Special Report: The US Federal Aviation Administration is known to be slow in mandating changes related to safety. The FAA has come under widespread criticism for Congress and families of crash victims, in recent history with increasing frequency. Sometimes called the Tombstone Agency, this name emerged after the FAA repeatedly failed to implement safety requirements until after fatal or near-fatal air crashes. But as this Special Report shows, actions—or the lack of them—have roots going back to the propeller days.
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By Colleen Mondor
March 6, 2025, © Leeham News: On Jan. 31, two days after the midair collision near Reagan National Airport in Washington (DC), the FAA announced it was indefinitely restricting usage of the two low level helicopter routes through the airspace.
Two weeks later, the Wall Street Journal reported the agency was moving to permanently delete those routes. For longtime FAA observers, this was yet another example of reactionary response, further proof of a “tombstone mentality” that permeates the FAA bureaucracy. For those who subscribe to such a view, the FAA never does anything until the cost is so high there is no other choice. In Flying Blind, Flying Safe, former Department of Transportation Inspector General Mary Schiavo said the attitude was pervasive but then relied upon a common construct to support the claim: the anonymous source. In her case, she quoted a third hand exchange between an unnamed FAA official and unknown journalist where the official apparently said: “We regulate by counting tombstones.”
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The origins of the tombstone moniker are unknown. On his website, consumer advocate Ralph Nader shares a quote from an unnamed National Transportation Safety Board (NTSB) official dating to the time of his 1994 book on airline safety. This official allegedly said, “that the FAA operates under a ‘tombstone imperative’.” The same terminology was headlined by the Tampa Bay Times that year and in 2001 the Washington Post referred to “tombstone regulation” writing that “Great leaps forward in aviation safety often occur after crashes.” Last month, on February 12, the New York Times cited the crashes in DC, Pennsylvania and Alaska, to make the reference again, saying the FAA “has earned the nickname the tombstone agency among aviation safety advocates for not addressing potential problems until disaster struck.”.
Tombstone Agency or Tombstone Politics?
For believers of the tombstone analogy, the repeated use of the reference over decades proves their point that the FAA rarely does anything positive for flight safety until there are too many dead to ignore.
However, this assertion, while effective in making the agency the villain in nearly all aviation accidents, undercuts the significance that political power has always had on the FAA. To appreciate that dynamic, and how it has affected flight safety policy for nearly seventy years, requires taking a long view. All of the FAA’s history must be considered and only then does a different pattern emerge showing chronic budget battles, gaps in leadership, understaffing, and political influence. This is the true story of the FAA, an agency that was intentionally formed in the aftermath of disaster.
The accident that led to the FAA
The accident that led to the creation of the FAA: A TWA Constellation and a United DC-7 collide over the Grand Canyon. Complaints about today’s FAA are virtually identical to those of the agency it replaced, the CAA. Credit: Smithsonian Channel.
On June 30, 1956, United Airlines flight 718 and TWA flight 2 collided in midair over the Grand Canyon killing 128 people. It was the first aviation accident involving more than one hundred fatalities in the U.S. Earlier that year, in recognition of commercial aviation’s growth, President Eisenhower appointed Edward Curtis of the Eastman Kodak Company to the new position of Special Assistant to the President for Aviation Planning. Curtis was immediately tasked with directing a study to meet the country’s rapidly changing needs for airspace management. He was in the midst of that plan when the midair occurred, revealing in the starkest of terms how rules and practices for air traffic spacing, which were formulated for the slow moving aircraft of previous decades, were no longer suitable for modern aircraft, let alone the jets of the near future.
In the accident’s aftermath, one source of confusion was why the two aircraft were in uncontrolled airspace which left them relying on visual cues even though UA flight 718 was assigned an instrument clearance. More specifically, a common question was why no controlled transcontinental airway route existed from Los Angeles, the departure point for both airlines. During the investigative hearing, the director of air traffic control at the Civil Aeronautics Administration (CAA) had a simple answer to that query: “Funds, personnel and equipment.” The same response has been made to nearly every major accident since.
