DANGER IN THE SKIES

The shocking truth about airplane safety, and how a former U.S. Inspector General, "Maximum Mary" Schiavo from the Midwest, took on powerful airline interests

American Eagle Flight 4184, en route from Indianapolis to Chicago, was in a routine holding pattern late one Halloween afternoon in 1994, waiting its turn to land at O'Hare airport. To combat the freezing drizzle at 10,000 feet, the two pilots in the state-of-the-art cockpit of the new ATR-72 turned on the deicers.

The plane had been guided by the auto pilot through a series of lazy turns for about a half hour. Unbeknownst to the passengers and crew, as little as 3/4-inch of ice was building up on the wings, creating a vacuum over one aileron and pushing the other one down. The auto pilot fought silently against the forces which threatened to cause the plane to spin out of control. Suddenly, it happened.

The plane flipped on its side in a 70-degree roll. The startled crew revved the two Pratt & Whitney engines and the aircraft started to come around, but only for a moment. It rolled farther right, nearly turning over, its nose pitched down. Within seconds, the plane was inverted, turning a full spiral before it slammed into a muddy bean field near Roselawn, Indiana. The pilots, two flight attendants and 64 passengers died. According to the flight data recorder, from the time the auto pilot popped off, to the moment of impact, the whole terrifying episode lasted only 25 seconds.

Debris was scattered like confetti across the landscape. The largest piece of wreckage was a mere six-by-eight-foot section of the tail, and not a single body remained intact. It was a gruesome scene, a preventable tragedy.

Like many other plane crashes, this was one that shouldn't have happened. The Federal Aviation Administration (FAA) had had ample evidence for more than ten years that this particular model of aircraft, and its sister ship, the ATR-72 - 410 of which were built by a French-Italian consortium and continue even today to be flown on short hauls by carriers worldwide - was especially vulnerable to icing conditions. Pilots protested. Safety experts sounded the alarm. But the FAA reacted slowly, halfheartedly, to restrict the ATR's flight in bad weather.

No safety advisories were in effect at the time of the Indiana crash. This despite the fact that there had been at least 12 reported rolls and stalls -- what the National Transportation Safety Board euphemistically calls "departures from controlled flight." It had even happened twice on one day in 1986 to two separate atrs flying through identical weather, causing one to lose altitude so fast over Detroit that it didn't recover until it was just 500 feet above the ground.

It occurred again in 1988, right before Christmas, as an ATR was carrying passengers to Mosinee, WI. In that incident, the plane tipped on its left side to 80 degrees, the pilot thrust the throttles forward and, after several rolls, re-gained control -- only 1,000 feet above the ground.

Avions de Transport Regional, which made the planes, had blamed extreme weather conditions and pilot error for these close calls. But after a fatal crash in Italy, it became apparent that something about the design of the high-tech wings and inadequate deicers could combine to create in-flight emergencies from which pilots could not recover.

Before the Roselawn crash, the Federal Aviation Administration (FAA) had three times issued "airworthiness directives," including warning pilots to avoid a certain flap setting in icing conditions. However, it lifted the restrictions after the manufacturer made what the Airline Pilots Association bitterly complained were merely "BandAid" fixes.

Robert McCracken, the FAA engineer who was in charge of ATR's at the time, recalled that restrictions were lifted in part because "We were being argued with pretty steadily" by ATR, and the government didn't want to alienate a country like France.

Incredibly, the FAA had never tested the troubled plane in freezing drizzle and rain, just a light mist, and its standard is 30 years old. In fact, the droplets hitting the ATR that crashed in Indiana were later estimated to be five to 50 times bigger.

Investigations in the aftermath of recent air crashes have revealed the inadequacy of the FAA's response not only to risks caused by bad weather, but air-traffic congestion, terrorism, hijackings, sloppy maintenance, and counterfeit aircraft parts.

So why does an agency that's supposed to protect the public, so often side with the airline industry and fail to do its job?

When an airplane hurtles downward, deserted by thrust and abandoned by lift, our feelings of security plummet with it. Although passengers aren't rushing to buy insurance from airport vending machines like travellers did in the 15th, most flyers will admit to an extra sense of apprehension these days every time they board a flight. The reason, of course, is a spate of stories about plane crashes, some of whose causes remain a mystery.

