The Washington Post - 01.08.2019

THURSDAY, AUGUST 1 , 2019. THE WASHINGTON POST EZ RE A

BY MICHAEL LARIS

The Federal Aviation Adminis-
tration’s top safety manager, fac-
ing his most rigorous public ques-
tioning since two Boeing jets
crashed under similar circum-
stances, repeatedly defended the
FAA’s approach to safety Wednes-
day but also acknowledged a key
agency misjudgment.
Ali Bahrami, the FAA’s associ-
ate administrator for aviation
safety, sought to blunt criticisms
during a Senate hearing that the
agency had given Boeing too
much power to oversee the safety
of the planes it builds. He called
the FAA’s system giving compa-

nies far-reaching oversight of

their own technical work “sound.”

The approach allowed the FAA to

focus on improving overall safety

systems, he said.

Bahrami also conceded that

the FAA had misjudged the risk of

a second disaster coming so

quickly.

Two crashes of new Boeing 737

Max jets within five months in

Indonesia and Ethiopia have

brought new scrutiny to FAA

practices. Certification of the Max

specifically, and airplanes in gen-

eral, remain the subject of on-

going probes.

“We have relied on the industry

more than we should... to do the

job that we should do to make

sure the American public is safe,”

said Sen. Joe Manchin III

(D-W.Va.), who is a pilot, at

Wednesday’s hearing.

Bahrami previously served as

vice president of the Aerospace

Industries Association, and be-

fore that was a longtime FAA

manager overseeing the certifica-

tion of airplanes built by Boeing

in the Seattle area.

Current and former FAA offi-

cials have pointed to Bahrami as a

champion of the FAA’s highly del-

egated approach. The Organiza-

tion Designation Authorization

program gives companies such as

Boeing responsibility for much of

the detailed, technical work of

finding whether government

safety standards are being met.

Last year, as part of the FAA

funding bill, Congress gave Boe-

ing and other firms greater power

to oversee themselves under the

ODA system.

Carl Burleson, the FAA’s acting

deputy administrator, argued

that delegation is a critical piece

of the U.S. safety record. “It

doesn’t mean each decision we’ve

made has always been perfect.

But I do think the fundamental

process of how we went about

certifying the Max was sound,”

Burleson said.

Critics have pointed to major

problems with the certification

system.

For the Max, Boeing designed

— and the FAA certified the safety

of — a flawed automated feature

known as the Maneuvering Char-

acteristics Augmentation System

(MCAS). Investigators say bad in-

formation from an external sen-

sor prompted the MCAS to re-

peatedly force down the noses of

the planes before they crashed,

resulting in the deaths of 346

people. Boeing is working on soft-

ware fixes to address that and a

separate potential problem with

the flight control computer dis-

covered since the crashes.

Senators pressed Bahrami on

why the FAA was not more explic-

it about the specific dangers of

the MCAS feature in an emergen-

cy Airworthiness Directive last

November. That order said erro-

neous data could lead to trouble

controlling the airplane and “pos-

sible impact with terrain.” It or-

dered airlines to augment 737

Max flight manuals with instruc-

tions for how pilots should re-

spond if the plane showed signs of

“runaway” controls. Boeing also

issued bulletins to customers.

Sen. Jack Reed (D-R.I.) said the

FAA order did not include crucial

information about the nature of

the problem and Boeing’s plans

for a software fix.

“The implication was that this

pilot change would be sufficient,”

Reed said. “That lack of transpar-

ency, I think, is not appropriate.”

Bahrami said that the FAA

joins accident investigations to

obtain real-time information to

help it protect aircraft. As part of

that, the FAA agrees not to dis-

close “any indication [about]

what may have gone wrong in

that particular case,” he said.

“That is a very delicate balance

for us to play.... From the safety

perspective, we felt strongly what

we did was adequate,” Bahrami

said. “Based on these reviews that

come out, we will definitely make

adjustments.”

The emergency order after the

Indonesia crash in October was

supposed to be an interim step,

Bahrami said.

“Based on our risk assessment,

we felt we had sufficient time to

be able to do the modification,

and get the final fix,” Bahrami

said. The risk assessment was

first reported by the Wall Street

Journal.

Then, the Ethiopian Airlines

plane crashed March 10.

Boeing said it “began work on a

potential software update shortly

after” the Indonesia crash. “The

safety of everyone flying our air-

planes was paramount as the

analysis was done and the actions

were taken,” the company said.

[email protected]

Senators grill FAA safety o∞cial on Boeing 737 Max crashes

Manager defends

agency’s approach but

admits to a misjudgment

BY AMANDA COLETTA

woodstock, ontario — Eliza-
beth Wettlaufer arrived for her
first day of work as a nurse at the
Meadow Park nursing home in
2014 with glowing references. She
was well liked, they said, a “good
worker” who “loved to mentor
and teach.”
None revealed that Wettlaufer
had been disciplined several
times for incompetence, mal-
treatment of residents and col-
leagues, and medical errors. Her
supervisors did not indicate that
she had been fired for administer-
ing insulin to the wrong patient.
But even if her behavior had
raised suspicions, no one imag-
ined the dark truth.
Wettlaufer, 52, has admitted to

intentionally injecting eight sen-

iors in her care with fatal overdos-

es of insulin as she worked at

multiple nursing homes and

long-term care facilities in Ontar-

io from 2007 to 2016. The killings

shook public confidence in On-

tario’s long-term care system.