The Grand Canyon accident immediately prompted demands for moving administration of the country’s aviation system away from the Department of Commerce and into a new independent agency. To a certain degree that process was underway before the crash through Curtis’s assignment, which included not only assessing future aviation needs but the more immediate concerns of airspace control. His report had been under review with Congress for a year when the next two midairs occurred, in April and May 1958. Those accidents, in Las Vegas and Brunswick, Maryland, resulted in sixty-one more fatalities and involved collisions between civilian airliners and military jets. The military aircraft were in busy civilian airspace but flying visually, which made them outside control of CAA authorities. Two days after the second accident, Sen Mike Monroney of Oklahoma and Congressman Oren Harris of Arkansas introduced the Federal Aviation Act.
Regulating Safety and Promoting Aviation: the conflict begins
When it was signed into law on August 23, all functions of the CAA plus the development and oversight of a comprehensive air traffic control system, which would accommodate faster jet traffic and address both instrument and visual flight, were transferred to the new Federal Aviation Agency (FAA). The issuing of regulations, which previously was under the purview of the Civil Aeronautics Board (CAB), was also transferred to the FAA. (The CAB continued to investigate aviation accidents.) Finally, the new agency was tasked with promotion of civil aviation in such a manner that would best foster its development and safety. Likely based on Cold War fears that US civil aviation was falling behind the Soviet Union, a not uncommon media topic of the era, this task would frequently prove to be a primary source of attacks against the agency.
In 1966 the Department of Transportation (DOT) was formed, and the FAA lost its independence. (It became the Federal Aviation Administration, and the CAB was transformed into the NTSB). The decade had already been one of upheavals for the FAA, whose remit expanded to include security from air hijackings and a host of technological improvements such as ground proximity warning systems and emergency locator beacons. Battles were waged over extending regulatory mandates to privately owned and business aircraft while airlines bemoaned constant delays at busy airports due to Air Traffic Control (ATC) understaffing.
The initial move of the FAA into the DOT was not without problems. In 1967 DOT Secretary Alan Boyd was forced to address charges from Sen. Monroney that bureaucrats in his department were “placing handcuffs” on the FAA’s staff. Monroney also demanded that the FAA Administrator “be independent in matters of air safety.” Boyd denied any interference but told reporters FAA Administrator William McKee had told him “If you knew what was going on in your department, you’d know what the problem was.” Acerbic comment aside, Boyd insisted the two were “great friends.”
Understaffing at the FAA
Meanwhile, in 1968 the FAA asked Congress for additional funds for 3,627 more air traffic controllers and other positions, explaining that the additional personnel were needed to “cope with heavy air travel”. The agency was not exaggerating its needs. The decades of the 1960s and ‘70s witnessed a litany of accidents. There are 75,435 accidents in the NTSB’s aviation database from its first year of online recordkeeping, 1962, through 1979. As the database is notably incomplete for the early 1960s, the actual number is likely higher by several thousand.
The probable causes for commercial airline crashes in that period ranged from a midair bomb explosion in 1961, (likely from a suicide bomber seeking an insurance payout to cover debts), to mechanical failures and flight crew errors. In many cases, the CAB and later the NTSB chided the FAA in probable causes and new regulations and policies were the result.
Graphic showing the difference between the American Airlines DC-10 decompression (left) and the THY (right). Graphic: Federal Aviation Administration.
But there were also questions about the FAA’s commitment to flight safety issues. In December 1974 a report conducted by a team of 10 FAA investigators into the 1972 DC-10 crash of Turkish Airlines flight 981 in Paris was leaked to the press. In light of this rapid decompression accident which killed 346 and followed a similar near-crash after take-off from Detroit, the investigators determined that the aircraft’s manufacturer had not complied with agency regulations and, further, that FAA aircraft certification officials did not adequately consider failures of the rear cargo door which led to the cabin floor collapsing and destruction of the control cables.
The report resulted in the approval of the Airworthiness Directive notification system but also led to the resignation of the agency’s associate administrator for aviation safety. Oscar Bakke was with the FAA from the beginning, in a career that began in 1946 with the CAB. He led the Paris team and after completion of the report was recommended for promotion by the administrator to oversee all agency safety programs. For reasons not released to the public, DOT vetoed that decision, prompting Bakke’s immediate retirement.
