Aviation Safety: FAA and DOD Response to Similar Safety Concerns
(22-JAN-02, GAO-02-77).
The informal and formal networks used by the Federal Aviation
Administration (FAA) and the military services to exchange
critical aviation safety information have proven useful. However,
because recent and expected retirements threaten to erode
informal networks, additional formal channels of communication
are needed to ensure that common safety risks are identified and
addressed in a systematic and timely manner. This includes the
exchange of information on how FAA and the military services have
addressed particular aviation safety concerns. Existing gaps in
the formal processes used by FAA and the military services to
exchange information could allow for communication lapses and
delays in getting critical safety information to the right
parties in a timely manner, potentially resulting in the loss of
lives and aircraft.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-02-77
ACCNO: A02531
TITLE: Aviation Safety: FAA and DOD Response to Similar Safety
Concerns
DATE: 01/22/2002
SUBJECT: Commercial aviation
Military aviation
Safety standards
Transportation safety
Apache Helicopter
Boeing 737 Aircraft
Boeing E-4B Aircraft
C-17 Aircraft
FAA Flight Operational Quality Assurance
Program
FAA Ground Proximity Warning System
FAA Traffic Alert and Collision
Avoidance System
H-65 Helicopter
Boeing 747 Aircraft
C-130 Aircraft
Globemaster Aircraft
Hercules Aircraft
AH-64 Helicopter
Black Hawk Helicopter
FAA Enhanced Airworthiness Program for
Airplane Systems
******************************************************************
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******************************************************************
GAO-02-77
United States General Accounting Office
Report to the Honorable Norman Y. Mineta, Secretary of Transportation, and
the Honorable Donald H. Rumsfeld, Secretary of Defense
January 2002 AVIATION SAFETY FAA and DOD Response to Similar Safety Concerns
GAO- 02-
Letter
Results in Actions of FAA and the Military Services to Address Aviation
Safety Concerns Vary Shortcomings in Existing Processes Used for Sharing
Aviation
Safety Information Conclusions and Recommendations Agency Comments
1 2 3
5 11 22 23
Appendix I Objectives, Scope, and Methodology Appendix Fixed Wing Military
Aircraft and Their Civil
Derivatives Operated by DOD Appendix Key Similarities and Differences in FAA
s and
the Military Services Aviation Safety Oversight Processes
Appendix Case Study on Aromatic Polyimide Wire Insulation
Appendix Case Study on Adoption of Cockpit Safety Equipment
Appendix VI Case Study on Flight Operational Quality Assurance ( FOQA)
Programs 52
FAA Continues to Encourage FOQA Programs Among Airlines 54 The U. S.
Military Services Are Still in the Early Stages of
Developing FOQA Programs 57
Page i GAO- 02- 77 Aviation Safety
25 27 29 40 47
Appendix VII Case Study on Communication Delays Between the Air Force and
Civil Aviation Community 60
Appendix VIII Case Study on Strandflex Control Cable Appendix IX Comments
from the Under Secretary of Defense Appendix X GAO Contacts and Staff
Acknowledgments 69
GAO Contacts 69 Acknowledgments 69
Tables
Table 1: Examples of Mechanisms for Information Exchange Between FAA and the
Military Services 14 Table 2: Flight Operational Quality Assurance Programs
Timeline 53 Table 3: Status of Military Efforts to Implement FOQA Programs
as
of August 1, 2001 59
Figure
Figure 1: Examples of FAA Involvement in Certifying Air Force Aircraft as
Airworthy
Page ii GAO- 02- 77 Aviation Safety
63 66
36
Abbreviations
AD Airworthiness AMCOM Aviation and Missile ATSRAC Aging Transport Systems
Rulemaking Advisory AWIGG Aircraft Wiring and Inert Gas Generator Working
CPDF Central Personnel Data DOD Department of DODIG Department of Defense
Office of Inspector DOJ Department of DOT Department of DOTIG Department of
Transportation Office of Inspector DSB Defense Science EAPAS Enhanced
Airworthiness Program for Airplane EGPWS Enhanced Ground Proximity Warning
FAA Federal Aviation FOQA Flight Operational Quality FSCAP Flight Safety
Critical Aircraft GAIN Global Aviation Information GAO General Accounting
GIDEP Government- Industry Data Exchange GPWS Ground Proximity Warning IRT
Independent Review JSSC Joint Service Safety MOA Memorandum of NTSB National
Transportation Safety OC- ALC Oklahoma City Air Logistics OPM Office of
Personnel OSD Office of the Secretary of OSHA Occupational Health and Safety
SAE Society of Automotive SWAMP Severe Wind And Moisture- TAWS Terrain
Awareness Warning TCAS Traffic Alert and Collision Avoidance TKT Teflon-
Kapton- UPN Unapproved Parts Page iii GAO- 02- 77 Aviation Safety
United States General Accounting Office Washington, DC 20548
January 22, 2002 The Honorable Norman Y. Mineta Secretary of Transportation
The Honorable Donald H. Rumsfeld Secretary of Defense
Safety of aircraft is a paramount concern in both civilian and military
aviation because safety deficiencies can cost lives and equipment and affect
mission accomplishment. The Federal Aviation Administration ( FAA) and the
military services often face common safety issues as they oversee the
operation of similar aircraft or even dissimilar aircraft that use common
parts and materials. Our preliminary work, however, showed that in some
cases FAA and the military services have taken different actions to address
similar aviation safety concerns. We recognize that there could be
reasonable explanations for FAA and the military services taking different
approaches in addressing such concerns.
To shed more light in this area, we used a case study approach supplemented
by a review of FAA s and Department of Defense s ( DOD) aviation safety
oversight processes and related interdepartmental communication efforts to (
1) examine different responses by FAA and DOD/ military services to similar
aviation safety concerns and ( 2) assess the processes used by FAA and DOD 1
to communicate information about similar aviation safety concerns. To select
case studies for this review, we identified aviation safety problems shared
by FAA and the military services, selected examples in which FAA and DOD/
military services had taken a different approach to solving a similar
aviation safety problem or had a need to be informed about such a problem,
and discussed potential case studies with FAA and the military services.
To examine different responses by FAA and the military services, we used two
cases in which FAA and the military services took different actions or
1 For the balance of the report we refer to FAA and the military services,
rather than FAA and DOD. We recognize that DOD has ultimate authority for
directing the services actions on aviation safety oversight. Also, unless
otherwise noted, the Coast Guard, which is a part of Department of
Transportation ( DOT) , is included under the discussions of the military
services. Despite its peacetime missions, the Coast Guard s aviation safety
oversight activities parallel those of the military services.
Page 1 GAO- 02- 77 Aviation Safety
similar actions at a different pace when faced with common aviation safety
problems. These cases pertain to aircraft wiring insulation and cockpit
equipment designed to improve safety and support quality assurance programs
for flight operations. In addition, we selected two case studies to assess
the exchange of aviation safety information between FAA and the military
services. These include a specific brand of wire rope used in the
construction of aircraft control cables and problems of fuel pump
performance and overheating in fuel tanks in the E- 4B, a military variant
of the Boeing 747.
We interviewed and obtained relevant documentation from federal officials
and others familiar with FAA s and the military services aviation safety
oversight systems. We asked these officials about the extent to which these
entities share information on aviation safety issues of common interest.
This review focuses primarily on issues involving similar civilian and
military aircraft equipment, parts, and material issues related to aviation
safety, rather than issues concerning the operation of aircraft. It does not
address aviation security issues, such as hijacking, sabotage, or terrorist
activities. See appendix I for additional details on our scope and
methodology.
Results in For one of the two cases that we reviewed where FAA and the
military services reacted differently to similar aviation safety concerns,
the
differences reflect the agency s and services different missions and
operational environments. In the second case, the military services have
reacted more slowly than civil aviation due to resource tradeoffs between
aviation safety and other mission- readiness issues.
In the first case, when the Navy identified potential safety problems
concerning the use of a specific type of wire insulation on aircraft in a
moist operating environment, each of the military services and FAA assessed
the insulation s safety in various environments and responded differently.
For example, FAA issued advisory notifications to the civil aviation
community to help identify and minimize the potential risks associated with
the use of this insulation; the Navy promptly removed it from areas prone to
infiltration by moisture; while the Coast Guard lagged behind the Navy in
removing this insulation, it later took the most extensive action by
systematically removing it from an entire fleet of helicopters after it
experienced in- flight fires. These different responses are largely a
function of these entities respective missions and operational environments.
In the second case, the military services have lagged as much as two decades
behind FAA in requiring the installation of collision
Page 2 GAO- 02- 77 Aviation Safety
avoidance technologies aboard passenger- carrying aircraft. Despite the
attention focused on the need to equip such aircraft with safety alerting
systems 2 after the 1996 crash involving the death of then- Secretary of
Commerce Ronald Brown, timelines for equipping such aircraft extend out as
far as 2009. The installation of these devices must compete with other
demands to ensure mission readiness. Some DOD officials expressed concern
that aviation safety does not receive adequate visibility. The office
responsible for aviation safety currently occupies a relatively low
organizational position within the Office of the Secretary of Defense ( OSD)
. As a result of downsizing by OSD several years ago, five safety positions,
which shared responsibility for aviation safety issues, were abolished and a
single staff member hired. This staff member s responsibilities include
aviation safety and a number of other responsibilities, including compliance
with the Occupational Safety and Health Act of 1970 ( OSHA) , as amended;
fire and emergency services; range and weapons safety; and traffic
transportation.
For the two cases where we evaluated the communication processes between FAA
and the military services, our review showed that existing formal networks
of communication have not always been sufficient to ensure the comprehensive
exchange of all critical aviation safety information. Specifically, we found
( 1) a lack of a common definition of what constitutes an aviation safety
hazard of mutual concern and ( 2) gaps in the formal communication
processes, which caused delays in bringing critical safety information to
the attention of key officials. In addition, the informal information
exchange is currently sustained largely by personal rather than formal
agency/ service relationships, and is therefore vulnerable to the retirement
of key aviation safety personnel and senior leaders. For these reasons, we
are making a recommendation to improve the formal processes used by FAA and
the military services to exchange aviation safety information of mutual
interest.
FAA, an agency located within DOT is responsible for regulating and
promoting the safety of civil aviation. The Coast Guard is part of DOT,
except when operating as a service in the Navy during time of declared
2 Traffic Alert and Collision Avoidance Systems ( TCAS) alert pilots to
potential collisions with other airborne aircraft, and Ground Proximity
Warning Systems ( GPWS) alert pilots to impending collisions with terrain.
Page 3 GAO- 02- 77 Aviation Safety
war or when the president otherwise directs; 3 however, the Coast Guard
follows its own rules for aviation safety oversight, which parallel the
structure and operations followed by the military services rather than those
of FAA.
In contrast to FAA, DOD is both an operator and a regulator of aviation for
the military services. Its primary mission is national defense, one
component of which is aviation safety. OSD maintains oversight of the
military services aircraft aviation safety processes but has delegated to
the heads of the military departments the responsibility for aviation safety
programs. For example, the secretary s office is responsible for issuing
policies and directives pertaining to aviation safety that the military
services must implement as they address their respective missions. Within
OSD, aviation safety is the responsibility of the Office of Safety and
Occupational Health, under the Office of the Deputy Undersecretary for
Installations and Environment, which, among other responsibilities, includes
traffic safety, OSHA compliance, and toxic hazards.
There are three key similarities and three differences between the aviation
safety oversight systems used by FAA and the military services. They share
common internal processes for disseminating safety information; managing
aviation safety risks ( e. g. , they each use variations of a five- step
process) ; and certifying that aircraft meet civil aviation standards ( FAA
provides the certification services to the military at no cost) . They
differ, however, in their processes to certify that aircraft meet their
unique safety standards and to investigate aircraft accidents, as well as in
the timetables and thresholds for acting on potential and identified
aviation safety problems. For example, the command and control structure of
the military services allows immediate action to be ordered, such as the
grounding of a fleet of aircraft, after weighing the impact on their
respective missions. In contrast, although FAA can and has taken similar
immediate action when necessary, the agency often has more to consider
before taking equivalent action, such as consulting with airlines and other
stakeholders, given the potential ramifications for the nation s economy and
the public interest. See appendix III for additional information on key
similarities and differences between FAA s and the military services
aviation safety oversight systems.
3 The Coast Guard normally performs multiple civil missions, such as
maritime search and rescue, law enforcement, and environmental protection.
During wartime, the Coast Guard operates under the authority of the
Department of the Navy.
Page 4 GAO- 02- 77 Aviation Safety
Flight operations for military aircraft can differ from those of civil
aircraft in their nature and severity ( e. g. , turns may be made at steeper
angles and aircraft may ascend and descend at higher speeds) . Although
standard parts may be common, the stress on the parts and materials in the
environment in which they are used may be quite different. As such, the
Coast Guard and the Navy frequently fly aircraft in close proximity to
water, 4 a condition that poses special maintenance concerns, while most
commercial civil aircraft are not typically exposed to similar conditions.
In addition, according to some military officials, military aircraft can be
operated closer to the edge of the envelope maximum recommended speeds,
weight, and other parameters than commercial civil aircraft. Such conditions
can also accelerate wear of aircraft.
FAA and the military services oversee the safety of some similar aircraft
types, 5 such as the Boeing 737 and executive jet aircraft. See appendix II
for a more detailed listing. Even dissimilar civil and military aircraft
often have common parts and materials such as bolts, fasteners, and wiring.
Civil and military aircraft are manufactured, modified, and repaired using
standard type parts, although their application may differ.
Interdepartmental communication about aviation safety issues of mutual
interest is important to ( 1) ensure timely correction of structural,
mechanical, or material weaknesses on aircraft that could lead to safety
problems ( e. g. , loss of lives and aircraft) and ( 2) make effective use
of federal dollars by sharing lessons learned about specific problems.
Similar aviation safety concerns do not necessarily lead FAA and the
military services to take the same actions to mitigate or eliminate them or
to act at the same pace. Different actions taken by these entities based on
assessments of safety risk can in some cases be appropriate and reflect
mission differences or, in other cases, may not seem warranted. The examples
below, describing the potential safety concerns associated with the choice
of electrical wire insulation and the pace of equipping aircraft Actions of
FAA and
the Military Services to Address Similar Aviation Safety Concerns Vary
4 Both the Navy and Coast Guard fly their aircraft in close proximity to
water, often for extended periods of time, which can corrode aircraft. For
example, Coast Guard helicopters take on water from rescue swimmer training
and rescue operations and are often not protected from moist conditions due
to a lack of adequate hangar space.
5 For purposes of this report, similar aircraft refers to aircraft types
that civilian and military entities operate, such as the Boeing 737, 747,
and DC 10. In some cases the military versions have been modified.
Page 5 GAO- 02- 77 Aviation Safety
with warning devices to alert pilots to impending collisions, illustrates
this point.
Assessments of Similar Aviation Safety Risks by FAA and the Military
Services Can Vary
Given different operating environments, the same safety risk can vary in
probability and/ or severity. For example, one of the military services
could determine that, based on its mission requirements and a unique and
harsh operating environment, an aviation safety hazard poses an extremely
high risk because it is likely to occur frequently and have a critical or
catastrophic impact. Conversely, FAA might determine that, based on the
standard operating environment for civil aviation, the hazard poses a low
safety risk because it is unlikely to occur, even if its severity is deemed
critical. Given the prohibitively high cost of eliminating all potential
aviation safety hazards, officials responsible for aviation safety must
often accept some level of residual risk. FAA and military service officials
acknowledged that some of the components used in preparing such safety risk
estimates are subjective, but said they rely to the extent practical on
technical experts to inform the decision- making process.
