Even as the Ebola outbreak still raged in West Africa, congressional watchdogs began investigating how well-prepared U.S. airports and airlines were to deal with a rapidly spreading disease.

They found a patchwork of local plans and federal agencies pointing fingers at one another over who was responsible for knitting them together. The investigators, from the Government Accountability Office, said the country needed one national plan — something that was required under U.N. aviation standards.

The Transportation Department and the Centers for Disease Control and Prevention agreed that such a plan was a good idea, but each said the other ought to be in charge of developing it.

Five years later, as the novel coronavirus takes hold in the United States, those disputes have been left largely unresolved, and opportunities to be better prepared for an outbreak were missed.

The airline and travel industries, now brought to their knees by the outbreak and seeking a $50 billion government rescue, opposed efforts by the CDC to set new rules for tracing infected passengers, calling them “burdensome.”

And as the coronavirus has swept through the aviation system, front-line workers like those who clean airplanes, Transportation Security Administration officers and customs agents say they are exposed to danger, lacking clear guidance and training from their bosses. Travelers, meanwhile, have reported inconsistencies in the way they are being screened for illness when they come into the country.

In a 2015 report on its findings, the GAO recommended that the Transportation Department step up and craft the plan, but it has resisted. Even as the coronavirus outbreak began, the Transportation Department said that the Department of Health and Human Services and the Department of Homeland Security needed to step in, said Heather Krause, a GAO official.

Rep. Rick Larsen (D-Wash.), chairman of the aviation subcommittee, said he requested the GAO review because there seemed to be no clear policy on how to contain Ebola, and he wanted to make sure the nation would be better prepared for the next outbreak.

In an interview, Larsen said that the aviation system’s response hadn’t been a disaster but that it could still have been better prepared.

That was before the rollout of travel restrictions on European countries earlier this month led to overwhelming crowds and hours-long waits at some airports as Americans rushed home. Larsen posted a tweet revising his view.

“Last week I told a reporter that the US govt preparation efforts in airports for COVID-19 wasn’t a disaster but we could do better. I now want to amend that response: it’s a disaster,” he tweeted.

A House bill to deal with the coronavirus pandemic, unveiled this week, includes a provision that would require the Transportation Department to take the lead on developing a plan in the future.

'Did we not learn anything …?'

In a response to the GAO report, the Transportation Department said any such plan should be part of a “broader national communicable disease planning effort that is not limited to the aviation sector.”

It reiterated that position in a response this month to questions from The Washington Post about the absence of a national aviation plan for dealing with communicable diseases.

In outlining the actions it has taken as the coronavirus outbreak has spread, the Transportation Department focused on the Federal Aviation Administration’s role as a liaison between industry and various government agencies.

“When there are concerns relating to communicable disease, FAA, as appropriate, hosts and coordinates calls between airlines, aviation associations, HHS/CDC, [the Occupational Safety and Health Administration], and DHS that include preparedness measures,” the department said in a statement.

The lack of a plan has drawn scrutiny from Democrats on Capitol Hill in recent weeks.

“Did we not learn anything about processes and procedures from those previous diseases?” Sen. Tammy Duckworth (D-Ill.) asked officials at a recent hearing.

The inability to pull together a national plan follows a common pattern, experts say. In the months and years after an outbreak or tragedy, recommendations flow. Gaps are identified, and actions are recommended. But officials don’t always follow through.

Vicki Bier, director of the Center for Human Performance and Risk Analysis at the University of Wisconsin at Madison, said such scenarios are common, not just in government, but in virtually all industries and organizations.

“Reacting in the short term and then forgetting in the long term to close the loop and act on their plan is a very widespread problem,” said Bier, who has a background in pandemic preparedness.

Solving it can be difficult.

“In complicated problems like this, yes, there needs to be somebody who is responsible for meeting deadlines — ‘Yes, we will have a plan for x,’ ” Bier said.

Despite the lack of a unified plan, former government officials say the aviation system’s defenses have been hardened in recent years.

Peter Houck, a former CDC quarantine officer, said the SARS outbreak in 2002 and 2003 spurred international aviation authorities to get better prepared for new diseases, work that he said paid off when Ebola flared up in West Africa in 2014.

More preparations were undertaken in recent years, too.

On the final day of the Obama presidency, the CDC finalized long-stalled rules on how to track airline passengers who might have been exposed to a sick person. The GAO had urged the government to be better prepared since 2004.

But officials at the New York City Department of Health and Mental Hygiene said the rules that were ultimately proposed weren’t strict enough and urged the CDC to require airlines to collect more information on passengers.

“Rather than relying on information ‘available and already maintained by the airline,’ the regulations should mandate that airlines collect and maintain additional passenger data to facilitate contact tracing,” the department wrote in a formal submission to the CDC in October 2016. “For example, the contact information collected, particularly in the case of domestic flights, is not sufficient for contact tracing.”

But the travel industry balked at the proposed rules, saying they would be expensive and burdensome to follow. A host of lobbying groups, including Airlines for America, wrote in their submission to the CDC that the rules would be “cost prohibitive and operationally unrealistic,” and to the extent the rules applied to domestic flights, the costs would be “vastly higher.”

“Given these considerations, we suggest that the [proposal] be withdrawn,” the groups wrote.

The CDC pressed ahead, but it discovered when the coronavirus outbreak began that it was having difficulty tracking passengers even under the rules established in 2017. In February, it issued emergency rules along the lines of those proposed by the New York officials, saying that airlines were best positioned to collect the necessary information.

