It was one of the worst disasters in aviation history. On Dec. 12, 1985, an Arrow Air DC-8 charter crashed in Newfoundland, killing 256, most of them American soldiers headed home for Christmas.
Investigators never found the cause of the accident. But they did find a lot of problems with the way Arrow maintained its planes.
On the plane that crashed, adhesive tape had been used to hold shut some windows and panels. And in congressional hearings after the accident, a former Arrow Air pilot said the company performed "only marginal maintenance."
Only a year before the crash the airline had been fined for putting off repairs and using inadequate training manuals. In the nine years after the crash, the government cited Arrow 24 times for operations and maintenance violations.
Earlier this year, a Federal Aviation Administration team, acting on a tip, investigated Arrow again and uncovered a number of obvious problems overlooked by the regular FAA inspectors.
Maintenance procedures had not been followed. Arrow had flown jets on hundreds of trips without having made modifications required by the FAA, like replacing cargo-door latch bolts.
Workers did not have all the proper tools, and many of the tools they had were miscalibrated. A training manual was out of date.
The government responded by shutting down Arrow, based in Miami, until it was satisfied that the airline had fixed the problems. The shutdown lasted for more than two months. Arrow, with seven planes, now carries only cargo.
Executives of Arrow Air said in a statement that they had addressed the areas of concern found by the FAA, and also checked "each and every area" of their operations.
The FAA's deputy director of flight standards, William J. White, called the airline's violations the worst he had seen in his 16 years with the agency.
Yet the FAA says it did not discipline the three original inspectors who missed the carrier's problems, nor send them back for basic training. They were simply reassigned.
After five airline crashes last year that killed 257 people, the government set an ambitious goal for an American industry that moves 1.5 million people a day: to drive down the accident rate to zero.
That would require that the aviation agency not only catch major problems, but wring out minor ones before they combine to cause a crash. The agency's last line of defense to do that is its inspectors.
But an examination of the agency's inspection system -- based on government documents and interviews with inspectors, agency officials and industry experts -- reveals two shortcomings.
The first is that, as in the case of Arrow Air, some employees are not held accountable for lax oversight or more serious infractions. The second is that a significant number of FAA inspectors still lack training on the planes and equipment they are assigned to oversee.
Those two shortcomings alone played a role in at least six airline accidents over the decade that ended in 1993, the last year for which the National Transportation Safety Board has completed accident investigations. And in other cases like Arrow Air's, the shortcomings make it clear that the government's system for insuring passengers' safety has holes.
Of course, much of the fault for many airplane crashes lies with the aviation industry.
It is unrealistic to think that the aviation agency, with its limited resources, can find every problem.
But some things that can prevent crashes -- like dealing aggressively with inspections that are seriously lax and training inspectors so they can do their jobs right -- are within the agency's control.
The agency's failure to deal aggressively with lax oversight was named by the safety board as a factor in three fatal airline accidents that include the 1988 crash of a Delta 727 in Dallas that killed 14 people.
As for inadequate preparation, many FAA inspectors say they are assigned responsibilities, like overseeing a fleet of 737's, without ever receiving training in the aircraft.
Inadequate training of FAA inspectors has been cited by the safety board as one cause of at least three airline accidents since 1983.
In one of those accidents, the passenger cabin of an Aloha Airlines 737 ripped open in flight in 1988, sweeping a flight attendant to her death. Federal investigators said one factor contributing to the accident was that the FAA's principal maintenance inspector for Aloha had not received any training in problems that led to the accident, including corrosion control and metal fatigue.
Asked about such weaknesses, agency officials say the inspection system works, and they point to the nation's air accident rate -- among the lowest in the world -- as proof.
"When you look at the number of times the system fails," said Anthony J. Broderick, the agency's associate administrator for regulation and certification, "it is tiny."
Sen. William S. Cohen, the Maine Republican who chairs a congressional subcommittee that plans to hold a hearing soon on the inspection system, said recently that he had been bothered by the agency's unwillingness to acknowledge the holes in its safety net.
"Deny, defend and deflect," he said, "that has been the attitude of the FAA."
Congress has its eye on cutting the FAA's annual budget of about $8.6 billion, mostly for air traffic control, even though the agency is taking a greater role in assessing aviation safety in foreign countries to which many Americans fly.
The transportation secretary, Federico F. Pena, said last week in an interview that he had been trying to infuse the agency with a more "business-like" culture, in part, by bringing in new managers. When he took over the agency in 1993, he said, he encountered a culture he said was characterized by "aloofness."