FAA and the Military Services Took Different Actions to Address Potential
Safety Concerns Posed by a Type of Wire Insulation
When faced with a similar potential safety concern posed by the use of a
specific type of wire insulation known as aromatic polyimide, FAA and each
of the military services used common research findings, evidence collected
from flight operations, and mission priorities to independently assess the
safety risk of continued use of this wire insulation. Each arrived at
different decisions about the level of hazard it posed and the actions
warranted based largely upon mission differences and specific design
requirements. Aviation safety officials involved in these risk assessments
provided some explanations for the differing results.
Environment: One of the main considerations used to assess its safety risk
was the operating environment of the aircraft. For example, FAA also
considered that naval aircraft routinely operate in more harsh environments
than commercial aircraft on aircraft carriers where they are constantly
exposed to moisture. Ballistic Testing: To explain differences between FAA s
decision and the
Navy s decision, some officials pointed out that the genesis of the Navy s
concerns grew out of ballistic testing a survivability issue that was not a
concern for FAA and commercial operators. For example, in 1986, Navy tests
found that bullets fired into an aircraft could sever wires, cause arc
tracking events, and trip circuit breakers. Aircraft Design Dictates Wire
Installation Practices: According to FAA and
military safety officials, another consideration that guided FAA to a
Page 6 GAO- 02- 77 Aviation Safety
different result from the Navy is that transport passenger aircraft have
much more room to run wires than fighter aircraft. As a result, wires
require much less bending that can potentially cause their insulation to
degrade.
The Navy took the lead in identifying and examining potential problems
associated with the use of this wire insulation type and in mitigating
hazards. In the mid- 1980s, when the Navy began experiencing problems with
this wire insulation, it enlisted the support of experts from other military
services and FAA to further characterize the problems and identify possible
solutions. Researchers determined that prolonged exposure of this type of
wire insulation to moisture could cause it to deteriorate and that it was
susceptible to arc tracking. Arc tracking can occur when two cracks in the
insulation are close enough together to allow the current to form a
conductive path between them at temperatures that can cause the insulation
to char and carbonize. This carbonization can turn the insulation into an
electrical conductor, and, eventually, can trip a circuit breaker. When a
pilot presses the switch to reset a tripped circuit breaker, an entire wire
bundle can be disabled and potentially compromise the safety of an aircraft
s entire electrical system.
Ultimately, the Navy and the Coast Guard took the most active measures to
address potential problems with aromatic polyimide, which some experts
attribute to these entities unique aircraft operations near water. . In
December 1985, the Navy decided that aromatic polyimide would no longer be
its wiring insulator of choice and subsequently removed it selectively from
parts of aircraft where it was most problematic ( e. g. , fore and aft
flaps, wheel wells, and around unsecured seals that could leak) . The Coast
Guard lagged behind the Navy in taking action to address problems with this
wire insulation; however, it took the most extensive action by stripping it
from its largest fleet of helicopters as a precautionary measure after
occurrences of in- flight fires and cockpit smoke and fumes between 1993 and
1996. While no aircraft were destroyed, these incidents led to poor
visibility in the cockpit and, in some cases, the loss of all electrically
powered flight instruments. A senior Coast Guard safety official said that
the Coast Guard completed removal of this wire insulation from its entire
fleet of H- 65 helicopters in September 2001. In contrast, the Army did not
experience similar safety problems. While it independently confirmed the
Navy s findings in 1986, the Army concluded that it did not have the same
problems with aromatic polyimide. The Army did have durability concerns,
however; it found the degree to which aromatic polyimide chafes in Apache
and Blackhawk helicopters is
Page 7 GAO- 02- 77 Aviation Safety
unacceptable over time and decided to remove it gradually as it refurbished
older aircraft.
In response to the Navy s finding of potential hazards with the use of
aromatic polyimide, FAA conducted independent research, tracked related
research and operational data from industry and the military services, and
decided that mandating the removal of this wire insulation from commercial
aircraft was not warranted. However, FAA did issue three Advisory Circulars
related to the use of this wire insulation type, in 1987, 1991, and 1998, to
provide policy guidance to help prevent electrical problems and potential
fires and to describe acceptable practices for aircraft inspection and
repair, including wire installation.
Recognizing the need for sustained attention to aircraft wiring issues, FAA
has ongoing efforts to assess the health of wire in aging aircraft through
its Aging Transport Systems Rulemaking Advisory Committee ( ATSRAC) . To
date, working groups under ATSRAC have conducted visual ( nonintrusive) and
extensive physical ( intrusive) inspections of wiring on aging aircraft.
However, according to National Transportation Safety Board ( NTSB)
officials, it is too soon to determine how well the agency is doing in its
assessment. These officials pointed out that ATSRAC has a seven- step
objective of reviewing wiring in aging aircraft, and its recent intrusive
inspection is only one step in the process.
In August 2001, FAA announced a new initiative, the Enhanced Airworthiness
Program for Airplane Systems ( EAPAS) , a cooperative effort with industry
that is intended to ( 1) enhance the safety of aircraft wiring from design
and installation through retirement, ( 2) increase awareness of wiring
degradation, ( 3) implement better procedures for wiring maintenance and
design, and ( 4) ensure that the aviation community is informed. In the same
month, the Transportation Safety Board of Canada announced that, as a result
of its investigation of the crash of Swissair Flight 111, it ( 1) concluded
wire failure can play an active role in fire initiation and ( 2) recommended
a more stringent certification test regime. FAA officials told us that the
agency has not yet responded to the conclusions and recommendations of the
Transportation Safety Board of Canada. See appendix IV for a more detailed
summary of actions taken by FAA and the military services to address
concerns about aromatic polyimide.
Page 8 GAO- 02- 77 Aviation Safety
The Military Services Acted More Slowly Than FAA to Require Installation of
Cockpit Safety Equipment to Reduce Crashes Into Terrain, and Midair
Collisions, and to Monitor Other Potential Safety Problems
The military services have lagged as much as two decades behind FAA in
requiring the installation of cockpit technology in passenger- carrying
aircraft to alert pilots to impending collisions. In 1974, FAA responded to
NTSB recommendations by requiring operators of large commercial aircraft to
equip the cockpits of these aircraft with Ground Proximity Warning Systems (
GPWS) to provide pilots with warnings of potential collisions with terrain (
land or water) . FAA extended this GPWS requirement to operators of smaller
airplanes and turbojet- powered airplanes with 10 or more passenger seats in
1978. However, the military services did not plan to systematically install
GPWS in passenger- and troop- carrying aircraft until after the 1996 crash
of a military aircraft carrying then- Secretary of Commerce Ronald Brown and
34 others. Subsequently, a senior military safety official reported that the
crash would almost certainly have been prevented had the aircraft been
equipped with enhanced GPWS. The enhanced version of GPWS provides flight
crews with earlier auditory and visual warnings of terrain, forwardlooking
capability, and more time to make smoother and more gradual corrective
actions.
FAA also took action in 1989 based on a 1987 congressional mandate to reduce
the number of midair collisions by requiring certain civil aircraft to be
equipped with Traffic Alert and Collision Avoidance Systems ( TCAS) . These
systems help pilots to avoid midair collisions by providing them with
messages of an impending collision with another aircraft. According to FAA,
since the advanced version of TCAS ( TCAS II) was introduced in 1993, civil
midair collisions in the United States have declined by 80 percent. While
acknowledging the benefits of TCAS, the military services have equipped
their passenger- carrying aircraft with TCAS at a slower pace. For example,
in August 1996, the Air Force published its Navigation and Safety Equipment
Master Plan for DOD Passenger- Carrying Aircraft, which established guidance
for equipping passenger- and troop- carrying aircraft, including GPWS and
TCAS in two implementation phases. Phase 1 requires installation by 2001 of
all equipment used to transport senior military leaders, and Phase 2
requires installation of this equipment on remaining passenger- and troop-
carrying aircraft by 2005. As of January 2001, the Air Force had equipped 49
percent of its passenger- and troop- carrying fleet with these technologies,
but in some cases the timelines for equipping these aircraft with GPWS and
TCAS extend out as far as 2009. As of July 2001, the Navy had equipped less
than 20 percent of its
Page 9 GAO- 02- 77 Aviation Safety
passenger- carrying fleet with GPWS 6 and TCAS. According to an official
from the Department of the Army, as of August 2001, units had equipped 38 of
the Army s 294 fixed wing aircraft with enhanced GPWS and 90 of these same
aircraft with TCAS. The remaining fixed wing aircraft must be equipped with
these technologies by fiscal year 2006. The Army has not equipped any of its
rotary wing aircraft ( i. e. , helicopters) with GPWS or TCAS and currently
has no plans to do so. In contrast, by 1998, the Coast Guard had installed
TCAS in all of its fixed wing and rotary wing aircraft. In addition,
according to a senior Coast Guard safety official, it has equipped its C-
130 fleet with GPWS, and the majority of the remainder of its fleet is
helicopters; however, due to the erratic nature of rotorcraft flight as
compared to fixed wing aircraft flight, 7 making use of GPWS on helicopters
is much more difficult and the technology development lags behind that for
fixed wing aircraft. This official stressed that as such there is no FAA
mandate that civil helicopters be equipped with GPWS or its enhanced
version. See appendix V for more details on GPWS and TCAS.
In addition, some major U. S. air carriers, in coordination with FAA, have
generally acted sooner than the military services to install
passengercarrying aircraft with flight data recorders and to establish
programs that collect and analyze aircraft data from routine passenger
flights to detect potential safety, training, and maintenance problems.
These programs are commonly referred to as Flight Operational Quality
Assurance ( FOQA) programs. In July 1995, as part of FAA s strategy to
achieve significant reductions in aviation accident rates, the agency
initiated a 3- year, $ 5.5 million FOQA Demonstration Project to promote the
voluntary implementation of FOQA programs by U. S. airlines. In response,
several major carriers have initiated FOQA programs.
In October 1999, the safety chiefs for each of the military services agreed
that FOQA had value and endorsed projects and research by all services. A
Memorandum of Agreement signed by the services safety chiefs in August 2000
followed this. Efforts by the military services to initiate FOQA programs
are in the very early stages, with the Air Force taking the lead through a
demonstration project using the C- 17 aircraft. The Air Force
6 The Navy is currently installing GPWS and plans to install the enhanced
version sometime in the future. 7 Helicopters can stop, pedal turn, and
hover, while fixed wing aircraft are often operated in a fairly narrow band
of forward motion, which makes their near- term flight path more
predictable.
Page 10 GAO- 02- 77 Aviation Safety
selected a software contractor for its FOQA program in June 2001 and has
since begun analyzing data it has collected since 1994 from nearly 11,000
flights. See appendix VI for additional information.
Some officials with OSD told us that because of the relatively low
organizational position of aviation safety within DOD this issue does not
receive the visibility that is warranted. Aviation safety is located within
the office of the Deputy Undersecretary of Defense for Installations and
Environment within the Office of Safety and Occupational Health and is one
of 26 competing oversight responsibilities of this office, which includes
OSHA compliance, traffic safety, and toxic hazards. Currently there is no
aviation safety manager/ officer for OSD. Several years ago, five safety
positions were abolished as part of an OSD downsizing effort and a single
staff member was hired to cover aviation safety and a multitude of other
responsibilities including OSHA compliance, fire and emergency services, and
range, weapons, traffic, and transportation safety.
While FAA and the military services have numerous mechanisms in place to
exchange aviation safety information, we found ( 1) a lack of a common
definition of what constitutes aviation safety information of mutual concern
and ( 2) gaps in the formal processes currently used to exchange aviation
safety information. These gaps are illustrated by two cases where existing
formal networks of communication were not sufficient to ensure prompt and
comprehensive exchanges of aviation safety information and follow- up
actions responding to identified problems. The heavy reliance by FAA and the
military services on informal communication networks to exchange aviation
safety information is vulnerable to an expected wave of retirements.
Shortcomings in
Existing Processes Used for Sharing Aviation Safety Information
Numerous Mechanisms Are Used to Exchange Aviation Safety Information
FAA and the military services have established numerous mechanisms for
exchanging aviation safety information, including informal networks among
aviation safety personnel, use of Web sites, meetings among senior leaders
and attending each others meetings and conferences.
. Informal Networks: Technical staff at FAA and the military services ( e.
g. ,
aerospace engineers) have developed an informal network that has facilitated
the exchange of information about similar aviation safety issues. These
officials reported that they have set some joint research priorities,
routinely share research findings and information gleaned from accident
investigations, and conduct joint aircraft testing. According to FAA and DOD
officials in the research and development arena, the
Page 11 GAO- 02- 77 Aviation Safety
exchange of information on aviation safety is excellent, routine, and
reliable. This communication has provided them with a means of alerting
colleagues in other agencies and services about key issues or problems.
These officials cautioned that the effectiveness of this type of
communication is attributable to its informal nature and that formalizing
these processes would hinder rather than help their work.
For example, officials from the FAA Technical Center, military services, and
National Aeronautics and Space Administration meet at least semiannually to
set common research priorities, share the research workload, and, in some
cases, this has led to formal cost- sharing for research and development on
aging aircraft systems. This allows each of these entities to leverage the
federal dollars spent on common aviation safety problems. While formal
initiatives are in place regarding shared federal agency research on
aviation safety and aging aircraft systems, these meetings and research
sharing activities evolved from informal communication. One outgrowth of
this informal communication has been the sharing of costs by the Navy and
FAA to develop a new smart circuit breaker that can detect and interrupt
electrical surges associated with arc tracking and minimize the damage to
wires. This technology should help to prevent much of the damage that
currently occurs and goes undetected. In addition, miniaturizing this new
circuit breaker is a priority for both the military services and FAA, for
example, for use on military aircraft that have limited space and aboard
civil aircraft to increase the number of functions for which the circuit
breaker can be used. Such sharing of aviation safety research priorities
helps to ensure the timely exchange of lessons learned among FAA and the
military services ( e. g. , about how a specific aviation safety hazard was
addressed) and the effective use of federal funds dedicated to aviation
safety oversight. Use of Web Sites: Exchanges of information between FAA and
the military
services also take place when information of mutual interest is posted to
their respective Web sites. For example, the Air Force currently maintains
the most exhaustive database on the hazards of aircraft striking birds. It
is used extensively by the other military services and FAA to identify,
among other things, altitudes and migratory flight paths commonly used by
bird species. It also serves as a mechanism to alert pilots and aviation
safety officials to avoid certain flight levels and airspace, when
practical. In addition, the Army s Aviation and Missile Command ( AMCOM)
makes use of its Web site to post critical aviation safety messages (
stripped of privileged and classified information) pertaining to its
helicopter fleet, thus allowing the other military services and FAA to
monitor potential safety hazards. Similarly, FAA s Web site provides access
to many of the agency s safety databases as well as airworthiness
directives, which are
Page 12 GAO- 02- 77 Aviation Safety
generally posted on a real- time basis. Communication Among FAA and DOD
Senior Leaders: Senior leaders at
FAA and DOD reported that they generally keep informed about aviation safety
issues common to both organizations through networking, such as telephone
and working lunches. According to a senior DOD official, this networking has
been a very effective way to exchange information with FAA, as senior
leaders from both entities have become well acquainted and use these
personal relationships to keep lines of communication open and active. A
senior FAA safety official also characterized informal working relations
between FAA and DOD as effective.