The industry completed its deadliest year ever in 1996, with a total of 2,040 civil aviation accidents, and 1,185 passengers killed on commercial flights around the world. That's a 73% increase in the total number of deaths over 1995. In the United States, the explosion of TWA Flight 800, which killed 230 people, and the crash of ValuJet Flight 592, which killed 110, were both among the year's top news stories.

This contrasts with 1993, when there was not a single crash involving a major U.S. air carrier, and only one death involving an accident on the ground.

Though a miracle of modern technology that we take for granted, flying is, after all, an unnatural act. Sealed in a metal tube and propelled through space at the speed of a bullet seven miles up in the sky, the chances for something to go wrong are myriad and potentially disastrous.

No longer is air travel the province of a jet-set elite. Because of discount fares, even people of modest means are seduced by the prospect of spending a relatively small amount of money, stepping on a plane, and soaring off to far-away places -- for vacation escapes to exotic locales half a world away, to family reunions, to business appointments with distant clients.

By jet aircraft, Los Angeles is only an afternoon away from New York, Sydney a day's journey from London. It is no exaggeration to say that flying has made the world smaller.

Whose Statistics To Believe?

Defenders of the airline industry point out that the total number of fatalities suffered in U.S. aviation since the Wright brothers' first flight equals only four month's toll on our highways.

A Massachusetts Institute of Technology study, based on data from 1990 to the present, shows than an airline passenger stands a one-in-8,000,000 chance of dying in a crash. That means you'd have to fly every day for 21,000 years before a plane you're in goes down.

Yet crashes are occurring -- along with scores of equipment failures, near-misses, pilot errors and other close calls. The ntsb also estimates that at least 48 fatal air accidents over the last 11 years can be linked to defects in federal surveillance.

For a long time, the travel industry has skewed figures to suggest that flying is dramatically safer than driving. But if you measure the riskiness by comparing deaths with the number of trips made rather than the miles covered, aircraft score far worse than cars.

The London Economist recalculated the figures per number of trips, and reported that cars look 12 times safer than airplanes, and only motorcycles look more dangerous. Even the more neutral measure of the fatality rate per man-hour of exposure puts cars and aircraft on a par.

There are other indicators, not generally known by the American public, that Midwest Today has uncovered in its investigation, which lend credence to the belief that flying is becoming -- if not dangerous - at least less safe. For example:

• Boeing, which makes two out of every three jet airliners, says there could be a big air crash once a week by the year 2010, when a billion people are expected to board planes each year -- twice as many as do now.
• Randolph Babbitt, president of the Air Line Pilots Association, said at a gathering of about 1,000 aviation officials that safety is being jeopardized. "I think we've seen a fairly constant erosion of the margins of safety," he said. "That doesn't mean the system isn't safe, but the margins of safety have eroded since deregulation." He said the reason was "fairly simple. It's this myopic focus on cost."
• Bureaucracy bashers who complain that the government is too big, too meddlesome, and too unfriendly toward private enterprise, have effectively deprived federal regulators of the assets needed to properly assure public safety in the skies. And the pro-business, anti-regulatory fervor institutionalized in the Reagan era has produced a bureaucracy that too often backs down when it should crack down.
• Limited by serious restraints on budget, training and time, the 2,600 FAA inspectors spend a third of their time overseeing aircraft maintenance, mostly by reviewing paperwork. It's simply impossible for them to inspect all 7,300 airline aircraft, as well as 11,000 charter planes and the almost 200,000 general aviation aircraft operating in the U.S.

  In addition, an anonymous FAA staff member and a former airline employee testified at Congressional hearings that air safety is compromised by inspectors who are not always properly trained for their assigned tasks. "I've checked a plane when I didn't know how to open the door," confessed one. The General Accounting Office (GAO) has complained for years about this problem.

  "It's easy to fool them," a disguised airline pilot told Senators. "Often they look at paperwork, not a real plane. And where the records were, we kept attractive females."