Controllers strike and modernization
In 1981, following the disastrous air traffic controllers strike, Congress insisted there needed to be another overhaul and modernization of the air traffic system. However, over the next decade, and after spending at least half a billion dollars, the system largely remained a fantasy. In 1994, FAA Administrator David Hinson canceled the plan and authorized a smaller version. Senator William Cohen of Maine, on the subcommittee overseeing the FAA, very publicly blamed agency mismanagement for the debacle, saying “If the agency devoted more time to managing itself and less time to defending its deficiencies, the air traffic control system would have been replaced years ago.”
While there were plenty of people pointing fingers over what went wrong, a more insidious problem was the lack of consistent agency leadership. The FAA cycled through seven administrators between 1981 and 1996, including 30 months when no one was in charge. In a 1996 interview, Joseph Del Balzo, a career FAA employee, blamed the FAA’s “structure” for the failure to develop the new air traffic control system. What he did not explain was how he handled that problem when he was acting administrator for eight months in 1993.
Problematic oversight
With leadership mired in the struggling upgrade and congressional demands, other, more serious, areas of concern were being ignored. In 1986 the General Accounting Office (GAO) testified before a congressional committee that the FAA could not be certain airlines were in regulatory compliance as inspections were insufficient and the FAA lacked “adequate internal management controls.” That assessment was especially prescient in the years that followed.
In 1994, an American Eagle ATR-72 crashed in Roselawn (IN) killing all 68 people onboard. It followed a series of ATR-72 and ATR-42 accidents in the U.S. and Europe all of which occurred in icing conditions. The Roselawn tragedy resulted in a cavalcade of negative media coverage culminating with a familiar assertion uttered by Congressman James Oberstar of Minnesota that the FAA was “…doing safety by body count.”
The regional airline industry had rapidly expanded after deregulation in 1978 and attracted several foreign manufacturers, including ATR which is based in France. But the FAA did not expand the then 12-person office responsible for certifying foreign aircraft and, by necessity, they often relied on the work of foreign authorities who submitted the aircraft for approval.
15 years of studies, out-of-date standards
This was not the only area of the FAA that lacked critical personnel. The New York Times reported in 1995 that in the previous 15 years numerous studies cautioned “…the FAA lacks not only manpower but the technical expertise to spot flaws in new planes.” This dearth of knowledge likely had a direct impact on ATR certification.
Richard Adams, the agency’s top icing expert in the 1980s, had warned that the FAA’s 40 year old standards for testing performance in icing conditions were outdated. He was not consulted during the ATR certification process and retired in 1989. There was no replacement for Adams because, as reported by the Times, the FAA “…could not find a qualified replacement willing to work at a government salary.” A 1993 GAO report noted that those responsible for certifying aircraft were “falling farther behind in understanding the principles and effects of ice on aircraft designs.”
As questions swirled about the ATR certification, Sen. John McCain of Arizona said there was no way the FAA could avoid a hearing. The Senate was expected to ask if the agency contributed to accidents by responding too slowly to potential safety problems. “I have found the FAA to be unresponsive and insensitive and reluctant to do their job,” Sen. Larry Pressler of South Dakota told the Times. Meanwhile the FAA announced it had funds approved for 300 new inspectors and was seeking funds for 200 more in the next year.
ValuJet crash a trigger point
Then, ValuJet flight 592 crashed in May 1996.
The ValuJet accident was caused by a subcontractor mislabeling oxygen generators causing them to be improperly loaded. They consequently started an inflight fire and all 110 people on the McDonnell Douglas DC-9 were killed. In the ensuing investigation, it was found that local FAA inspectors had raised concerns for some time about ValuJet operations but were ignored by superiors. Still, immediately after the accident FAA Administrator Hinson and Secretary of Transportation Frederico Peña voiced their support for the company and similar “low-cost” air carriers. As more revelations about ValuJet came out, they changed their minds, claiming the FAA didn’t know the extent of the airline’s issues. This was incorrect. Quickly the media lens turned, as it always does, to the FAA.