Other Mechanisms for Information Exchange: FAA and the military services use
a range of other mechanisms for exchanging information about aviation
safety. These include attending each other s meetings and professional
conferences, exchanging practices for assessing safety risks, and developing
technical standards. Table 1 provides further examples of ways that FAA and
the military services communicate.
Page 13 GAO- 02- 77 Aviation Safety
Table 1: Examples of Mechanisms for Information Exchange Between FAA and the
Military Services Communication mechanism Information exchange activities
Commercial Aviation Safety This team was created to identify, analyze, and
prioritize aviation safety hazards and appropriate actions to mitigate these
problems.
Government- Industry Data Exchange Program ( GIDEP) A cooperative activity
between industry and government managed by the Navy through an agreement of
the Joint Logistics Commanders. Provides a medium to exchange technical
information about the quality and reliability of parts, components,
equipment, and services used by the federal government. It is not aviation-
specific.
Aging Transport Systems Rulemaking Advisory Committee Currently, FAA,
industry, DOD, and other stakeholders are conducting
( ATSRAC) research on wiring systems in aging aircraft.
Military Flight Operational Quality Assurance ( FOQA) conferences Two such
conferences have been held to share information among the
airlines and the military services on the FOQA concept and its
implementation.
Safety Risk Management FAA and NASA sponsor an annual conference on Risk
Analysis and Safety Performance Measurement. These conferences have been
attended by the military services.
Society of Automotive Engineers ( SAE) A subset of this group is developing
specifications for the new smart circuit breaker. Two engineers, one from
the Naval Air Systems Command and the other from FAA s Technical Center, are
leading this effort.
Global Aviation Information Network ( GAIN) This network is still in the
early stages of development. Ultimately, it will provide a means to
voluntarily exchange information among users worldwide, including the
military, to improve aviation safety.
Meetings Among Senior Senior DOD and FAA leaders invite their counterparts
to attend aviation safety meetings ( e. g. , FAA is a permanent guest of the
Joint Service Safety Chiefs and a participant in the Joint Aeronautical
Commanders Group) .
Aviation Rulemaking Advisory A formal FAA advisory committee established in
1991. It is comprised of representatives from the aviation community and
provides the agency with industry input during FAA s rulemaking activities.
DOD is not a standing member, but participates on occasion.
Memorandums of Understanding/ Memorandums of These memorandums are used to
clarify how DOT/ FAA and DOD work together ( e. g. , the sharing of civil
and military airspace and information on air carriers performance) ) .
DOD liaisons at DOD liaisons working at FAA focus primarily on air traffic
control issues; however, they relay requests for safety information to
appropriate officials when requested.
Risk Management Information System ( RMIS) Software designed by the Army to
collect and share information internally, with the other services, and
agencies on a near real- time basis.
Flight Safety Critical Aircraft Parts ( FSCAP) A joint DOD and FAA effort to
identify, dispose of, and control military surplus FSCAP available for civil
purchase.
Interagency agreement regarding information exchange Agreement signed in
1997 by FAA, DOT Office of Inspector General,
about problem parts and Federal Bureau of Investigation, U. S. Customs and
Defense Criminal Investigative Service regarding the exchange of information
and technical support for suspect aviation parts.
Source: FAA and the military services.
Page 14 GAO- 02- 77 Aviation Safety
FAA and the Military Services Have Not Developed a Common Definition of
Aviation Safety Information of Mutual Concern
FAA and the military services have not developed a common definition of
aviation safety information of mutual interest, and, in particular, what
information should be considered critical. As a result, the information
exchanged is based on individual judgment rather than on the systematic
identification and exchange of information. Various definitions of critical
aviation safety information have been established, such as that used by DOD
for procuring aircraft materials and parts. 8 Policies have also been
established to facilitate the exchange of aviation safety information of
common interest between FAA and the military services; however, the basis
for such communication is unclear and left up to individuals interpretation.
A fundamental step in developing this definition is establishing the
universe of civil aircraft and their military aircraft derivatives,
something senior FAA officials told us the agency has not been able to do. 9
See appendix II. Such a definition is needed to help ensure that all
aviation safety information of common interest, especially that deemed
critical, is promptly identified and reported to responsible officials.
Gaps Exist in the Processes Used By FAA and the Military Services to
Exchange Aviation Safety Information of Mutual Concern
While FAA and the military services routinely exchange some aviation safety
information of mutual concern, there are gaps in the processes used by both
entities, including the sharing of how specific aviation safety concerns
were addressed. For example, FAA sends its emergency Airworthiness
Directives ( AD) a type of critical safety information to only five U. S.
military addressees, as requested by the military services, with the same
level of urgency that they are sent to owners and operators
8 The Department of Defense Standard Practice for System Safety defines
safety critical as a term applied to any condition, event, operation,
process or item whose proper recognition, control, performance, or tolerance
is essential to safety system operation and support ( e. g. , safety
critical function) . MIL- STD- 882D ( Feb. 10, 2000) .
9 Both FAA and the military services also rely on airframe manufacturers to
collect and maintain data on potential aviation safety risks on similar
civil and military aircraft and common parts and materials.
Page 15 GAO- 02- 77 Aviation Safety
of civil aircraft. 10 , 11 These military addressees represent only a small
subset of the military entities that could be affected. 12 FAA officials
told us that it has added specific military users to its list of addressees,
but has had limited success maintaining accurate and current contact
information.
Despite FAA s general practice of posting emergency ADs to its Web site in
real time, the site contains a disclaimer that the agency cannot guarantee
the accuracy of the information it posts for instance, the information
posted could be vulnerable to tampering from computer viruses 13 or computer
hackers. As a result, FAA requires that all emergency ADs be sent
immediately via telegram or fax to owners and operators of civil aircraft
and that their receipt be documented. While FAA is not required to send
these directives to the military services, 14 it appears prudent to do so
when it involves information of mutual interest, given their common
responsibilities for aviation safety oversight.
Similarly, the military services provide FAA with some of their aviation
safety information, but generally not with the same level of urgency with
which they distribute it to the other services. For example, the Army s
Aviation and Missile Command strips privileged and classified information
from its critical safety messages pertaining to its helicopter fleet, sends
them all to the other military services and FAA, and posts them to its Web
site. In contrast, the Navy uses its judgment to send some of its aviation
safety messages to FAA, while the Air Force s, Coast Guard s, and Army s
10 FAA officials said that the agency s distribution of ADs relies on the
FAA Civil Aircraft Registry and Civil Operations databases. For DOD
aircraft, FAA distributes ADs according to DOD s requests. It is FAA s
understanding that DOD wants ADs sent to certain specific contact offices,
not to the operating units.
11 Army officials said that AMCOM receives and reviews all emergency ADs
from FAA and, when necessary, converts them into Safety of Flight and
Aviation Safety Action Messages. They further noted that this centralized
control is necessary to ensure compliance and because they do not want such
FAA notices going to units that are not affected by a given message.
12 As of July 18, 2001, FAA s addressee list for emergency ADs included five
U. S. military recipients as follows: Naval Air Systems Command,
Jacksonville, Florida ( TPE331 engine) ; U. S. Army Aviation and Troop
Command, St. Louis, Missouri ( BHT- 206 engine) ; U. S. Air Force, Scott Air
Force Base ( DC- 9 and JT8D engine) ; U. S. Air Force, Oklahoma City,
Oklahoma ( Boeing- 737- 700) ; and U. S. Navy, Pentagon ( DC- 8 and DC- 9) .
13 Access to FAA s Web site was disrupted in August 2001 by a computer
virus. 14 FAA is responsible for notifying owners and operators of aircraft
on the agency s civil aircraft registry of airworthiness directives.
Military aircraft are not listed in this directory.
Page 16 GAO- 02- 77 Aviation Safety
Safety Centers generally provide aviation safety information to FAA only
upon request.
The formal processes used by FAA and the military services to exchange
aviation safety information of mutual concern, including information
critical to flight safety, have not always been sufficient to ensure the
comprehensive exchange of such information. While informal communication
networks have helped to facilitate the exchange of aviation safety
information, these exchanges are not required and systematic, and do not
provide assurances that such information is exchanged in a timely manner.
The automatic exchange of critical safety information is important to the
safe operation of both civil and military aviation to help ensure that
entities that could be affected receive notification promptly to provide
them with as much time as possible to mitigate or eliminate a given hazard
and avoid potential loss of lives and aircraft.
Two Cases Illustrate How FAA and the Military Services Do Not Always
Exchange Critical Aviation Safety Information on a Systematic and Timely
Basis
The importance of effective and timely information sharing between civil and
military aviation entities on aviation safety issues was highlighted during
the investigation of the 1996 crash of TWA Flight 800. It was not discovered
until 1999 that the Air Force had contracted with Boeing in the late 1970s
to study problems it experienced with fuel pumps and overheating in the
center fuel tanks in the E- 4B aircraft the military variant of the Boeing
747. The Air Force was concerned about the E- 4B engines continuing to run
satisfactorily if a main ( wing) fuel tank pump malfunctioned. There was
also a concern over running of the air conditioning packs under the center
wing fuel tank for extended periods of time ( e. g. , for 48 hours when
operated in an alert mode) . In this mode, the center wing tank was full of
fuel, and heated up slowly to a high temperature. Boeing found that, under
certain circumstances, air conditioning wires running through the fuel tank
could create a potential safety problem, but determined that the engine
would continue to operate successfully provided certain operating
restrictions were implemented. While the central focus of the Air Force s
concerns and Boeing s analysis was fuel pump performance, not fuel vapor
flammability, NTSB officials said that the information contained in this
report would have assisted them with their investigations of fuel tank
overheating.
A senior NTSB official told us that it is not likely that earlier sharing of
the report s findings would have prevented the crash of TWA Flight 800.
However, had NTSB received the study in 1996 following the crash, valuable
time and resources in conducting its investigation could have
Page 17 GAO- 02- 77 Aviation Safety
been saved. In August 2000, NTSB released its report on the TWA Flight 800
accident, which included the following statement regarding the report Boeing
prepared for the Air Force on fuel tank overheating in the E4- B:
The Safety Board recognizes that the military variant of the 747 is not
directly comparable to the civilian 747 and that the focus of that study was
fuel pump functionality, not flammability. Nonetheless, it is unfortunate
that potentially relevant information about 747 center wing [ fuel ] tank
overheating and corrective measures were not provided to the FAA or to 747
operators earlier.
In addition, according to the NTSB chairman and director of aviation safety,
the report might have been helpful to NTSB in its investigation of a Boeing
737 aircraft explosion in 1990 at Manila Airport in the Philippines. The
explosion occurred in the aircraft s center fuel tank. Both the chairman and
the director said that it is possible that if they had received this study
in 1990, safety recommendations made as a result of the TWA Flight 800
investigation concerning fuel tanks might have been issued sooner. See
appendix VII for more information about this case.
According to DOD, the wire rope produced by Strandflex and used to construct
aircraft control cables is critical to the safe operation of flight control
systems, such as aircraft rudders, steering, and brakes, on affected
aircraft, while FAA officials contend that it is not always critical to
flight safety. According to these officials, this is because civil federal
aviation regulations require that aircraft control systems incorporate
redundancies, meaning that failure of control cables would not cause loss of
the airplane. 15
The wire rope produced by Strandflex became the subject of a Defense
Criminal Investigative Service investigation when the military discovered
that it was not being tested to ensure that it met military specifications
and an independent DOD test demonstrated that it did not meet strength
requirements. The DOD Office of Inspector General ( DODIG) notified the
military services and FAA s Office of Civil Aviation Security at the same
15 FAA officials also told us that civil aircraft cable assemblies are often
designed to be five times stronger than they need to be. Furthermore, once
aircraft control cables are assembled, they are tested in a manner that
would reveal weaknesses in the wire rope.
Page 18 GAO- 02- 77 Aviation Safety
time of potential problems with Strandflex. 16 The military services quickly
addressed this situation by alerting responsible officials of the need to
assess and address safety concerns associated with the use of this product.
In contrast, as confirmed by a DOT Office of Inspector General s ( DOTIG)
investigation, FAA did not issue an Unapproved Parts Notification ( UPN) to
notify civil aviation community officials of potential problems with the
Strandflex product for a year a problem the inspector general attributed to
weaknesses in the agency s overall processing of UPNs. 17 FAA officials
acknowledged that there was a delay in issuing the UPN, but said that they
had assessed the situation and concluded that it did not require urgent
action.
Among other things, FAA did not inform the DOD Office of Inspector General (
DODIG) that the appropriate recipient of its messages pertaining to suspect
unapproved parts is its Suspect Unapproved Parts Program Office until the
DOTIG initiated its investigation. While the DOTIG did not identify this as
a key contributor to the year- long delay by FAA, even simple communication
breakdowns such as not informing DOD of the appropriate addressee could lead
to potential safety hazards being overlooked or going unreported to
responsible officials.
Recognizing the fundamental nature of this shortcoming, the manager of FAA s
Suspect Unapproved Parts Program Office cited a change in the FAA addressee
as the first among numerous corrective actions that had been taken to
address weaknesses identified by the DOTIG in the agency s processing of
UPNs. Specifically, this manager advised the DOTIG general that the FAA copy
of DOD alert messages would be sent directly to the Suspect Unapproved Parts
Program Office rather than going through the Office of Civil Aviation
Security. FAA and DOD officials told us that, while the Office of Civil
Aviation Security remains the addressee on the official DOD notification
letter to FAA, a facsimile copy is now sent directly to the Suspect
Unapproved Parts Program Office. See appendix VIII for additional
information on this case.
16 DOD did not send its notification to FAA s program office primarily
responsible for suspect unapproved parts. Rather it followed the standard
procedure of transmitting it to FAA s Office of Civil Aviation Security and
to the DOTIG.
17 OIG Investigation of Responses to Information About a Serious Flaw in
Aircraft Cables , U. S. Department of Transportation, Office of the
Inspector General ( Mar. 2, 2001, Report Number CC- 2000- 290) .
Page 19 GAO- 02- 77 Aviation Safety
Informal Channels of Communication Might Weaken As Key Personnel Retire
Some key individuals that have made informal communication on similar
aviation safety issues effective between FAA and the military services have
retired or can be expected to retire over the next several years. This makes
succession planning an important part of aviation safety oversight for both
departments.
Expected retirements among senior leaders over the next several years, along
with recent and expected retirements among aviation safety personnel and
senior leaders, may diminish the effectiveness of informal networks and make
formal agency- based communication mechanisms even more important to the
exchange of safety information between these entities. This is especially
true, given that informal networks are sustained primarily by personal
rather than agency- based relationships. The anticipated departure of these
employees makes human capital planning an issue warranting management
attention at both departments.
As we reported in April 2001, 18 DOD can expect 15 percent ( over 45,000
employees) to retire by the end of fiscal year 2006. Retirements have
already affected some senior aviation safety positions during the past year.
For example, the key civilian at the Navy Safety Center retired in April
2001 and according to Naval safety officials a replacement was difficult to
find due to the high demands of the job and lack of commensurate pay. 19
Similarly, one of the Army s key civilians in charge of aviation safety
responsible for the Safety of Flight Messages and routing FAA Airworthiness
Directives to the appropriate aircraft program managers has also retired.
Army officials said that the departure of this individual has had little or
no impact on the issuance of flight safety messages. 20 However, both of the
retired aviation safety officials played a central role in the informal
communication network for sharing aviation safety information among an
extensive network of contacts both within and outside their respective
services.
18 Federal Employee Retirements: Expected Increase Over the Next 5 Years
Illustrates Need for Workforce Planning ( GAO- 01- 509, Apr. 27, 2001) . 19
A replacement began work in late August 2001.