• Planes designed to be obsolete in 20 years are approaching 30 years of service. New maintenance procedures are desperately needed. Only a handful of the more than 1,800 aged aircraft undergo detailed examination each year.
• The air traffic control system - which keeps your plane separated from all others in the sky -- is dangerously out of date. While the rest of the world has moved to sophisticated computers, the U.S. air traffic control system is so antiquated it still depends on vacuum tube era equipment that is almost beyond fixing. There are frequent radar breakdowns, random communications outages, and a lower standard of safety for the flying public. Plans for updating have been bungled and delayed by the FAA's chronic mismanagement. Though air traffic has increased by 30% since the early 1980's, there are fewer controllers today than a decade ago. The 15,000 air traffic controllers, who are all Federal Aviation Administration employees, are stretched too thin and stressed out.
• Although weather is known to cause 40% of all plane crashes and 65% of air traffic delays longer than 15 minutes, only 16 Doppler radar wind-sheer detection systems are operational at airports around the country. Over $350 million worth of parts for the system -- which had been promised after a disastrous 1985 Dallas crash that was caused by wind shear -- are languishing in warehouses, unsent to the airports that need them. Two more crashes caused by wind shear have since occurred.
• About half of all communications by pilots and controllers include at least one error, according to an FAA Civil Aero-medical Institute report. The study found mistakes in 40% of 2,500 controller communications and 59% of 5,900 pilot communications.
• The system for guiding planes over the Atlantic Ocean is the most primitive of all. Since the FAA has no radar or radio system powerful enough to track them all the way across the sea, pilots have to report their positions about once an hour to the 15th's center on Long Island. But to do so entails using prewar high-frequency radio technology and contacting a private company calledArinc, which types their messages into a computer that sends it to a printer at the FAA center. Then it is relayed by hand to a controller. All of this delay can be dangerous in rapidly-changing flying conditions.
• After several plane crashes in the mid-1980s, an aviation safety commission began studying the FAA's structure. It issued a report in 1988 calling for an overhaul of the FAA and the appointment of a safety czar. Nine years later nothing substantive has happened.
• Over the past decade, incidents involving hazardous cargo aboard airplanes have increased nearly seven-fold, U.S. Transportation Department records show. Statistics compiled by the FAA, the National Transportation Safety Board and the National Aeronautics and Space Administration (NASA) reveal that pilots frequently fly uninformed about the hazards in their cargo holds. Pilots and crew members - sometimes fearing retribution - have complained anonymously to NASA, which serves as an ombudsman for the airline industry.
• Senior U.S. counterterrorism officials say U.S. commercial carriers lag woefully behind foreign airlines in security measures. American carriers are vulnerable, and the tactics and technologies that would improve the odds against terrorist attacks have for the most part not been implemented.
• Counterfeit aircraft parts including scrap parts, poorly repaired and painted over to look like new -- even parts taken from cars and passed off as being for aviation -- are being sold by unscrupulous, unlicensed, unregistered and untrained brokers to un monitored repair stations used by airlines that farm out their maintenance.

  Former Inspector General Mary Chiao's office turned up counterfeit engines, fuel pumps, seals, turbine blades, bearings, cockpit warning lights, helicopter rotors, avionics, landing gears, valves, switches, wheels, brake components, windshields and even wings. Any one of which could cause a catastrophic in-flight failure and crash.

  In deep denial about the problem, the FAA at the very least has come close to obstructing justice in thwarting attempts by investigators to crack down on bogus parts dealers. Still, criminal prosecutions have occurred, thanks to Schiavo.

• Air quality and cabin pressure are two factors which can not only adversely affect passenger comfort, but their health as well. Airlines cut fuel consumption by recirculating cabin air. But this can lead to airborne illnesses spreading to passengers, as in the case of a woman with tuberculosis who infected 14 other passengers last year. In addition, the amount of carbon dioxide the FAA permits in airplane cabins is many times higher than normal. When CO₂ levels get too high, people experience headaches, fatigue and drowsiness. The high altitude compounds the problem, making the air thinner -- an extra strain on those with heart or respiratory ailments.
• Unruly passengers are an increasing problem -- with reports of altercations doubling in the last couple of years -- and airline crew members are even coming under attack. During 1996, problems with out-of-control passengers included everything from a Saudi princess who assaulted a TWA flight attendant to a first-class passenger who hit a US Air stewardess so hard that she landed two rows deep in coach. Flight attendants and pilots are being pushed, punched, bitten, grabbed, scratched, slapped and cussed at by unruly passengers.

  At 30,000 feet above the Atlantic, on a Northwest Airlines London-to-Minneapolis flight, 18 inebriated British passengers engaged in a food fight. The captain had to leave the cockpit and restrain one of the rowdy bunch with handcuffs. Three U.S. Olympic wrestlers literally sat on others to subdue them.