On Wednesday, the govern-

ment-appointed commissioner

charged with investigating how

Wettlaufer’s crimes went unde-

tected for so long released her

chilling conclusion: No one

would have discovered that Wet-

tlaufer was Canada’s first health-

care serial killer if she had not

confessed.

“The evidence in this inquiry

shows that nothing would have

triggered an investigation into

Wettlaufer or the incidents un-

derlying the offenses,” Commis-

sioner Eileen E. Gillese told fam-

ily members, officials and report-

ers.

“This finding is significant be-

cause it tells us that to prevent

similar tragedies in the future, we

cannot continue to do the same

things in the same ways in the

long-term care system.”

Injecting insulin into a person

who doesn’t need it can cause that

person’s blood sugar to drop be-

low the normal range. Even if the

deaths of Wettlaufer’s victims had

been fully investigated, Gillese

wrote, it is unlikely they would

have produced evidence indicat-

ing her guilt.

The commissioner had the au-

thority to make findings of indi-

vidual misconduct. But she de-

clined, instead blaming “systemic

vulnerabilities in the long-term

care system” for which there is

“no simple fix.”

Gillese issued 91 nonbinding

recommendations, including

calls to strengthen the manage-

ment of medications at long-term

care homes, bolster background

and reference checks for prospec-

tive employees, and increase

funding for nursing staff when

necessary.

Merrilee Fullerton, Ontario’s

minister for long-term care, said

she would review the recommen-

dations and submit a report next

year detailing progress imple-

menting them. She promised that

the government would set aside

new funding to address systemic

issues.

“Today is a solemn day, and I

want to acknowledge the pain

and the trauma this tragedy has

caused and the impact it has had

in the province,” she said. “To the

families, I want to say, your loved

ones mattered, they had mean-

ing, and they will make a differ-

ence.”

Helen Matheson, 95, died at

Caressant Care in October 2011.

She was Wettlaufer’s fourth vic-

tim. Her son watched on Wednes-

day as Gillese delivered the inqui-

ry findings.

“All I can hope for is that what

is recommended in the report

becomes part of law,” John

Matheson said.

Wettlaufer pleaded guilty to

first-degree murder in the deaths

of the eight seniors, four counts of

attempted murder and two

counts of aggravated assault. She

is serving life in prison.

“The fact that Wettlaufer is

behind bars does not mean that

we are safe from health care serial

killers,” Gillese wrote. “It means

only that we are safe from her.”

Wettlaufer checked herself

into a mental health hospital in

Toronto in 2016 and began to talk

about the killings with her psy-

chiatrist. She wrote a four-page

confession that prompted the

hospital to contact police.

Wettlaufer detailed how she

killed each of her victims to po-

lice. After her marriage fell apart

in 2007, she said, she was “just

angry in general... at my job...

at my life.”

When she felt what she called

“the red surge” come over her, she

would kill. Each death, she said,

brought a feeling of “euphoria.”

The Ontario government

launched its inquiry after Wet-

tlaufer’s sentencing hearing in

2017. Over two years, the inquiry
      took testimony from about 50
      witnesses and reviewed more
      than 42,000 documents.
      Wettlaufer’s colleagues began
      sounding alarms about her from
      1995 — the year she began her
      nursing career — and continued
      until 2016, when she confessed.
      But the red flags weren’t
      enough to stop her from getting
      work, Gillese wrote. The ages of
      her victims, between 75 and 96,
      made them easy prey; few sus-
      pected that the deaths were any-
      thing but natural.
      “When Wettlaufer committed
      the offenses, the victims were still
      enjoying their lives and their
      loved ones were still enjoying
      time with them,” Gillese said. “It
      was not mercy to harm or kill
      them.”
      Wettlaufer was fired from her
      first job, at an Ontario hospital,

after working while high on anti-

-anxiety medication that she ad-

mitted to stealing.

She killed her first victim in

2007 at the Caressant Care facility

in Woodstock, 80 miles southwest

of Toronto. By the time she was

fired in 2014 for administering

insulin to the wrong patient —

not a victim — she had killed

seven people and injured four

others, often as the sole nurse

working at night.

Caressant Care sent a termina-

tion form outlining several com-

plaints to Ontario’s nursing regu-

lator, but the regulator did not

investigate. The nursing home

dismissed Wettlaufer with $2,

and a recommendation letter

stating that she had left for per-

sonal reasons, in part to avoid a

grievance from the nurses union.

Neither the nursing home nor

the union had a comprehensive

list of Wettlaufer’s disciplinary

history, Gillese wrote.

Vicki McKenna, president of

the Ontario Nurses Association,

said the union has been asking for

more funding for decades.

Jim Lavelle, the president and

owner of Caressant Care, said he

would work with lawmakers and

others to address the recommen-

dations.

[email protected]

Inquiry: Killings known

only through confession

Nurse guilty of 8 deaths

in Canada went years

without being detected

Call 844-404-

or visit UMUC.EDU

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