20 Among the military services, the Army has taken a unique step to develop
and maintain the continuity of its aviation safety expertise by creating a
separate career field for aviation safety at the Warrant Officer level. The
other services typically rotate their military personnel through aviation
safety positions or assign aviation safety as a collateral duty.
Page 20 GAO- 02- 77 Aviation Safety
In recent years, we have increasingly stressed the need to plan for
retirements within the federal government to help ensure the availability of
adequately trained personnel. As we recently reported, 21 if federal
employee retirements outpace the hiring of qualified replacement staff, the
resulting loss of institutional knowledge and expertise could adversely
affect mission achievement. This concern is especially great given that
retirees often represent any agency s most experienced and knowledgeable
staff. DOT is among the departments with a large number of personnel that
will become eligible to retire over the next several years.
According to the DOT 2000- 2005 Strategic Plan , the department plans to
expand its workforce planning, including succession planning, for
retirements in the next 10 years to ensure that DOT s staff has the skills
and transportation competencies to accomplish its goals. Among these
competencies, DOT has identified the Aviation Safety Series 22 job
classification as a mission critical occupation important to succession
planning. We estimate that 47 percent of the employees in this
classification will be eligible to retire within the next 5 years. 23 In
April 2001, we reported that almost 37 percent of DOT s workforce who are
eligible to retire by the end of fiscal year 2006 would actually retire.
Applying this percent of staff at DOT in the Aviation Safety Series who will
be eligible to retire by the end of fiscal year 2006, we estimate that about
17 percent will actually retire. DOT will thus need to do succession
planning for over 625 aviation safety positions.
Succession planning is one mechanism that FAA, DOD, and the military
services can use to help ensure that effective informal networks are
sustained and/ or replenished in the wake of retirements of key aviation
21 GAO- 01- 509, April 27, 2001. 22 GS- 1825 Aviation Safety Series includes
positions that involve primarily developing, administering, or enforcing
regulations and standards concerning civil aviation safety, including ( 1)
the airworthiness of aircraft and aircraft systems; ( 2) the competence of
pilots, mechanics, and other airmen; and ( 3) safety aspects of aviation
facilities, equipment, and procedures. These positions require knowledge and
skill in the operation, maintenance, or manufacture of aircraft and aircraft
systems. As of September 30, 2000, FAA also had nine employees in the 1815
Air Safety Investigating Series, which are included in the percentages of
safety employees eligible for retirement cited above.
23 Retirement eligibility rates are calculated for those staff working as of
September 30, 2000. Some of these staff might have retired between September
30, 2000, and September 10, 2001, when these numbers were calculated. Any
other separations or new hires since 2000 are not reflected in these
retirement rates.
Page 21 GAO- 02- 77 Aviation Safety
safety personnel. However, succession planning can be difficult. To
effectively deal with the expected retirements and other workforce
challenges, an essential step for FAA and DOD is to engage in a planning
process to identify human capital needs, assess how current staff and
expected future staff will meet those needs, and create strategies to
address any shortfalls or imbalances.
Necessary near- term steps for ensuring continuity of communication when key
aviation safety personnel and senior leaders retire is ( 1) developing a
common definition of aviation safety information of mutual concern,
especially information deemed critical; ( 2) formalizing the channels of
communication by creating an explicit process for exchanging all critical
aviation safety information of mutual concern, including how specific
aviation safety concerns were addressed; and ( 3) requiring that such
information exchanges occur. Such action would also close gaps created by
the current practice of sharing only some critical safety information on a
formal, systematic, and timely basis.
FAA and DOD Recognize the Need to Formalize Communication, but Efforts to
Date Have Not Addressed the Exchange of Critical Aviation Safety Information
Conclusions and Recommendations
FAA and DOD recognize the importance of formalizing communication on
aviation issues to help ensure that communications outlast the tenure of
specific individuals. This has been illustrated by efforts to develop more
timely, systematic, and agency/ service- based communication mechanisms
through memorandums of agreement/ understanding. For example, discussions
are currently under way to determine what FAA s future role should be in
certifying that military variants of civil aircraft meet the agency s
aviation safety requirements. 24 However, these discussions between the
departments to formalize communication channels do not include the broader
issue of requiring a formal exchange of aviation safety information, in
particular, that deemed critical.
Common aviation safety issues and responsibilities for safety oversight make
the systematic and timely exchange of information a critical component of
the aviation safety oversight systems of FAA and the military services. The
informal and formal networks established by FAA
24 The workload of FAA s certification staff is a central issue receiving
attention. FAA currently provides airworthiness certification services to
the military at no cost. Among the options currently being considered is an
arrangement under which DOD would reimburse FAA for the services it
provides. Otherwise, the military services would need to develop in- house
expertise to certify civil aircraft types operated by the military.
Page 22 GAO- 02- 77 Aviation Safety
and the military services to exchange critical aviation safety information
have proven useful. However, because recent and expected retirements
threaten to erode informal networks, additional formal channels of
communication are needed to help ensure that safety risks common to both
military and civil aircraft are identified and addressed in a formal,
systematic, and timely manner. This includes the exchange of information on
how FAA and the military services have addressed particular aviation safety
concerns. Existing gaps in the formal processes used by FAA and the military
services to exchange critical safety information evidenced by the
investigation of fuel tank flammability after the crash of TWA Flight 800
and the Strandflex case could also allow for communication lapses and delays
in getting critical safety information to the right parties in a timely
manner, potentially resulting in the loss of lives and aircraft.
To help ensure the systematic exchange of critical safety information, we
recommend that the Secretary of Defense and the Administrator of FAA, as
directed by the Secretary of Transportation, develop a memorandum of
agreement ( MOA) that defines the types of safety information to be
exchanged, the mechanisms for exchanging this information, and the parties
responsible for this exchange. This MOA should also establish a mechanism
for the two departments to exchange information on how they have responded
to specific safety concerns.
Agency We provided a draft of this report to the secretary of DOD and the
secretary of DOT for their review and comment. Both departments
generally agreed with the report and provided written technical comments,
which we have incorporated as appropriate. The Department of Defense agreed
with our recommendation and the Department of Transportation agreed to
consider it. See appendix IX for DOD s comments.
Page 23 GAO- 02- 77 Aviation Safety
Copies of this report will be made available upon request. Please call me (
202) 512- 2834 if you or your staff have any questions. Key contributors
this report are acknowledged in appendix X. Peter F. Director, Physical
Infrastructure Page 24 GAO- 02- 77 Aviation Safety
Appendix I: Objectives, Scope, and Methodology
For this assignment, we used a case study approach 25 supplemented by a
review of the Federal Aviation Administration s ( FAA) and Department of
Defense s ( DOD) aviation safety oversight processes and related
interdepartmental communication efforts to ( 1) examine different responses
by FAA and DOD/ military services to similar aviation safety concerns and (
2) assess the processes used by FAA and DOD to communicate about similar
aviation safety concerns. 26 This report focuses primarily on safety issues
pertaining to aircraft structures, parts, and materials that civil and
military aviation have in common not the safety of aircraft operations
within the nation s air traffic control system. In addition, it does not
address aviation security issues, such as hijacking, sabotage, or terrorist
activities.
For the first objective, we chose case studies using two key selection
criteria. First, we identified an aviation safety problem that was similar
for both FAA and the military services. Second, we selected examples in
which FAA and the DOD/ military services had taken a different approach to
solving a common aviation safety problem. After discussions with DOD and
FAA, we selected case studies that pertain to aircraft wiring insulation and
cockpit equipment designed to improve safety and support quality assurance
programs for flight operations. The latter case study includes Ground
Proximity Warning Systems, Traffic Alert and Collision Avoidance Systems,
Flight Data Recorders, and Flight Operational Quality Assurance Programs. In
conducting these case studies, we interviewed and requested documentation
from officials with FAA, Air Force, Army, Marine Corps, Navy, Coast Guard,
and others knowledgeable of their aviation safety oversight processes,
including the National Transportation Safety Board, Flight Safety
Foundation, National Aeronautics and Space Administration, Air Line Pilots
Association, Air Transport Association, and aircraft manufacturers, and the
DOT and DOD Offices of the Inspector General. In addition to our work in
Washington, D. C. , we also met with officials from each of the military
services safety centers and engineering organizations responsible for
maintaining the safety of military aircraft, as well as officials from the
William J. Hughes FAA Technical Center.
25 The case studies selected represent a judgmental sample. 26 For purposes
of this report, we refer to FAA and the military services, rather than FAA
and DOD. We recognize that DOD has ultimate authority for directing the
services actions on aviation safety oversight. Also, unless otherwise noted,
the Coast Guard, which is a part of the Department of Transportation ( DOT)
, is included under the discussions of the military services. Despite its
peacetime missions, the Coast Guard s aviation safety oversight activities
parallel those of the military services.
Page 25 GAO- 02- 77 Aviation Safety
Appendix I: Objectives, Scope, and Methodology
To answer the second objective, we interviewed the same officials cited
under objective one. We also selected two other case studies that illustrate
communication between FAA and the military services on aviation safety
issues.
These include a discussion of a brand of control cable wire rope, which is
used in the assembly of aircraft control cables, and the exchange of
information between Air Force and civil aviation officials on fuel tank
overheating in the E- 4B, a military variant of the 747.
To determine the number and percent of DOT employees in the Aviation Safety
job series who will be eligible to retire by the end of fiscal year 2006, we
used data in the Office of Personnel Management s Central Personnel Data
File ( CPDF) . Retirement eligibility dates were calculated using age at
hire, years of service, birth date, and retirement plan coverage. Although
we did not independently verify the DOT CPDF data, we had previously found
that government- wide data from the CPDF for the key variables in this study
( agency, birth date, service computation date, occupation, and retirement
plan) were 99 percent or more accurate. 27
We performed our work from November 2000 through January 2002 in accordance
with generally accepted government auditing standards.
27 OPM s Central Personnel Data File: Data Appear Sufficiently Reliable to
Meet Most Customer Needs ( GAO/ GGD- 98- 199, Sept. 30, 1998) .
Page 26 GAO- 02- 77 Aviation Safety
Appendix II: Fixed Wing Military Aircraft and Their Civil Derivatives
Operated by DOD
Military Aircraft Type/ Civilian Counterpart Coast Guard Army Air Force
Navy/
Marines
E- 3B/ C AWACS ( Boeing 707) 33 E- 4B ( Boeing 747) 4 VC- 4A ( Gulfstream I)
1 E- 6 A/ B Mercury ( Boeing 707) E- 8A/ C JSTARS ( Boeing 707) 4 E- 9A ( de
Havilland Dash 8, Model 102) 2 C- 9A/ C ( McDonnell Douglas DC- 9) 23 C- 9B
( McDonnell Douglas DC- 9) KC- 10A ( McDonnell Douglas DC- 10- 30- CF) 59 C-
12 ( Beechcraft/ Raytheon King Air) 122 C- 12C/ D/ F/ J ( Beechcraft/
Raytheon King Air) 39 RC- 12 ( Beechcraft/ Raytheon King Air) 47 UC- 12B/ F/
M Huron ( Beechcraft/ Raytheon King Air) EC- 18B ( Boeing 707 ARIA) 3 TC-
18E ( Boeing 707) 2 UV- 18B ( de Havilland Twin Otter) 2 C- 20A/ B (
Gulfstream III) 1 8 C- 20 D/ G ( Gulfstream III, IV) 3 C- 20H ( Gulfstream
IV) 2 C- 21A ( Learjet 35A) 78 C- 22B ( Boeing 727) 3 C- 23B+ Sherpa (
Shorts) 43 HU- 25 Guardian ( Falcon 20) 41 VC- 25 ( Boeing 747- 200B, Air
Force One) 2 C- 26B/ UC- 26C Fairchild ( Metro III) 11 12 7 VC- 32A ( Boeing
757- 200) 4 UC- 35B/ C Cessna Citation ( 560 Ultra) 23 8 C- 37GV/ A (
Gulfstream V) 1 2 4 C- 38A ( Astra SPX - Israeli) 2 C- 40A Clipper ( Boeing
737- 700) 29 CT/ T- 43A ( Boeing 737- 200) 11 C- 130E/ H ( Lockheed Martin
L- 100) 525 C- 130T ( Lockheed Martin L- 100) 20 HC- 130 Hercules ( Lockheed
Martin L- 100) 30 34 KC- 130 F/ R/ T ( Lockheed Martin L- 100) 77 KC- 130J (
Lockheed Martin L- 100) 52 C- 150 ( Cessna) 3 T- 1A ( Beechjet 400T Jayhawk)
180 T- 3A Firefly ( Slingsby T67M260) 114 T- 34C Turbomentor ( Beechcraft
Bonanza) 307 T- 39 D/ N/ G ( Rockwell Sabreliner) 26 T- 41D ( Cessna
Mescalero C- 172) 3
Page 27 GAO- 02- 77 Aviation Safety
16 28
4 57
7
Appendix II: Fixed Wing Military Aircraft and Their Civil Derivatives
Operated by DOD
Navy/ Marines Military Aircraft Type/ Civilian Counterpart Coast Guard Army
Air Force
T- 44A ( King Air) 55 HH- 65 Dolphin ( Aerospatiale SA365N) 95 HH- 60J
Jayhawk ( Sikorsky S- 70A) 42 UH- 60A Blackhawk ( Sikorsky S- 70A) 1,523 HH/
MH- 60G Pavehawk ( Sikorsky S- 70A) 110 CH- 60S Knighthawk ( Sikorsky S-
70A) HH- 60H HCS ( Sikorsky S- 70B) SH- 60B/ F Seahawk ( Sikorsky S- 70B)
SH- 60R ( Sikorsky S- 70B) TH- 57 B/ C Sea Ranger ( Jet Ranger 206) VH- 60N
Whitehawk ( Sikorsky S- 70A) UH- 1N/ Y Iroquois ( Bell Model 204/ 205)
Unknown 64
Page 28 GAO- 02- 77 Aviation Safety
247 39 232 248 119
8 204
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
The Federal Aviation Administration ( FAA) and the military services share
certain safety oversight systems, but three primary differences also exist.
Similarities include common processes for disseminating safety information,
managing aviation safety risks, and certifying that aircraft meet civil
aviation safety standards. Differences include processes to certify that
aircraft meet their unique safety standards and to investigate aircraft
accidents, as well as timetables and thresholds for making decisions about
potential aviation safety problems.
Internal Mechanisms to Communicate Safety- Related Information Are Similar
FAA and the military services have both created formal and informal internal
mechanisms to implement their aviation safety oversight programs.
Formal internal mechanisms are used to communicate official information,
such as orders and directives. For example, FAA issues Airworthiness
Directives ( ADs) to provide primarily owners and operators of civil
aircraft with formal notice of an unsafe condition. For large civil
commercial aircraft, 28 ADs are written by the agency s Transport Airplane
Directorate Aircraft Certification Service in Renton, Washington, and sent
to FAA s Oklahoma City office, which has responsibility for formal
distribution to owners and operators of registered civil aircraft and the
posting of this information to the FAA Web site. Similarly, the military
services issue near- equivalents of ADs to distribute aviation safety
messages to affected units and sister services aviation safety centers. . In
addition, the chiefs of the military services safety centers hold a Joint
Services Safety Conference every six months.
According to both FAA and military officials, formal communication
mechanisms also include internal meetings among engineering and program
staff as well as FAA senior managers or internal meetings of senior military
officers responsible for aviation safety. Both use training as another means
of formally sharing aviation safety information internally among agency/
service staff.