• The Chicago Tribune reports that each year there may be more than 700 medical emergency landings, 12,000 in-flight medical emergencies and up to 360 deaths, not counting those passengers who become ill on a plane and die after reaching a hospital. (Neither the FAA nor the airlines keep comprehensive records). Yet U.S. carriers, with the exception of American, have only the most meager medical supplies on board, in kits that are reminiscent of World War II. Despite the increasing affordability of portable electronic defibrillator used to revive victims of cardiac arrest, only two airlines now carry such equipment on board -- Australia's Quantas and British-based Virgin Atlantic Airways.
• All airline cabins are still being built to 1950's standards, with materials that produce toxic smoke. And the statically-tested seats are only required to resist nine forward g's; such seats have failed at three to four g's. By comparison, for over 20 years, the seats in every automobile sold in the United States has been required to resist 20 forward g's.

  Making matters worse is the fact that aircraft are doing about 200 mph on takeoff and landing, when 68% of all accidents occur; most car accidents involve speeds well under 50 mph

• Even airline food is a safety hazard, and that's no joke. Federal inspectors checking airline meals report finding problems with 11 major airlines, including food stored at improper temperatures to prevent bacterial growth, beer stored beneath a sewage line, rust and green slime in ice machines, beverages stored with lavoratory supplies, dirty coolers and utensils. Incredibly, Food and Drug Administration spokesman Arthur Whitmore described the findings as "routine."

Negative Effects of Deregulation

Critics have long been worried about the effects of the heavy monetary losses suffered by many major carriers in the midst of ticket price wars, mergers and bankruptcies that began when President Ronald Reagan adopted fare and route deregulation in the 1980s. Since that time, at least 161 airlines have gone out of business, and experts fear that more carriers will cut corners on safety in order to save money, for which the now-defunct Eastern Airlines was indicted in 1990.

Service demands and fierce competition are such that airlines now find it necessary to operate from a hub-and-spoke system -- flying planes out of a central airport on very tight schedules. Not only is there more intensive use of airplanes, but time spent on repairs is money lost, whenever a plane isn't carrying passengers. There is also pressure to cut maintenance outlays.

As a result, airline safety experts say, the industry is often just barely meeting minimum FAA airworthiness standards.

Jim Burnett, former chairman of the National Transportation Safety Board, says that he's not even sure "that there is any standard for saying what is an unsafe airline." He says that often, "the FAA is able to document violations, but it says the airline is still safe."

Under deregulation, the costs of preventive maintenance are no longer automatically passed on to the consumer. In this economic environment, instead of replacing a part on a jet before it breaks, the decision is more often to replace it when it breaks.

Ignoring even seemingly small repairs can have disastrous consequences. In April 1985, for instance, an engine fell off an American Airlines Boeing 727 after being hit by a frozen chunk of disinfectant that seeped out of a broken lavatory toilet. The stool had not been fixed, even though leaks had been reported for five months.

Too often, the FAA shows timidity in dealing with serious repair issues. For example, Boeing issued a service bulletin that was sent to 747 and 757 operators in August 1995, 11 months before the TWA Flight 800 crash, in which operators were warned to inspect fuel pumps for leaks that could cause fires. It wasn't until last Fall that the FAA announced that it was considering making inspection orders mandatory. Airlines strongly objected, so the FAA let still more time elapse.

Finally, in February of 1997 -- 17 months after Boeing first issued its warning -- the FAA ordered operators of the 747 and 757 aircraft to begin making regular inspections of fuel pumps and do electrical testing of surrounding wiring.

Even then the directive was issued only after the FAA received eight reports from airlines that the pumps of 747's were leaking, including one incident that resulted in a fire while the plane was still on the ground.

Another safety factor is that roughly 250 cities in the U.S., once served by major carriers flying mostly jets, now have only regional service, and most of that is on smaller turboprop commuter aircraft maintained by a patchwork of independent carriers that have partnership deals with the big airlines.

As history has shown, these smaller carriers and discount airlines tend to have underpaid, overworked, less experienced pilots and maintenance crews, with less stringent safety standards.

One impressive exception is Southwest Airlines. It ranks Number One among U.S. carriers in terms of safety (never having lost a plane), and is a true success story in combining no-frills service with sky-high customer satisfaction.