Airlines again pushed back, saying it could take a year or longer to develop a system for reliably collecting the information and that government agencies, including the DHS and the State Department, were better positioned to provide the information sought by federal health officials.

Katherine Estep, a spokeswoman for Airlines for America, the industry’s main trade group, did not respond to questions about whether airlines should have been more willing to help, saying only that the industry was doing what it could to pitch in.

“Since the first reports of coronavirus, we have been working closely with multiple federal agencies to help contain and prevent the spread of the virus,” Estep said. “We fully support expedited contact tracing and have put forward pragmatic solutions to assist in achieving the U.S. government’s objective of obtaining complete, accurate and verifiable passenger data.”

But airlines wanted no part of sharing passenger information. Under pressure to find a solution, Airlines for America said it would pay to develop a website and app that would allow travelers to submit their own information — including two phone numbers, an email and an address while in the United States — directly to the CDC. Nicholas E. Calio, president and chief executive of Airlines for America, said the app could be up and running within two weeks, and the website within four.

More than two weeks after airlines first floated the idea, no decision has been made on whether such a system will be used.

In the interim, federal officials have been collecting passenger contact data on paper forms, which are then input into computers by hand and sent to the CDC. At a Senate hearing earlier this month on the coronavirus outbreak and its effect on aviation, Joel Szabat, acting undersecretary for policy at the Transportation Department, said that the system worked, largely because information was only being collected from fewer than 1,000 incoming passengers a day, but that it would not be scalable should the number of passengers grow.

However, with new screening requirements now in place for travelers returning from 28 countries in Europe, passenger volumes may increase.

'A Petri dish waiting to happen'

Weaknesses identified in the 2015 GAO report have also continued to persist, records show. GAO investigators found that between 2012 and 2015, the Occupational Safety and Health Administration fined several companies that hold service contracts with airlines or airports for not having sufficient procedures to protect their employees from blood-borne pathogens. The violations involved companies that did not “provide employees with appropriate pathogen exposure control planning, training, vaccinations, and personal protective equipment.”

The companies took steps to solve the problems, and people interviewed by the GAO investigators said the industry had tightened up in the wake of Ebola.

But in late 2019, OSHA’s records show that it issued a fresh fine against Eulen, a major contractor, for violating the same rules.

The company did not address questions about the violation, but it shared a statement from the chief executive of its American operation, Xavi Rabell, that said: “Because the health and well-being of our employees comes first, the company has made sure all employees have access to prevention information.”

Tim Maddox, a union organizer and longtime airport employee in Los Angeles, said some cleaning crews there feel so unprepared that the union was stepping in to provide training.

“Our workers were reporting that they were told to clean international flights, including some coming in from China, and they hadn’t had any training and equipment; they were just told to clean the plane,” Maddox said.

Leaders of the unions representing TSA and Customs and Border Protection officers say their officers were similarly unprepared, even though they deal with the public and their luggage up close. At least two dozen TSA officers have tested positive for the virus.

“The checkpoints are a Petri dish waiting to happen in a bad way,” said a TSA official, who spoke on the condition of anonymity because he was not authorized to speak publicly.

The agency says it has increased cleaning at checkpoints and is allowing travelers to request that officers put on a new pair of gloves when screening them.

Bier said solving the planning problem is more complex than just naming a point person because agencies have different priorities they think are not well understood by those outside their operations.

“As a society, we have these very complex interacting systems that have outgrown our ability to manage them,” she added. “And so we compartmentalize — but there are some things that don’t get done well that way. And unfortunately there isn’t a good solution to that.”

Keeping airports and the aviation system safe relies on a stew of government agencies scattered across the Transportation Department, Labor Department, HHS and DHS. The GAO investigators uncovered examples of bickering between them dating back years, finding that in 2010, the Transportation Department asked the CDC to help more airports develop disease response plans.

“The request did not specify which airports to extend CDC’s outreach, in part because, at that time, CDC was resistant to any expansion,” according to the GAO report.

Good leadership is critical, said Howard Kunreuther, co-director of the Risk Management and Decision Processes Center at the Wharton School of the University of Pennsylvania.

“You cannot deal with this at the level of just saying let each agency operate,” he said. “You need to have some way to bring them together and to indicate that this is a problem, which cannot be solved by one agency alone. That is something that leadership is going to have to suggest — ‘This is the way to do it’ — and we don’t have that right now.”

A guide for airports published last year by the Transportation Research Board, an arm of the National Academies of Sciences, Engineering, and Medicine, underscores why planning is important. Airports need to know which ambulance services and hospitals stand ready to receive infectious patients and be ready for a “high percentage of employee absences, even among essential employees.”

In the case of the novel coronavirus, the emphasis quickly shifted from tracking sick passengers to ensuring airports can stay open as TSA officers and air traffic control workers fall ill, as well as guaranteeing the financial health of the airlines.

Stephanie Murphy, a former emergency management official at the Metropolitan Washington Airports Authority, said that airports now are generally in a good position to handle sick passengers but that planning for how to keep operations going with large numbers of absences has lagged at some smaller airports.

Murphy, now a consultant, has been working during the coronavirus outbreak to help airports ensure they can stay open.

“The beautiful piece and part is that we are having these conversations,” she said. “That’s a positive thing.”