28 The Transport Airplane Directorate issues ADs for airplanes type
certificated under 14 C. F. R. 25, which includes large commercial aircraft
and many smaller business jets. The Small Airplane Directorate in Kansas
City, Missouri, issues ADs for airplanes type certificated under a separate
regulation ( 14 C. F. R. 23) , which include many airplanes in commercial
service some of which are considered commuter airplanes. Other directorates
issue ADs for rotorcraft, engines, and propellers. The directorate of the
geographical area in which the manufacturer is located normally issues ADs
for appliances and parts.
Page 29 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
Both FAA and the military services also have internal informal networks in
place among aviation safety personnel that are used to share information.
These exchanges are typically self- initiated, occur on an ad hoc basis, and
are based largely on personal relationships. It is a primary means used
among the military services safety centers to keep apprised of current
aviation safety issues. According to FAA and military aviation safety
officials, personal relationships are a cornerstone of informal
communication within both FAA and the military services and have resulted in
extensive networking that allows for an active exchange of aviation safety
information.
FAA and the Military Services Use a Similar Process for Managing Aviation
Safety Risks
FAA and the military services all use variations of a five- step process for
managing aviation safety risks. 29
( 1) Identifying potential aviation safety risks . FAA and the military
services employ similar proactive and reactive methods for identifying
potential aviation safety risks. For example, they monitor pilots reports of
aircraft performance problems, manufacturers recommendations, , foreign
civil and military aviation authorities reports, , mechanics reports of
aircraft structural, part, or material weaknesses, inspectors reports of
aircraft conditions and maintenance records, and information exchanges
between stakeholders ( e. g. , airlines, pilots, and engineers) in the
aviation community. Reactive methods include actions taken as the result of
findings and recommendations from aircraft mishaps and accident
investigations.
( 2) Assessing safety risks to determine if corrective action is warranted .
Both FAA and the military services assess the safety risks of a potential
aviation safety problem to determine if action is warranted. This includes
weighing the costs and benefits that taking action might have in mitigating
or eliminating a safety risk and fulfilling their
29 Technically, the Army ( 1) identifies hazards, ( 2) assesses hazards, (
3) develops controls and makes decisions, ( 4) implements controls, and ( 5)
supervises and evaluates. The Air Force has further divided these steps to
create a six- step process: ( 1) identify hazards, ( 2) assess risks, ( 3)
analyze risk control measures, ( 4) make control decisions, ( 5) implement
risk control, and ( 6) supervise and review [ implementation of control
measures ] . The Coast Guard uses a seven- step process: ( 1) identify
mission tasks, ( 2) identify hazards, ( 3) assess risks, ( 4) identify
options, ( 5) evaluate risk versus gain, ( 6) execute decision, and ( 7)
monitor situation. FAA s process includes ( 1) receiving and compiling
problem reports; ( 2) evaluating the impact on safety, which includes an
assessment of associated risk; ( 3) determining what, if any, corrective
action is warranted; and ( 4) implementing corrective action ( e. g. ,
issuing an AD) .
Page 30 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
responsibilities. For example, this process assists military decision-
makers in choosing if and how much to fund a project and in comparing its
urgency to other projects competing for resources.
DOD requires the military services to use risk management and accident
investigations as decision- making tools for identifying potential safety
problems, assessing safety risks, and implementing and monitoring corrective
actions. 30 FAA requires the use of safety risk management by all offices,
consistent with their role within the agency. 31
FAA and the military services commonly use a risk assessment matrix to
estimate the level of risk associated with a potential or identified
aviation safety risk. The safety risk is estimated in terms of its
probability and severity. For example, FAA and the Air Force use a risk
matrix to classify identified or potential safety problems into one of four
categories of risk extremely high, high, medium, and low. FAA and military
service officials acknowledge that some of the components used to prepare
this type of safety risk estimate are subjective but, to the extent
practical, they rely on technical experts to inform the decision- making
process.
An assessment of safety risk may lead decision- makers to conclude that no
action is warranted or that the implementation of measures to mitigate a
problem will achieve an acceptable level of safety risk. For example,
according to Air Force safety officials, if a major command concludes that a
risk to life, health, property or environment posed by the operation of an
aircraft system or subsystem falls within acceptable limits without
mitigation or upon completion of mitigation efforts a formal decision will
likely be made to accept the residual risk.
Assessments of risks associated with aircraft safety can vary among FAA and
the military services, even when they share a similar safety hazard.
According to FAA and military officials, this variability can be attributed,
in part, to differences in missions, operating environments, and aircraft
operational practices.
30 Department of Defense Instruction, DOD Safety and Occupational Health
Program, Number 6055. 1, August 19, 1998 and Department of Defense
Instruction, Accident Investigation, Reporting, and Record Keeping, Number
6055. 7, October 3, 2000.
31 FAA Order 8040. 4 requires that safety risk management be used for all
high consequence decisions ( $ 100 million per year) and requires a formal,
documented plan/ process for each staff office and line of business.
Page 31 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
( 3) Determining a corrective course of action to be taken . According to
FAA and military officials, when determining the appropriate course of
action to address a potential or identified aviation safety hazard, their
organizations consult with technical experts, including engineers,
manufacturers representatives, , pilots, and maintenance personnel. These
experts identify a range of potential remedies, weigh the costs and benefits
of each remedy, and select the most appropriate course of action to minimize
danger to air crews and damage to aircraft by eliminating a safety risk or
achieving an acceptable level of residual risk. For example, following the
crash of Alaska Air Flight 261 on January 31, 2000, FAA determined that an
emergency AD was warranted to inspect several McDonnell Douglas aircraft for
excessive wear of their jackscrew assemblies on the horizontal stabilizer.
Such wear could severely limit the ability of aircrews to control an
airplane and posed an unacceptable level of risk to flight safety.
The military services follow a similar process. For example, according to a
senior Army safety official, once Army engineers from the Aviation and
Missile Command ( AMCOM) have determined an appropriate course of action for
a given aviation safety hazard, they prepare a narrative describing to field
personnel the precise remedy that they are ordered to implement. This
narrative also indicates whether the action is an interim or final approach
for reducing the hazard. AMCOM engineers may require the replacement of a
defective part immediately; the operation of aircraft at or below a
prescribed speed; more frequent inspections of aircraft; or that the
aircraft be grounded immediately. The Army took the last action in June
2001, when investigators in Israel discovered damage to an Apache helicopter
s tail rotor after a low number of flight hours. In response, AMCOM
engineers decided that the potential risk to flight safety warranted
grounding the majority of the Army s fleet of Apache helicopters to allow
tail rotors that had been in service for greater than 1000 hours to be x-
rayed immediately.
( 4) Implementing corrective actions . According to FAA and military
officials, their organizations also have similar methods to implement
corrective actions to address a potential or identified aviation safety
problem. Corrective actions can be taken to restore the safety of approved
products to the level of safety required by airworthiness standards ( e. g.
, through the issuance of an AD by FAA) or to upgrade airworthiness
standards through the issuance of new rules that will apply to aircraft at
Page 32 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
some future date. For example, FAA issues an AD to notify primarily civil
aircraft owners and operators of an unsafe condition and to mandate a
specific corrective action. 32 The military services issue their respective
equivalents. Both identify required actions and time frames for implementing
those actions.
Depending on the perceived level of safety risk to flight operations, a
directive may require corrective action once a certain number of flight
hours has been reached. Physical inspections might determine if a problem
exists on a given aircraft, if a certain part must be repaired or replaced,
or if the installation of equipment is required. Alternatively, a directive
may place restrictions on certain flight maneuvers, while continuing to
permit an unlimited number of flight operations. Finally, a directive may
not be deemed necessary and an advisory message issued instead. Such
advisories are designed to alert flight crews and maintenance personnel to
potential equipment defects or limitations.
When FAA determines that action is warranted, it may develop a regulation
through the federal rulemaking process. As we recently reported, 33 in doing
so, it must balance the potential consequences for the aviation community
and the nation with the consequences of inaction on public safety. On the
one hand, the process of developing regulations, or rulemaking, is complex
and time- consuming. Because rules can have a significant impact on
individuals, industries, the economy, and the environment, proposed rules
must be carefully considered before being finalized. On the other hand,
threats to public safety and the rapid pace of technological development in
the aviation industry demand timely action. A need for rulemaking can be
identified internally, by one of FAA s offices, or externally, by an outside
source such as Congress through a statutory mandate or the National
Transportation Safety Board ( NTSB) through a recommended rulemaking. When
the Congress mandates a rulemaking, FAA is required to initiate the process.
When NTSB issues a recommendation, FAA studies the situation and decides
whether to initiate the rulemaking process.
32 The FAA Aircraft Certification Service also issues Special Airworthiness
Information Bulletins to communicate information to enhance safety, but not
to mandate that a specific action be taken.
33 Aviation Rulemaking: Further Reform Is Needed to Address Long- standing
Problems
( GAO- 01- 821, July 9, 2001) .
Page 33 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
Both FAA and the military services maintain emergency procedures to compel
immediate action. If FAA determines, for example, that a serious threat of
an unsafe condition exists, the agency may decide to issue an emergency AD.
This process allows FAA to issue an emergency directive first and submit it
for stakeholders comments and potential revision at a later date. Issuance
of an emergency AD can require that aircraft operators comply before making
their next flight.
Each branch of the military maintains a similar emergency process. For
example, the Army may issue an Emergency Safety of Flight Message that
immediately grounds all affected aircraft. The Air Force and Coast Guard,
likewise, signal an emergency situation by publishing a Time Compliance
Technical Order. The Navy issues a message called a Bulletin Technical
Directive ( Immediate Compliance) .
( 5) Monitoring to ensure that corrective actions have been taken . Both FAA
and the military services monitor compliance with required corrective
actions largely through inspections and audits. For example, federal law
establishes that the airlines are responsible for providing service with the
highest possible degree of safety in the public interest and FAA is
responsible for, among other things, overseeing airlines compliance with the
statute and regulations. This includes, for example, examining airlines
operations when they seek a certificate to operate and for conducting
periodic inspections to oversee airlines continued compliance with safety
regulations. FAA also tracks various reports from flight crews to monitor
airline compliance with FAA requirements.
Similarly, the military services also rely upon inspections and audits to
ensure that corrective actions have been implemented. Compliance measures
include recording in aircraft logbooks or other official documents that
corrective actions have been taken and, in some cases, reporting compliance
directly to the responsible oversight organization by unique aircraft
identification numbers.
Page 34 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
The Military Services Adhere to FAA s Regulations to Establish and Maintain
the Airworthiness of Some Military Aircraft That Are Civil Variants
The military services use FAA s civil aircraft certification services to
establish the airworthiness of some similar aircraft types ( e. g. , the
civil variant of the Air Force s T- 43 is the Boeing 737 commercial
aircraft) and can retain this certification by maintaining the aircraft in
accordance with the civil federal aviation regulations. FAA has
responsibility for certifying that civil aircraft meet federal airworthiness
requirements. To document that aircraft comply with these requirements, the
agency issues type ( aircraft design) , production, and airworthiness
certificates for aircraft produced by civil aircraft manufacturers in the
United States. In some cases, FAA may issue aircraft type, production, and
airworthiness certificates for a military variant of a civil aircraft as
well as supplemental type certificates when modifications to an aircraft are
made, but still meet civil airworthiness standards. 34 See figure 1.
Discussions among senior FAA and DOD officials are under way to determine
FAA s future role in certifying that military aircraft that are variants of
civil aircraft comply with FAA s minimum safety requirements. Some
consideration is being given to the military reimbursing FAA for its
certification services.
34 The Coast Guard does not certify the airworthiness of aircraft in a
similar manner to FAA. While FAA certification is sometimes a requirement
for the aircraft it purchases, subsequent changes to aircraft do not receive
such certification.
Page 35 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
Figure 1: Examples of FAA Involvement in Certifying Air Force Aircraft as
Airworthy
Source: U. S. Air Force.
Different Methods Are Used to Certify the Airworthiness of Military Aircraft
That Do Not Meet Civil Standards
Different certification methods are used when military aircraft derived from
civil variants are modified for mission- readiness purposes to the extent
that they no longer meet civil standards for airworthiness and when an
aircraft is operated exclusively by the military ( e. g. , fighter aircraft)
. 35 In such cases, DOD engineers must use their own standards to certify
that an aircraft meets requirements for the minimum level of safety. For
example, if the military modifies a C- 130 ( a variant of the civil L- 100)
to convert it
35 There is no requirement that the military services maintain their civil
derivative aircraft in accordance with FAA standards. However, doing so
allows an aircraft to be sold for use in civil aviation at a later date.
Page 36 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
from a passenger- carrying aircraft to one used for air- to- air aircraft
refueling, the modifications would not meet civil airworthiness standards.
Consequently, DOD engineers would assume responsibility for certifying the
airworthiness of this aircraft and it would no longer maintain its safety
certification for civil use. In contrast to FAA s aircraft certification
procedures, the military services serve as both the approving officials and
the ultimate users of military aircraft. In addition, the approval process
must consider not only the safety and airworthiness of an aircraft, but also
its suitability and effectiveness to meet mission readiness requirements.
Furthermore, the military services do not issue certificates documenting
that military aircraft meet military standards for aircraft type ( design) ,
aircraft production, and airworthiness.
Civil and Military Accident Investigation Processes Differ
A second key difference is the accident investigation process: the military
services conduct their own accident investigations while civil aviation
accident investigations are conducted primarily by an independent agency,
NTSB. 36 Following an aircraft accident, the military conducts a safety
investigation to determine the cause of an accident, , followed by a
separate legal accident investigation to obtain and preserve evidence for
the chain of command and for use in litigation, claims, disciplinary action
or adverse administrative actions against flight crews. 37 In contrast, the
NTSB, which has the authority to conduct all civil accident investigations,
performs a single investigation following an aircraft accident. FAA conducts
the on- site investigations in most ( 80 percent) of general aviation
accidents and submits a factual report to NTSB. During accident
investigations, FAA looks into the potential roles of the air traffic
control system, navigational aids, pilots flight and medical qualifications,
, as well as the adequacy of the agency s rules and whether or not those
rules were followed.
The reports of military safety investigations contain two types of
information nonprivileged and privileged. Nonprivileged data, such as
36 Under 49 USC 1131 ( a) ( 2) ( B) , the NTSB will surrender lead
investigation status on a transportation accident when the attorney general,
in consultation with the chairman of the Safety Board, notifies the board
that circumstances reasonably indicate that the accident may have been
caused by an intentional criminal act. At this point, the Federal Bureau of
Investigation takes over the investigation, and the NTSB only provides
requested support.
37 Following aircraft accidents, the military services safety investigations
are conducted strictly for mishap prevention purposes, while legal
investigations ( also known as collateral investigations) cover all other
issues related to an accident.
Page 37 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
engineering analyses, may be released to the public. Privileged data, 38
such as confidential witness statements 39 made by flight crew members,
reluctant witnesses, and some contractors, are not made accessible to the
public or used in litigation, claims, disciplinary actions or other adverse
administrative actions. 40 The intent of this discretion is to quickly
identify root causes by encouraging candor among flight crews and witnesses
to prevent similar accidents in the future and to help ensure military
readiness. In contrast, during the civil version of the safety investigation
by the NTSB, the only protection against potential criminal action available
to civil commercial pilots is refusing to be interviewed or testify.