Public Demands Cheap Air Fares

There's no doubt about it: the American people love discount airlines. The Department of Transportation estimates flyers saved $6.3 billion last year flying the budget carriers.

These airlines are the product of a marketplace in which the bigger carriers are too expensive for the average family, even with 21-day advance ticket purchases. For those who have spur-of-the-moment travel needs, or dare to think of first class, the cost of flying is even more daunting.

Somewhere along the line, Americans have come to believe that cheap air fares are an inalienable right. However, the economics of these low-cost carriers come with risks that most ticket holders never knew existed.

Writing in Newsday, Walter J. Boyne said "If we want to find out who is at fault for the seemingly endless series of tragedies besetting airline travel, we have only to look in the mirror.

"We demand lower fares, and frighten the airline carriers into believing that we will not pay the extra $10 or $20 per ticket it would take to resolve safety problems. We have been living in a fool's paradise for the past ten years, comforted by the admittedly excellent safety records airlines have established.

"Unfortunately," he observed, "those records were based on the past training and performance of the airline personnel involved, and as cheap fares have reduced profits and forced all airlines to greater economies, the personnel picture has changed from captain down to baggage smasher. If you don't believe me, simply watch the typical x-ray inspection of baggage done at any security checkpoint in the country. The people hired to do these jobs are at the low end of the minimum-wage food chain."

Improved Training Needed

While poor maintenance and lax inspection are contributing factors to air disasters, another area of concern to safety experts is pilot training. Estimates are that up to 70% of all crashes, including the many that go under the frightening acronym CFIT (or "controlled flight into terrain"), are the result of "pilot error." On a few occasions -- such as when a pilot handed over the controls to his son and when a pilot's English was too poor to communicate properly with the control tower -- the cause of a crash is obvious. But in most cases, the term "pilot error" is more complicated: it means only that if the crew had reacted differently, the accident would theoretically not have occurred.

Today's aircraft are operated by a combination of computers and people. So-called "fly by wire" technology means that pilots have less to do; but the new instruments still need some human help. There is evidence that older pilots in particular have found it difficult to adapt to the new technology. Experts are urging that rules be changed so that seniority counts for less than competence.

Airlines now realize that they must give more intensive training to pilots who switch to automated cockpits. Indeed, for a time in the late 1980s it looked as though technology was causing more accidents than it prevented because of confusion over whether the pilot or the computerized flight-management system was in control. An international study led by the FAA concluded last Autumn that there had been at least 24 accidents or serious incidents caused by such problems.

Pilots agree that their training needs to be improved. At present, the focus is on how to avoid errors in the first place; but pilots say greater emphasis should be placed on how to deal with human mistakes, which will inevitably occur.

"The best pilots are no longer the traditional macho guys with the best bodily motor skills," says Michael Willett, safety director at the Civil Aviation Authority in Britain. "They are now those with the best information-management skills to work with digital cockpits."

The FAA's Dual Roles

Why is the FAA so recalcitrant about making airlines toe the line on safety matters?

Geraldine Frankoski, director of the Aviation Consumer Action Program, points out what she considers to be a built-in conflict of interest at the FAA that works to the detriment of safety. By law, she notes, the FAA is responsible for fostering and promoting civil aviation, a mandate that includes safeguarding the financial health of airlines, "while also administering and regulating safety. They can't honestly do both," she concludes.

The aviation industry can be a clubby world in which safety-related problems are usually discussed in private, while an image of trouble-free transportation is projected to the public. With the clout that many large carriers exert, critics contend, the agency is often reluctant to take steps that would undercut confidence in air travel, even when serious safety problems are uncovered.

ValuJet Got Away With Murder

The crash of ValuJet Flight 592 in the Florida Everglades last May is a case study in how the laxity of the discount carrier and the lack of stringent enforcement of existing safety regulations by the FAA combined to produce deadly results.

Initially, ValuJet was the darling of Wall Street, bragging in financial reports to investors how it paid employees below prevailing market levels and held down its operating costs. They located routes in the South where wages are cheap and demand is high. They acquired the oldest planes in the modern fleet.

They forced pilots to pay for their own training, gave flight attendants the most cursory instruction, and demanded long hours from personnel - some of whom were kept in check by extended periods of probation, and whose placement occurred through an employment agency owned by the company president Lewis Jordan's ex-wife and daughter. ValuJet grew quickly and kept its fares low by outsourcing the expensive functions that other airlines do themselves.