Trust in the FAA?
Sen. Cohen was certain the entire agency was the problem telling BusinessWeek “I don’t think just one individual being fired or let go is going to change the culture.” In a blistering article entitled “Can we Ever Trust the FAA?”, TIME magazine attacked the agency’s “benign tolerance” of companies like ValuJet and alleged many former Administrators “have close ties to the airline industry”. Mary Schiavo, then in her position as DOT Inspector General, said the dual mission of promoting the industry and overseeing flight safety made the FAA ineffective. DOT, she was quick to assert, had no such conflicts. “It’s not my job,” she said in an appearance on Nightline, “to sell tickets on ValuJet.”
While the media’s language conjured covert deals with industry leaders, the reality of the FAA’s staffing issues could not be ignored. At the same they were bashing the agency’s poor oversight, TIME also confirmed it was “financially strapped” and down 5,000 employees since 1993. The magazine said the FAA was short of inspectors and the ones it had, “…must devote increasing amounts of time to clerical tasks.” And yet the article’s primary message was that the depleted FAA was still negligent and failing at its mission. It was the same message from decades past and what the FAA would be accused of yet again after the series of accidents earlier this year.
Near collisions safety crisis: politics again
In 1987, under the headline “Near Collisions of Aircraft Among Signs of Safety Crisis…”, a New York Times article reported a litany of truths about aviation. There were 839 reported near-misses in the air, 115 “runway errors” on the ground, and 313 “operational errors” where ATC failed to maintain proper spacing between aircraft in controlled airspace. The FAA was short of air traffic controllers and aircraft inspectors. The head of the NTSB accused the FAA and DOT of lacking “the courage or capacity” to deal with the current safety crisis. The Reagan administration refused to allow the $5bn in the Aviation Trust Fund to be used for capitol airport improvements, as sought by Congress, while Congress refused to support the administration’s efforts to pay operating expenses and salaries from the fund. The FAA Administrator had been in his position for three years and was resigning partly due to funding disputes. “There are going to be growing pressures on the air traffic system, more aircraft and more flights,” said Congressman Oberstar. “Congress is prepared to provide financially whatever the FAA needs to do the job.”
The problem in 1956, according to a House subcommittee, was that there were then 75 subcommittees and agencies dealing with aviation. “A lack of well-defined authority and responsibility in aviation matters…has resulted in compounding confusion rather than in the resolution of critical problems.” In the decades since the Federal Aviation Act was passed, Congress has relentlessly argued about the best way to oversee and fund the agency it established for the purpose of overseeing and regulating aviation.
Now, again, Congress, the media, and the president as well, are asserting the FAA is complacent and slow to address safety concerns. It is always “the FAA” in these complaints, a faceless, nameless bureaucracy that dwells at the center of all air safety problems. It is always Tombstone Agency that is at fault.
Modern day: More studies, still understaffed
In 2023 the FAA commissioned an independent review to come up with a plan to improve its handling of aviation risks. The review team, which included former heads of the FAA and NTSB, recommended several actions including, “changing the culture at the agency to one where concerns are tackled before they worsen and lead to disaster.”
And yet last summer, when the head of the Professional Aviation Safety Specialists union testified before the House subcommittee on aviation, one of his primary questions concerned the 2021 Aircraft Certification Safety and Accountability Act which authorized $81m over three years to recruit and retain safety specialists. The union head noted that the DOT Inspector General had found over 50% of FAA safety offices were short-staffed, a situation the Act was supposed to correct but the funding had yet to materialize.
When Leeham News attempted last month to determine the status of the $81m it was told by congressional sources that while the funds were authorized, they were not appropriated and how much money would eventually make its way to the FAA from the Act was unknown.
In mid-February, the FAA announced the loss of 400 employees due to administration-directed job cuts. In covering the losses, on Feb. 24 the Washington Post reported Sen. Ted Cruz of Texas, chair of the subcommittee on aviation, was determined to solve the air safety problem. “I believe that the tragedy last month may well bring lawmakers to the table to finally enact the change we need,” he said. But then he continued, “Standing here today, I can’t definitively say what those changes must be, precisely.”
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