Pace of Decisionmaking and Thresholds for Safety Actions Differ for Military
and Civil Aviation
The pace with which FAA and the military services make decisions about
potential and identified aviation safety concerns differs, as do the
thresholds used to determine that action is warranted. For example, the
command and control structure of the military services allows immediate
action, such as the grounding of a fleet of aircraft, after considering the
impact on their respective missions, but without consulting outside entities
or considering economic impact. In contrast, while FAA can and has taken
similar immediate action, the agency must also weigh the potential
ramifications for the nation s economy. Arriving at such a decision may
involve consultation with manufacturers, operators, and other aviation
stakeholders. Such consultation and coordination can take place at a very
rapid pace when dictated by an unsafe condition.
FAA and DOD operate under different formal requirements for issuing aviation
safety regulations. For example, when DOD issues an order to address an
aviation safety hazard, the military services are required to issue
instructions implementing the order, which are effective upon signature by
the approving official. In contrast, FAA, as a regulator of civil aircraft,
must often follow a complex rulemaking process ( except in emergency
situations) . This includes providing a full and open notice and
38 While there is no equivalent privilege protection for civil aviation,
there are some provisions for protecting the disclosure of data, such as
closing some parts of the court docket and disallowing the release of
cockpit voice recordings.
39 Witness statements taken during safety investigations are deemed
privileged only if a promise of confidentiality is made. 40 Privileged
material also includes deliberative and pre- decisional information that is
safeguarded to ensure a candid exchange among parties in the safety
investigation report prior to final approval.
Page 38 GAO- 02- 77 Aviation Safety
Appendix III: Key Similarities and Differences in FAA s and the Military
Services Aviation Safety Oversight Processes
comment period for stakeholders to help ensure that all aspects of any
regulatory change are fully analyzed before the change goes into effect. As
we recently reported, from fiscal year 1995 through fiscal year 2000, FAA
took about 2- 1/ 2 years on average to proceed from formal initiation of the
rulemaking process through publication of the final rule a process it
completed for 29 significant rules. However, for 6 of these rules it took 10
years or more to complete this process. 41 Furthermore, the thresholds used
by FAA and the military services to determine when and if a potential or
identified aviation safety problem should be addressed also vary due
primarily to mission differences. FAA s primary mission is safety, while the
military services must weigh multiple mission- readiness requirements
against taking action to maximize aviation safety.
41 Aviation Rulemaking: Further Reform Is Needed to Address Long- standing
Problems
( GAO- 01- 821, July 9, 2001) .
Page 39 GAO- 02- 77 Aviation Safety
Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
In the mid- 1980s, the Navy began experiencing problems with aromatic
polyimide, a general purpose wire insulator ( commonly known as Kapton 42 )
, that it did not fully understand. In response, the Navy enlisted the
assistance of experts from other military services and the Federal Aviation
Administration ( FAA) to better characterize the problems and develop
possible solutions. Ultimately, FAA and each of the military services
responded differently to the problems of aromatic polyimide.
Aromatic polyimide is the most commonly used wire insulation on many older
Boeing and McDonnell Douglas airplanes that were built beginning in the late
1960s. 43 It is lightweight, resistant to abrasion and cuts, is able to
withstand high temperatures, and is flame and environmentally resistant.
However, two weaknesses have also been documented. First, water alters the
chemical composition of this insulation and diminishes its integrity. A
second weakness occurs when two cracks in the insulation occur close
together, enabling the current to arc between the cracks ( arcing events) at
high temperatures. 44 Exposure to this heat causes the insulation to
carbonize and actually become a conductor rather than an insulator.
United States The Navy started using aromatic polyimide in the mid- 1970s,
began noticing cracks and breaks in the top coats of this insulation in 1980
and 1981, and undertook research to identify potential problems with its
use. In 1984, researchers at the Naval Research Laboratory reported that
moisture caused aromatic polyimide to break down when it was exposed to high
humidity, moisture, or water for long periods of time. It also found that
carbon deposits can form and build up between two cracks in this insulation
after several arcing events, a process that ultimately trips a circuit
breaker. When a pilot presses a tripped circuit breaker to reset it, an
entire wire bundle can be disabled, potentially causing catastrophic
results.
42 Kapton is Dupont s trade name for a specific type of wire insulation,
known as aromatic polyimide, which is also made by another manufacturer.
Aromatic polyimide will be referred to throughout this report in place of
Kapton, its military specification ( MIL- W- 81381) or Boeing s Military
Specification ( BMS 13- 51) .
43 The wire was initially produced in 1966 and used in Lockheed L- 1011s,
Douglas MD- 80s and MD- 11s, Boeing 727s, 737s, 747s, 757s, 767s, Grumman F-
14s, McDonnell F- 15s and F/ A18s, and General Dynamics F- 16s.
44 Arc- tracking temperatures vary according to wire size and the amount of
electrical current.
Page 40 GAO- 02- 77 Aviation Safety
Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
In December 1985, the Navy decided that aromatic polyimide would no longer
be its wiring insulator of choice. Subsequently, the Navy selectively
removed this wire insulation from parts of aircraft where it was most
problematic, such as fore and aft flaps, wheel wells, and around unsecured
seals that could leak. However, because the Navy still had a large supply of
aromatic polyimide on hand, it continued its use on aircraft in areas that
were not vulnerable to water infiltration. The Navy also took delivery of
some McDonnell Douglas aircraft in 1988 that were built with aromatic
polyimide wiring insulation that had been purchased before problems with
this wire insulation were recognized.
United States Coast In 1993, the Coast Guard also developed problems with
aromatic polyimide on its fleet of H- 65 Dolphin helicopters. These
helicopters are exposed to a significant amount of water during normal
operations, such as from swimmers undergoing rescue training and individuals
rescued. In addition, many of these helicopters often spend as long as 6
months patrolling at sea where they are constantly exposed to salt spray and
salt water.
Between 1993 and 1996, some serious events of in- flight fires resulting in
cockpit smoke and fumes occurred in the Coast Guard s H- 65 helicopters.
Some of these mishaps led to loss of all electrically powered flight
instruments. One incident ( at low altitude, over water, in fog, and at
dusk) nearly resulted in the loss of helicopter and crew. While no
helicopters were destroyed as a result of cockpit fires, the Coast Guard
decided to take precautionary measures to reduce the likelihood of future
fires in these helicopters by systematically removing aromatic polyimide. In
1994, they began replacing this type of wire insulation during the H- 65 s
regularly scheduled forty- eight month maintenance cycle and according to a
senior Coast Guard safety official, completed this removal in September
2001.
United States Air According to an Air Force wiring expert, the Air Force
also experienced failures associated with aromatic polyimide and took steps
to mitigate them. It was also aware of the concerns raised by the Navy and
sponsored a research program that led to the development of a composite
wiring construction ( Teflon- Kapton- Teflon) that mitigated many of the
problems exhibited by aromatic polyimide. In October 1988, the Air Force
chief of staff issued a policy statement on aromatic polyimide that no
perfect wire exists and such requirements as operational performance,
maintenance, logistics needs, resistance to combat damage, and safety and
Page 41 GAO- 02- 77 Aviation Safety
Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
environmental aspects must be considered when choosing a wire. Aromatic
polyimide would no longer be considered the wire of first choice for new
systems, modifications, or rewiring applications, and not be used in severe
wind and moisture- prone ( SWAMP) areas or in locations with frequent
flexing. However, wholesale removal of aromatic polyimide was not planned.
This policy remains in force.
United States In response to potential hazards identified by the Navy with
the use of aromatic polyimide, the Army conducted further testing in 1986
and confirmed the Navy s findings. In 1988, the Army concluded that it did
not have the same problems with aromatic polyimide that the Navy did and
determined that no action was necessary. The Army attributed the Navy s
problems with this insulation to its operating environment, in particular
the long- term exposure of its aircraft to salt water.
The Army s Aviation Missile Command ( AMCOM) officials decided that the use
of aromatic polyimide in Army helicopters was not a primary safety issue.
While the Army had experienced some wiring- related problems, there was no
evidence linking them to aromatic polyimide. The Army did have durability
concerns; however, it found the degree to which aromatic polyimide chafes in
Apache and Blackhawk helicopters is unacceptable over the long- term. The
Army did not order the immediate removal of this wire insulation, but has
decided to strip it from aircraft when they are refurbished. As of June
2001, aromatic polyimide had been removed from 1, 389 of the 1, 523
Blackhawk helicopters in the Army s fleet. According to an AMCOM official,
current funding is sufficient to remove this wire insulation from only 4 of
the 134 remaining Blackhawks.
AMCOM also conducted a system safety risk assessment on aromatic polyimide
for its Blackhawk helicopters, issued in July 2001. The assessment concluded
the most appropriate action is to replace Kapton ( aromatic polyimide)
wiring with non- Kapton wiring during scheduled upgrades or any time the
aircraft is sent into a depot to be rebuilt, overhauled, or refurbished.
This approach would allow all aircraft that are currently wired with Kapton
to be upgraded to non- Kapton wiring by 2008.
Federal Aviation FAA wiring experts reported that they were aware of only
one incident on a commercial aircraft linked to aromatic polyimide wire
insulation. In 1985, a Boeing 757, operated by Monarch Airlines in the
United Kingdom, experienced an arc- tracking event in aromatic polyimide
wire insulation after circuits were tripped, and smoke appeared in flight.
Investigators
Page 42 GAO- 02- 77 Aviation Safety
Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
suspect that the wire bundle was damaged when it was marked with a hot
stamping tool and subsequently came into contact with fluid leaking from a
lavatory.
FAA has not mandated the removal of aromatic polyimide from commercial
aircraft. The agency, however, has issued three advisory circulars ( AC) on
wiring practices: ( 1) in March 1987, FAA issued AC 25- 10 to provide
guidance on the installation of miscellaneous, nonrequired electrical
equipment; ( 2) in April 1991, the agency issued AC 25- 16 on electrical
fault and fire prevention and protection, including the need to keep
aromatic polyimide away from moisture- prone areas; and ( 3) in September
1998, FAA issued AC 43.13- 1B to describe acceptable methods, techniques,
and practices for aircraft inspection and repair, including wires insulated
with aromatic polyimide.
In addition, FAA s Technical Center conducted studies on arc tracking under
wet conditions in August 1988 and found, among other things, that certain
polyimide ( including aromatic polyimide) wire insulation constructions can
be modified to resist wet- wire arc tracking by applying thin protective
coatings. It conducted an additional study on arcing events under dry
conditions in July 1989 and found that severe dry arc tracking occurred for
all aromatic polyimide samples, with extensive damage to all wires in the
bundles. This was followed by a study of electrical short circuit 45 and
current overload tests on aircraft wiring in March 1995. This study found
that circuit breakers provide reliable protection against excessive or
dangerous rises in temperature in the conductor or its insulation caused by
direct short circuits.
A senior FAA official stressed that improved safety margins can be achieved
by measures other than wire replacement: use of enhanced circuit protection,
increased separation of wires, removal of flammable materials, or protection
of wires from moisture. These methods may be more effective than wholesale
modification or re- manufacture.
The same official told us that the rules that admitted aromatic polyimide 20
years ago would prohibit it today because of the failure modes that have
been identified. Much more is known now about the limitations of this type
of wire insulation, specifically that it has the potential to arc
45 A short circuit occurs when there is an abnormal connection between two
points of a circuit that results in excess and often damaging flow of
current between these points.
Page 43 GAO- 02- 77 Aviation Safety
Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
track and can contribute to a single event or combination of events that
could be a hazard to aircraft. According to this official, given current
knowledge, it would be difficult for FAA to support the use of aromatic
polyimide insulation, in its original form, in new aircraft designs.
However, this same official noted that while new wire insulation types
introduced on the market are likely to have improved performance
characteristics, they are also likely to have shortcomings not anticipated
at their introduction into service.
Boeing Commercial In response to the Navy s problems with aromatic
polyimide, Boeing conducted laboratory experiments in 1985 and 1986 and
found that they could simulate arc tracking in Boeing commercial aircraft.
Boeing officials told us that they immediately notified Dupont Chemical
Corporation, the manufacturer of Kapton ( aromatic polyimide) . Boeing
officials also told us that the company wanted to anticipate any potential
FAA rulemaking on aromatic polyimide and began using a new wire insulator
known as BMS- 60, or Teflon- Kapton- Teflon ( TKT) , in 1993. This wire
retained aromatic polyimide s favorable mechanical qualities while embedding
the aromatic polyimide between layers of Teflon to strengthen it. Boeing
still uses aromatic polyimide for wiring to power feeders that run from a
set of engines into a power panel. These runs are long and do not require
that the wire be bent; Boeing reported that it has not found any instances
of cracks or arc tracking in these areas.
Joint Military/ FAA/ Industry Efforts
In February 1997, the White House Commission on Aviation Safety and Security
issued a report to President Clinton identifying aging wiring as a safety
issue in aviation. The Commission recommended that three federal agencies
FAA, Department of Defense, and National Aeronautics and Space
Administration expand their aging aircraft program to include the issue of
aging wire systems in commercial aircraft. These agencies have established
research initiatives and partnerships with industry to address wiring issues
in aging aircraft as a part of ongoing informal coordination and in response
to this recommendation.
In October of 1998, the director of Navy Safety and System Survivability
established a government and industry forum, known as the Aircraft Wiring
and Inert Gas Generator Working Group ( AWIGG) , to ( 1) ensure that
information on aircraft wiring and fire suppression is shared and understood
by all interested parties and ( 2) combine the resources of interested
participants to accelerate the development of aviation safety technologies.
AWIGG membership now totals more than 350 individuals,
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Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
representing military services, airlines, aircraft and wire manufacturers,
pilots and mechanics unions, researchers, FAA, National Transportation
Safety Board, NASA, and others.
In October 1998, FAA established the Aging Transport System Rulemaking
Advisory Committee ( ATSRAC) 46 to serve the public interest by providing a
forum for interaction among FAA, the military, NASA, the airlines, airline
pilots, manufacturers, and their representatives on aging aircraft. FAA
believed that the level of expertise and balanced viewpoint of this
committee would enable early identification of potential problem areas and
accelerate development of cost- effective corrective actions. Under ATSRAC
two separate working groups were created one to conduct visual (
nonintrusive) inspections and another to conduct comprehensive physical (
intrusive) inspections of aging aircraft wiring.
One ATSRAC working group conducted visual ( nonintrusive) inspections of
eighty- one in- service aircraft that were over twenty years old. The
working group was comprised of lead airline representatives from each of the
fleet types, the airframe manufacturers, and FAA. The purpose of these
inspections was to assess the condition of the U. S. transport fleet with
respect to wiring, identify areas of concern, and make recommendations, if
necessary. The results were released August 1, 2000, and found that the
majority of discrepancies with wire were in areas of frequent maintenance
activity where wiring was unprotected from debris and fluid contamination.
To complement and extend the results of the nonintrusive inspections, ATSRAC
requested a joint working group effort to conduct extensive physical (
intrusive) inspections of aging aircraft wiring systems. FAA conducted this
work in conjunction with ATA and with the support of the Navy and Air Force.
Intrusive inspections were performed on six recently decommissioned
airplanes to assess the conditions of the electrical wiring on aged
airplanes. 47 , 48 The results were released December 29, 2000. The working
group report identified two items that FAA should pursue
46 In June 1998, the Air Transport Association ( ATA) formed the Aging
Systems Task Force. The group was later cosponsored and rechartered by the
Aging Transport Systems Rulemaking Advisory Committee.
47 The six airplane models used were two DC- 9s, one DC- 10, one 747, one L-
1011, and one A300. 48 This second major inspection effort was entitled the
Intrusive Inspection Working Group.