Perhaps its biggest mistake was that ValuJet subcontracted its maintenance work out to SabreTeck (to name one) and SabreTeck in turn "farmed out" some of their work. ValuJet operated one plane with a leaky hydraulic system for 140 flights before it was corrected. Pilots complained of one malfunctioning on-board weather radar unit 31 times before it was fixed. Workers also falsified documents on cargo that was suspect.

One flight attendant resigned rather than board a succession of ValuJet flights that she deemed unsafe. A Florida crash victim, also a flight attendant, reportedly had told relatives that she was concerned for her safety.

The very aircraft that ended up in the Florida Everglades had had a string of safety problems in the previous two years alone, including equipment failures, aborted takeoffs and emergency landings.

The doomed plane was a Delta castoff built 28 years earlier. A similar geriatric ValuJet in 1995 was destroyed by fire and passengers evacuated, because engine rust was covered up during its refit in Turkey.

When the Defense Department examined ValuJet's operation in August 1995 to determine whether military personnel should take flights on the airline, its inspectors issued a scathing report and turned down the airline.

"ValuJet's quality assurance program does not provide the oversight required to ensure that aircraft maintenance programs are in accordance" with FAA regulations, the report warned.

An internal FAA document showed ValuJet's accident rate -- even before the crash -- exceeded those of almost all of its low-fare peers. And ValuJet's accident rate was more than 14 times higher than the rate of the nation's big airlines.

The FAA unconscionably kept the general public in the dark about all this. Giving up a meal on a no-frills airline is one thing, but unwittingly boarding a plane run by a company that pays mechanics less when repairs cause delays -- as ValuJet did -- is another.

Subsequent investigation blamed the cause of the Florida crash on unsafe and mislabeled oxygen cannisters which had exploded in the cargo hold, causing a fire and the subsequent crash.

The FAA has long been accused by critics of coddling the airlines, and in the case of ValuJet, it appears that the agency bent over backwards to keep the carrier flying.

Certainly the FAA knew there were serious problems with the discount carrier, but gave the airline a reprieve by launching a 120-day review - allowing it to fly in the interim. That review was three-fourths finished when Flight 592 crashed.

Nine years earlier, the National Transportation Safety Board recommended that fire detectors and suppression systems be installed in airplane cargo holds. Then-NTSB Chairman Carl Vogt told FAA administrator David Hinson that "a fire should not be allowed to persist in any state of intensity in an airplane without the knowledge of the flight crew."

But the FAA brass sided with the airlines, saying the devices were not cost efficient. That decision saved the airlines millions of dollars. Passengers ended up with dime-store smoke alarms in cabin restrooms (to make sure nobody sneaked a cigarette), but nothing in the cargo compartments, where combustible materials were stowed.

Astonishingly, in the days following the ValuJet crash, David Hinson and Transportation Sec. Federico Pena assured travellers that ValuJet was safe to fly. The U.S. Inspector General for the Dept. of Transportation, Mary Schiavo, publicly challenged such assertions, and ValuJet was grounded temporarily.

Acting on an anonymous tip, she even sent federal agents to a meeting of top FAA heads to seize an incriminating internal memo showing the agency was aware of serious deficiencies in ValuJet's operation long before the crash and, in fact, had been warned that it should be grounded. Officials at first denied the existence of such a memo, but the next day it was released in a stack of papers.

Now with Mary Schiavo no longer in a position to keep a watchful eye on U.S. airlines, and a chaotic FAA without a director, airlines seem to be getting bolder all the time.

WMAQ Radio in Chicago reported a recent incident involving United Flight 43, bound for Honolulu, that was forced to return to O'Hare airport on March 9, 1997 after the plane experienced suspicious vibrations over Dubuque, IA. The cause of the problem was not hard to diagnose. It seems that in an effort to save money, United had strapped an extra engine on one of the wings of the DC-10 so it could ferry it overseas without the expense of putting the engine in a cargo plane.

There were 261 passengers on the flight, many of whom were incensed that United had jeopardized their safety by modifying a plane that was not designed for this purpose.

FAA spokeswoman Tanya Wagner said the practice was approved by the agency. Somehow, that's not surprising.

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