that indicative of?

Maybe they're afraid.

What else can you do then? If they're afraid, what else can you do? You encourage them that they will be protected; there will not be any action whatsoever. In fact, we welcome you telling us what you know, because it's critically important. But the facts belie that, in terms of something's going on out there that we don't know about. The fact is, we're operating the safest air transportation system in the world, bar none. And the best way to continue to deliver on the public's best interest is to work in a fashion that causes industry and government to share information, because when people work together, you can solve many, many problems.

Of course, the reason it is as safe as it is, is that there has always been a constant push to make it safer. And what some people have suggested in talking to them is that we've kind of plateaued here because of the economic realities, because of the change in dynamics, regionals vs. major carriers. You know, last six crashes over [six] years, all regional carriers. Isn't that saying something?

I don't know what you mean by a crash. A crash has no legal definition. Is that a fender bender? Is it a fatality? What is that? Let's take that period of time between 2006 and February of '09. No, none, zero 121 accidents. None. Not a scratch on anybody.

I guess what I'm trying to drive at here, because I don't get to see the FOQA data and the ASAP data -- you've seen this over the years -- is this a system that is fooling us into thinking it's safer than it is? Is it teetering because of so many pressures being brought to bear on it?

I seriously doubt that. If you look, again, at across history, the greatest contributor to the reduction of accidents over time has been technology. One of the greatest contributors was the turbine engine. It improved engine reliability a hundredfold, and that in turn eliminated those kinds of accidents. And if you look over time, the intervention of TCAS -- Terminal [sic] Collision Avoidance System -- enhanced ground proximity warning systems, we no longer have CFIT accidents or controlled-flight-into-terrain accidents in the United States because of the technology.

[Editors' note: The correct name of TCAS is Traffic Collision Avoidance System.]

And that is what is so important about where we are today, moving from forensics, post-accident investigation. There will always be that when those events do occur, but proactively, every day, you have got to be engaged in prognostics, the sharing of the data that is captured every day and looked at by professional analysts who can say, "Here's what we're seeing as a trend." And I think that is a strong environment that is certainly keeping us moving ahead, because that is what's going to deliver a continued safe air transportation system.

I guess what would be of concern is that there is this sense, there is this atmosphere that they feel they can't do that.

One of the things that we're working very hard on is assuring that we have, within FAA as well as externally, a safety culture, a culture that encourages people to come forward and tell us about what they're seeing. It's management's responsibility to ensure that that kind of culture is being cultivated. Is it perfect? Probably not. But that's what we were setting about doing, and there is a strong effort on the way right now to continue to do that, to assure people -- FAA people -- that they can come forward. Don't be concerned about any retribution; there won't be any.

And who in their right mind in a leadership position would want to take action against someone when by doing that, you put yourself in harm's way? So if anything, I would welcome you with open arms. You have something to tell me? Come and tell me, and you will be protected.

Does the FAA need to change its culture?

We have to move the culture to continue to emulate that epitome of a safety culture. I said it's not perfect, but they're working hard at getting that to be a just culture across the board, not just in the FAA, [but] in airlines, in industry, anywhere -- the medical community, etc.

So maybe it lost sight of that somewhere along the way.

I don't think it did.

But it needs improving.

It needs improvement. Nobody's perfect. And when you think you've reached that perfection, you'd better double-check again and make sure of that, because no one ever reaches perfection.