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Appendix IV: Case Study on Aromatic Polyimide Wire Insulation
aggressively to develop options to eliminate or mitigate electrical hazards:
arc- fault circuit breakers and nondestructive test equipment for aircraft
wiring. An arc- fault circuit breaker is being developed by a number of
government and industry organizations, including the Navy and FAA. This type
of circuit breaker can detect and react to an electrical arc much faster
than those currently used in aircraft today. When an arc is detected, this
type of circuit breaker can disable the circuit and provide a warning that a
fault exists. The report did not recommend systematic removal of aromatic
polyimide from aging aircraft.
The report also included a dissenting opinion from one of the working group
members. Among other things, this member contended that ( 1) the data
collection and analysis was seriously flawed, that the group inappropriately
reinterpreted data and that they had little or no opportunity to review and
validate the original data; ( 2) there was a lack of rigor in the process as
demonstrated by informal, changing, or imprecise definition of terms; ( 3)
the testing protocols were not executed rigorously; and ( 4) certain
findings were not classified appropriately. The working group disagreed with
these and other criticisms raised by this member, responded formally to them
in the report, and invited other interested parties to read both the report
and the dissenting opinion to ascertain the merits of each.
Page 46 GAO- 02- 77 Aviation Safety
Appendix V: Case Study on Adoption of Cockpit Safety Equipment
Beginning in the early 1970s, a number of studies looked into the occurrence
of accidents where a properly functioning aircraft under the control of a
fully qualified and certified crew flew into terrain with no awareness by
the crew. According to the Flight Safety Foundation, this type of accident
represents the single largest safety risk to aircraft. In the mid- 1980s,
the high number of aircraft accidents caused by midair collisions also
became a central concern for aviation safety. To address these safety
issues, the Federal Aviation Administration ( FAA) required the installation
of Ground Proximity Warning Systems ( GPWS) on most passenger- carrying
aircraft to alert pilots to potential collisions with terrain and Traffic
Alert and Collision Avoidance Systems ( TCAS) to warn pilots of potential
airborne collisions with other aircraft and provide them with information to
take evasive action. 49 The military services have moved more slowly to
install similar safety equipment in their passenger- and troop- carrying
aircraft due to resource tradeoffs between aviation safety and other
mission- readiness issues.
FAA Has Required GPWS Aboard Passenger- Carrying Aircraft Since the 1970s
In 1974, as a result of studies and recommendations from the National
Transportation Safety Board, FAA required all operators of large turbine-
powered airplanes and some operators of large turbojet airplanes to install
approved GPWS equipment. In 1978, the FAA extended the GPWS requirement to
operators of smaller airplanes and turbojet- powered airplanes with ten or
more passenger seats. In 1992, in response to studies by the NTSB, FAA
required GPWS equipment on all turbine- powered airplanes with 10 or more
passenger seats.
Advances in terrain mapping technology led to the development of a new type
of ground proximity warning system that provides greater awareness for
flight crews. FAA ultimately approved the advanced equipment known as the
enhanced ground proximity warning system ( EGPWS) . 50 EGPWS equipment
standards have been improved to provide flight crews with earlier auditory
and visual warnings of terrain, forward- looking capability,
49 Specifically, TCAS I provides pilots with nonverbal alerts of potential
collisions, while the more advanced version, TCAS II, provides pilots with
verbal advice to execute an evasive maneuver ( e. g. , climb, descend, or do
nothing ) to avoid other aircraft.
50 Because FAA expected that a variety of EGPWS technologies could be
developed that would meet the improved standards, it is currently using the
broader term terrain awareness and warning system ( TAWS) .
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Appendix V: Case Study on Adoption of Cockpit Safety Equipment
and additional time to take corrective actions in a more smooth and gradual
manner.
In 1996, a FAA study concluded that existing GPWS would have prevented 75
percent of 44 accidents that occurred on smaller capacity aircraft between
1985 and 1994, while EGPWS would have prevented 95 percent of those
accidents. A second study, focusing on the merits of retrofitting large-
capacity scheduled and unscheduled airline fleets with EGPWS, showed that
four of nine accidents, or 44 percent, should have been prevented by the
basic GPWS if it had been functioning or utilized properly. The study
concluded that the EGPWS technology would have prevented all nine of those
accidents.
In 1998, FAA issued a draft rule proposing that all turbine- powered U. S.
airplanes registered with FAA that have six or more passenger seats be
equipped with a FAA approved EGPWS. On March 29, 2000, the agency issued the
final rule mandating the installation of EGPWS equipment on all such
aircraft. 51 The new regulation applies immediately to those aircraft built
after March 29, 2002. Aircraft manufactured on or before March 29, 2002,
will be required to comply by March 29, 2005.
FAA Has Required TCAS Installation Since the Late 1980s
For the past 13 years, FAA has taken active steps to require installation of
TCAS on commercial passenger aircraft. Following a 1986 midair collision
between two commercial aircraft in California, Congress passed a law in 1987
requiring FAA to mandate the use of TCAS. In January 1989, the agency
published a rule requiring installation and use of TCAS II ( enhanced
version) in commercial passenger- carrying aircraft and TCAS I in commuter
aircraft with 10 to 30 passenger seats. By 1993, all air carrier aircraft
with more than 30 passenger seats were equipped with TCAS II.
Furthermore, FAA has recently proposed a new regulation to require certain
cargo airlines to install TCAS to minimize the possibility of midair
collisions. The proposed regulation would require affected aircraft to be
equipped with TCAS II or another FAA- approved traffic alert and collision
avoidance system no later than October 31, 2003.
51 This applies to 14 C. F. R. 91 ( general aviation) , 14 C. F. R 121 (
commercial airlines) , and 14 C. F. R. 135 ( aircraft with six or more
passenger seats) .
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The Military Services Have Recently Begun Installation of GPWS and TCAS
The military services were aware of FAA s requirements for installing GPWS
and TCAS on civil aircraft and have requested technical information from the
agency on these technologies. While the military has lagged behind FAA in
issuing similar mandates for its passenger- and troopcarrying aircraft, the
Department of Defense ( DOD) recently required each branch of the military
to devise a plan for installing TCAS on its fleet of passenger- and troop-
carrying aircraft. Soon after then- Secretary of Commerce Ronald Brown and
34 others were killed in April 1996 in an Air Force passenger- carrying
aircraft that was equipped with GPWS, but not the enhanced version, the
secretary of defense mandated a program to improve navigation and safety
capabilities for passenger- and troopcarrying aircraft.
In August 1996, the Air Force published its Navigation and Safety Equipment
Master Plan for DOD Passenger- Carrying Aircraft, which established guidance
for equipping passenger- and troop- carrying aircraft, including GPWS and
TCAS. The plan calls for two phases of implementation. Phase 1 requires
installation by 2001 on all equipment used to transport senior military
leaders, and Phase 2 requires installation by 2005 of all equipment
components, including GPWS and TCAS, on remaining passenger- and troop-
carrying aircraft.
In 1997, the DOD Defense Science Board Task Force on Aviation Safety found
GPWS and TCAS to be effective in significantly reducing the risks of a major
accident ( e. g. , fatal accidents or total loss of aircraft) . The task
force membership included a cross section of representation from the
aviation community the airlines, universities, military services, and FAA
consultants. According to the board, GPWS and TCAS provide both safety and
flight efficiency benefits and significant opportunities exist to leverage
NASA, FAA, and commercial airline research and development initiatives
pertaining to aviation safety.
In April 1998, the Office of the Secretary of Defense issued a memorandum to
the secretaries of the Army, Navy, and Air Force to accelerate their
installation of TCAS. The military services are now moving forward to
implement this memorandum s requirements on the following schedules.
Army : No Army- specific policy directing field units to install GPWS or
TCAS in aircraft exists. Rather, the Army relies on the April 1998 DOD
memorandum as its prevailing guidance for TCAS. According to officials from
the Department of the Army, as of August 2001, units had equipped 38 of the
Army s 294 fixed wing aircraft with EGPWS and 90 of these same aircraft with
TCAS. The remaining fixed wing aircraft must be equipped
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Appendix V: Case Study on Adoption of Cockpit Safety Equipment
with these technologies by fiscal year 2006. The Army has not equipped any
of its rotary wing aircraft ( i. e. , helicopters) with GPWS or TCAS and
currently has no plans to do so. According to an Army safety official, the
Army s helicopters are typically operated at very low altitudes and pilots
are generally able to make effective visual contact with any hilly or
mountainous terrain and take action to avoid contact with the terrain
without the assistance of GPWS. As such, the Army would rather dedicate its
limited resources to improving its visual guidance systems for these
aircraft. Furthermore, according to Army officials, Army helicopters are
equipped with radar altimeter in lieu of GPWS, with the exception of some
legacy aircraft that are being phased out of the fleet.
Navy : In December 1996, the Navy Air Board agreed that installing safety
technology ( e. g. , TCAS) into new and existing aircraft would improve
safety. In June 1998, the Navy implemented a new policy requiring
installation of TCAS and other safety equipment in newly produced and re-
manufactured aircraft. . 52 In addition, it required passenger- and
troopcarrying aircraft to be equipped or retrofitted with additional
commercial safety systems that are already standard equipment in comparable
civilian aircraft.
Air Force : In 1996, the Air Force began installing TCAS in its
passengercarrying aircraft and is moving forward to implement the DOD
guidance cited above.
Coast Guard : In 1998, the Coast Guard completed installation of TCAS in its
entire inventory of fixed wing and rotary- wing aircraft. In addition, they
have equipped their fleet of C- 130 aircraft with GPWS. However, the
majority of the Coast Guard fleet is comprised of helicopters for which GPWS
technology is relatively new. According to a senior Coast Guard safety
official, due to the dynamic nature of rotorcraft flight as compared to
fixed wing aircraft flight, 53 making use of GPWS on helicopters is much
more difficult and has led technology development to lag behind that for
fixed wing aircraft. This official also said that the Coast Guard spends the
majority of its time flying over water and uses radar altimeter equipment
52 Some aircraft are re- manufactured rather than being replaced. This
involves refurbishing aircraft to varying degrees to install updated parts
and materials. 53 Helicopters can stop, pedal turn, and hover, while fixed
wing aircraft are often operated in a fairly narrow band of forward motion,
which makes their near- term flight path more predictable.
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to monitor the clearance under the aircraft along with a horn set by the
pilot to alert flight crews when a helicopter descends below an established
minimum altitude. In addition, this official noted that FAA has not mandated
the use of GPWS or its enhanced version in civil helicopters, but that a
certified enhanced GPWS became available last year and the Coast Guard is
monitoring the results of its use.
Page 51 GAO- 02- 77 Aviation Safety
Appendix VI: Case Study on Flight Operational Quality Assurance ( FOQA)
Programs
Flight Operational Quality Assurance ( FOQA) programs allow routine flight
data to be collected and analyzed to detect and resolve potential safety,
training, and maintenance issues. The experience of domestic and foreign
airlines with these programs attests to their potential to enhance aviation
safety. Given the potential of FOQA programs to improve both civil and
military aviation safety, this case study was selected to determine the
current status and pace of efforts by the Federal Aviation Administration (
FAA) , the aviation industry, and the military services to put them in
place.
History of In its 1992 study for FAA, the Flight Safety Foundation coined
the term Flight Operational Quality Assurance Program and defined it as a
program for obtaining and analyzing data recorded in flight to improve
flight crew performance, air carrier training programs and operating
procedures, air traffic control procedures, airport maintenance and design,
and aircraft operations and design. 54 The objective of a FOQA program is to
use flight data to detect technical flaws, unsafe practices, or conditions
outside of desired operating procedures early enough to allow timely
intervention to avert accidents or incidents. For example, FOQA data can be
used to improve aviation safety by identifying hazardous approaches into a
particular airport and helping to justify to FAA the need for a new approach
pattern that is less likely to lead to an accident under adverse conditions,
or to improve pilot training. These data can also yield operational
efficiencies, such as identifying and mitigating flight practices that place
unnecessary strain on aircraft engines and other parts.
Modern commercial aircraft contain sophisticated electronic systems that
gather, process, and manage digital data on many aspects of flight. These
data originate from various systems and sensors throughout the aircraft.
Some of these data are continuously recorded by the aircraft s digital
flight data recorder to help investigators understand what happened if the
aircraft is involved in an accident or a serious incident. 55 Designed to
54 Air Carrier Voluntary Flight Operational Quality Assurance Program ,
Flight Safety Foundation ( 1992) . 55 The National Transportation Safety
Board ( NTSB) , the official source of information on airline accidents,
defines accidents as events in which individuals are killed or suffer
serious injury, or the aircraft is substantially damaged. Incidents are
defined as occurrences other than accidents associated with the operation of
an aircraft that affect or could affect the safety of operations ( 49 C. F.
R. 830.2) . In the military, Class A Mishaps are accidents and Class B and C
Mishaps are serious incidents.
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Programs
survive crashes, flight data recorders generally retain the data recorded
during the last 25 hours of flight. Airlines with FOQA programs typically
use a device called a quick access recorder to capture flight data onto a
removable optical disk that facilitates the data s frequent removal from the
56 aircraft. British Airways has had a FOQA- type program in place since the
late 1960s. This program has served as the model for similar programs in the
United States and around the world. In July 1995, as part of FAA s strategy
to achieve significant reductions in aviation accident rates despite the
rapid increase in air travel anticipated over the next decade the agency
initiated a three- year, $ 5.5 million FOQA Demonstration Project to promote
the voluntary implementation of FOQA programs by U. S. airlines. The project
was designed to facilitate the start- up of voluntary airline FOQA programs
and to assess the costs, benefits, and safety enhancements associated with
such programs. FAA provided hardware and software to United, US Airways, and
Continental and each has implemented FOQA programs according to the
demonstration project requirements. Since that time, others including Delta
Airlines and American Airlines, have also initiated FOQA programs. The rules
under the project required airlines to provide FAA with access to aggregate
FOQA data on the airlines premises and did not require them to submit these
data to FAA. See table 2 for a timeline of key events pertaining to the
implementation of FOQA programs.
Table 2: Flight Operational Quality Assurance Programs Timeline Date Agency,
industry, or military branch Action
Late 1960s British Airways Inaugurates first airline FOQA program. 1992
Flight Safety Foundation Publishes study recognizing that acceptance of
FOQA programs by the aviation industry hinges on adequate protection of data
collected. March 1993 FAA Begins rulemaking effort. However, progress
quickly stalled by airline concerns about FAA s intended use of FOQA data.
56 These data typically include the parameters required to be collected on
the aircraft s flight data recorder plus many more parameters.
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Programs
Date Agency, industry, or military branch Action
July 1995 Begins a FOQA demonstration project Demoproj and issues statement
indicating commitment to using FOQA data for safety analysis purposes only.
1997 Department of Justice ( DOJ) Cautioned FAA that a federal regulator may
not be
able to exempt regulated parties from enforcement actions, even if
information is submitted voluntarily. 1997 2000 FAA and DOJ Work together to
develop a proposed FOQA rule
that would be acceptable to all stakeholders ( e. g. , industry, FAA, and
DOJ) . November 1997 Defense Science Publishes report finding that
inconsistencies exist
between civil aviation s commitment to use FOQA programs for safety purposes
and the military services own such commitment. Issues two related
recommendations to military. 1998 Publishes a policy statement indicating an
intent to
use FOQA data for enforcement purposes, but only when rule violations are
egregious ( ( i. e. , criminal or negligent) . October Joint service safety
chiefs ( heads of the military services Agree informally that FOQA has value
and endorse
safety centers) projects and research by all military services. July 2000
FAA Formally publishes a Notice of Proposed
Rulemaking on voluntary implementation of FOQA programs by U. S. airlines.
August 2000 Joint service safety chiefs Formally endorse military FOQA
programs
MFOQA and recommend full funding for their implementation. July 2001 FAA
Rule issued protecting voluntarily submitted
aviation safety and security data are protected from release ( e. g. , under
Freedom of Information Act) . October 2001 FAA and DOT Publication of final
FOQA rule.
Source: FAA, airlines, and the military services.
FAA Continues to FAA efforts to encourage the implementation of FOQA
programs have been under way for nearly a decade. In addition to the FOQA
Encourage FOQA demonstration project mentioned earlier, FAA has issued
separate rules
Programs Among on FOQA and issued a rule to protect those submitting
voluntary aviation safety information. Airlines
FAA Has Taken Steps to Key aviation industry stakeholders, including airline
executives, pilots and Alleviate Aviation Industry other crewmembers, are
enthusiastic about FOQA s continuing potential Concerns About Data Use for
saving lives, but they are nevertheless concerned about the possible
consequences of a FAA rule about FOQA. These stakeholders considered the
draft rule to be overly intrusive because of the agency s insistence that
these data be removed from airlines property and concerns about how
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Appendix VI: Case Study on Flight Operational Quality Assurance ( FOQA)
Programs
these data will be used ( e. g. , to take enforcement actions against pilots
or airlines) . However, as requested by industry, the final rule limits the
use of FOQA data by FAA to enforcement actions for criminal and deliberate
acts.
The 1992 Flight Safety Foundation study recognized that the acceptance of
FOQA programs by the aviation industry hinges on adequate protection of the
data collected. In particular, the study noted that airlines were concerned
about increased accident liability and possible punitive actions by FAA, for
rule infractions that could be revealed by FOQA. Airlines are also concerned
about the release of these data to the media and the potential for unfair
criticism of their commitment to safety if data are not interpreted in the
proper context. Pilots concerns focused on possible punitive actions by
airline management and FAA. We have also reported that resolution of data
protection issues was the primary impediment to the implementation of FOQA
programs among the major domestic carriers. 57
FAA began its FOQA rulemaking effort in January 1993. However, progress on
this rulemaking stalled due to unresolved concerns among the airline
industry about whether or not FAA would use the data submitted voluntarily
by the airlines under FOQA to take enforcement action. Before initiating the
FOQA Demonstration Project in 1995, FAA issued a statement that it was
committed to not using FOQA data for enforcement purposes. FAA reiterated
this position in 1998.
According to FAA officials, when the agency reestablished the FOQA
rulemaking effort in 1997, it encountered some resistance from DOJ.
Specifically, DOJ raised concerns that a government regulatory agency such
as FAA may not be able to exempt those who are regulated from enforcement
actions based on information received from them, voluntary or not. Between
December 1997 and June 2000, rulemaking officials, in conjunction with the
DOJ, worked to develop a rule that was acceptable to the industry and the
administrator. However, in response to continued industry concerns about the
use of FOQA data for enforcement, the FAA administrator published in 1998 a
policy statement that the agency would only use FOQA data for enforcement
purposes in egregious cases ( e. g. , if the violation were deliberate,
involved a criminal offense, or the violator
57 Aviation Safety: Efforts to Implement Flight Operational Quality
Assurance Programs
( RCED- 98- 10, Dec. 2, 1997) .
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Programs
had committed a similar violation within the previous five years) . The
statement further asserted that, in order to qualify for protection from
punitive action based on analysis of FOQA data, an airline must submit to
FAA for approval a FOQA implementation and operation plan describing its
procedures for taking remedial action on any identified deficiencies that
become apparent as the result of FOQA data analysis.
FAA Has Finalized FOQA Rule
In October 2001, FAA published a final rule on FOQA encouraging voluntary
implementation of FOQA programs by airlines. The final rule provided that
information obtained from airlines voluntary FOQA programs could be used in
enforcement actions against air carriers, commercial operators, or airmen (
e. g. , pilots) , only for criminal or deliberate acts. The final rule
requires air carriers participating in FOQA programs to submit aggregate
data to FAA for use in monitoring safety trends. FAA could also use these
aggregated data as a basis for initiating safety rulemakings. 58
However, there are outstanding concerns within the aviation industry about
the rule s possible ramifications. For example, the final rule says that FAA
will maintain the discretion to take enforcement action and that this action
will not be affected by the final rule. Concerns also persist about the
removal of FOQA data from airlines premises because this makes the airlines
vulnerable to other federal agencies reviews of the data. FAA s definition
of aggregate data is also unclear; ; if it refers to a single airline s
aggregate data, this is not acceptable to the airline industry, while
aggregate data reported industrywide would be acceptable.
FAA Issues Rule Intended to Protect Safety Data That Are Voluntarily
Submitted From Release to the Public
In June 2001, FAA issued a rule 59 that protects voluntarily submitted
aviation safety and security data from release, for example, under the
Freedom of Information Act. With this type of protection in place, the
agency is confident that it will be able to obtain more voluntarily
submitted safety and security data than it does currently. However, some
aviation industry stakeholders told us that they are still reluctant to
submit such data fearing that the media and/ or the public will misinterpret
it.
58 Airlines submit data to FAA, which determines if these data are
voluntary. For example, any data generated as part of a compliance
requirement must be given to FAA. 59 The Federal Aviation Reauthorization
Act of 1996 requires FAA to protect aviation safety and security information
that is submitted voluntarily ( 49 U. S. C. 40123) .
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The U. S. Military Services Are Still in the Early Stages of Developing FOQA
Programs
Another rule offering limited protection for voluntarily submitted FOQA data
is pending.
The U. S. military services readily acknowledge the potential benefits of
implementing FOQA programs despite varied mission requirements that could
make implementing such programs more difficult for them than it has been for
commercial aviation. 60 To date, the military services have taken various
levels of action from high- level discussions about how to proceed with FOQA
to initiating demonstration projects for specific aircraft types.
In February 1997, a Defense Science Board ( DSB) report Task Force Report on
Aviation Safety, conducted at the request of the Congress, found that
inconsistencies exist between aircraft used for passenger and troop
transport and civil aircraft leased for similar purposes and made two
recommendations specifically related to FOQA. First, it recommended that a
policy be developed for military transport aircraft that requires the same
safety equipment ( flight data recorders) as that required for commercial
airlines with waivers to be approved only at the service chief level. 61 It
also recommended that the military services fully exploit the new
opportunities afforded by flight data recorders to collect performance and
hardware maintenance data, and noted the value of flight data to monitoring
aircraft conditions, crew performance and communication, and aircraft
maintenance.
In October 1999, the Joint Service Safety Chiefs ( JSSC) agreed that FOQA
had value and endorsed projects and research by all services. A Memorandum
of Agreement signed by the JSSC on August 28, 2000, formally endorsed
military FOQA and recommended full funding of required resources. In
response to the safety chiefs endorsement of FOQA and in an effort to
increase cross- service communication on the subject, the military has held
two FOQA conferences and plans to hold such meetings annually for the
combined services. The first conference, held in
60 Airlines have the advantage of analyzing FOQA data from aircraft that
typically fly very prescribed procedures from point A to point B. In
contrast, , military aircraft are operated using a wide range of maneuvers
that vary by aircraft type and mission, while comparable maneuvers are
simply not done in civil aircraft. As a result, the military may find it
more difficult to analyze FOQA data.
61 Each of the military services has a safety chief responsible for
overseeing safety issues, including aviation.
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Programs
October 2000, introduced the services to FOQA; the second conference ( held
in March 2001) emphasized economics, policy, technology, and analysis
associated with FOQA. Aside from the safety chiefs formal endorsement of
FOQA and the two related conferences, the military branches have taken only
initial steps in implementing formalized FOQA programs, due in part to
budget tradeoffs between aircraft safety and other mission- readiness needs.
See table 3 for the status of the military services efforts to implement
FOQA programs.
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Programs
Table 3: Status of Military Efforts to Implement FOQA Programs as of August
1, 2001 Authority Key actions Air Force Policy established the Aircraft
Information Program with a main goal of enabling FOQA ( February 2001) .
Selected a software contractor to support a one- year FOQA demonstration
project ( June 2001) . Has collected data since 1994 on nearly 11,000
flights. The software support obtained in June 2001 has allowed them to
start processing these data. They will use a maximum of 30 C- 17 aircraft at
McChord Air Force Base in Washington state to operate this demonstration.
Marine The Executive Safety Board set a goal to initiate the FOQA process
with the MV- 22, the Marine s newest airplane ( August 2000) . It also set a
secondary goal to expand the FOQA process to other aircraft with digital
electronic systems, as soon as possible.
Navy Has proven the value of the FOQA concept using the C- - 2 aircraft. Is
still debating whether FOQA should be used as a training tool to improve
aviation safety or as an enforcement tool to protect taxpayer investments in
naval aircraft.
According to a senior Navy Safety Center official, the Navy could improve
its mission effectiveness by implementing a military FOQA program to improve
pilot training, make better use of limited flight hours, and ultimately
train better pilots. However, implementing FOQA in the Navy would be a tough
sell given the basic needs competing for resources, such as funding to
repair aircraft engines.
Coast Guard Currently examining how best to establish a FOQA program. All
helicopters are equipped with Flight Data Recorders ( FDR) . A proposal to
equip Falcon and C- 130 fixed wing aircraft has been submitted within the
Coast Guard; however, the Falcon aircraft are old, expensive to equip, and
may be nearing the end of their service lives. Is drafting and staffing a
military FOQA usage policy that mirrors FAA s protection of FOQA data. In
addition, some aircraft are already equipped with the hardware necessary for
collecting FOQA data. Furthermore, some aircraft have been/ are continuing
to be equipped with FDRs or new digital technology to capture flight data.
Source: Military services.
Page 59 GAO- 02- 77 Aviation Safety
Appendix VII: Case Study on Communication Delays Between the Air Force and
Civil Aviation Community
During the National Transportation Safety Board ( NTSB) accident
investigation into the July 1996 crash of TWA Flight 800, it was discovered
that the Air Force had experienced problems with overheating in the center
wing fuel tank of the E4- B aircraft ( a military variant of the 747) . In
response, the Air Force contracted with Boeing s Military Group to study the
problem between 1979 and 1980; the group issued a report to the Air Force in
1980. However, the report was not shared with the civil aviation officials
until 1999. 62 This case study illustrates the importance of effective and
timely communication between the military and civilian aviation communities
on similar aviation safety problems.
The Air Force was concerned about the E- 4B engines continuing to run
satisfactorily if a main ( wing) tank fuel pump malfunctioned. In addition,
there was concern over the running of the air conditioning packs under the
center wing tank for extended periods of time when the airplane was on
alert, idling on the ground with engines running for 48 hours. In this mode,
the center wing tank was full of fuel, and heated up slowly to a high
temperature. The 1980 Air Force report prepared by Boeing s Military Group
found that, under certain circumstances, air conditioning wires running
through the fuel tank could create a potential safety problem, but
determined that the engine would continue to operate successfully provided
certain operating restrictions were implemented.
The central focus of the Air Force s concerns and Boeing s analysis was fuel
pump performance, not fuel tank flammability. Federal Aviation
Administration ( FAA) officials said that this test was not envisioned as
one of flammability of the vapor in the fuel tank, but merely to assess the
effectiveness of fuel being fed to the engine. They added that it was always
assumed that fuel vapor might be flammable under certain conditions. 63
However, NTSB officials maintain that the information contained in this
report would have assisted them with their accident investigations related
62 Transportation Safety: Information Concerning Why a 1980 Aircraft Report
Was Not Provided Earlier to the National Transportation Safety Board ( GAO/
OSI- 00- 2R, Nov. 3, 1999) .
63 According to FAA, the philosophy at the time and until shortly after the
TWA Flight 800 accident was that no ignition sources be allowed inside of
fuel tanks. It was not until August 1996 that a Boeing 747 flight test was
conducted to investigate what effect the center tank heating would have on
fuel vapor flammability. FAA was aware that aircraft operated with the fuel
tank in the flammability range under certain conditions. This is why FAA
regulations require the elimination of ignition sources. However, NTSB has
recommended a different approach to the problem; namely inerting the fuel so
that it would not explode even if it came into contact with an ignited
source.
Page 60 GAO- 02- 77 Aviation Safety
Appendix VII: Case Study on Communication Delays Between the Air Force and
Civil Aviation Community
to fuel tank flammability. While the report s authors did not recommend
structural changes to the E- 4B aircraft, they did recommended taking
mitigating actions, such as flying the aircraft with the center fuel tank
empty.
In July 1996, NTSB began its investigation into the crash of TWA Flight 800.
As part of the investigation, Boeing was requested to search its database
for any information concerning heating problems with the 747 s center (
wing) fuel tanks. According to both NTSB and Boeing officials, the Boeing
Commercial Airplane Group told NTSB that it had no such data. However, in
December 1997, the Air Force report came to the attention of the Boeing
Military Group when it was found during a housecleaning effort. It was
determined that the report was the property of the Air Force and
subsequently sent to the Air Force Oklahoma City Air Logistics Command ( OC-
ALC) .
Boeing officials told us that the report should have been located and turned
over to NTSB in 1996, even though the Boeing Military Group prepared it for
the Air Force. They stated that human error had caused an incomplete search
to be made of the Boeing records system for information on heat studies
involving center ( wing) fuel tanks. A senior Boeing safety official told us
that the company has modified its electronic library to allow key word
searches across all of the company s reports. Its accident investigation
processes have also been revised to include electronic searches for
technical documents.
In 1998, the Air Force OC- ALC initiated an Independent Review Team ( IRT)
to discuss center ( wing) fuel tank issues connected with the E- 4B aircraft
in light of recommendations issued by the NTSB following its investigation
of the TWA Flight 800 accident. The Air Force OC- ALC held an IRT meeting in
March 1999 to continue to review safety issues concerning the center ( wing)
fuel tank of the E- 4B aircraft. As part of that meeting, the Air Force
included the report on the meeting agenda. Air Force officials told us that
the report was put on the agenda to show that the E- 4B aircraft was
equipped somewhat differently and was capable of operating under more
difficult conditions than the commercial 747, not for safety reasons.
Participants in this meeting included officials from Boeing s Commercial
Airplane Group and Military Group and NTSB. Officials of both Boeing s
Commercial Airplane Group and NTSB told us that this was the first time they
had heard about the report.
Page 61 GAO- 02- 77 Aviation Safety
Appendix VII: Case Study on Communication Delays Between the Air Force and
Civil Aviation Community
Air Force OC- ALC officials told us that when Boeing brought the report to
their attention, it was placed on the IRT agenda for discussion. These
officials said that they did not intentionally withhold the report from the
NTSB because both military and civilian personnel in their organization
considered it to be an operational or readiness study, not a safety study.
The NTSB director told us that, after the March 1999 IRT meeting, NTSB
requested a copy of the entire study from the Air Force, but instead
received a summary. In June, after intervention by a U. S. Senate committee,
64 the Air Force provided the entire study to NTSB.
A senior NTSB official told us that it is not likely that earlier sharing of
the report s findings would have prevented the crash of TWA Flight 800.
However, had NTSB received the study in 1996 following the crash of TWA
Flight 800, it would have saved valuable time and resources in conducting
its investigation. Both the NTSB s chairman and director of aviation noted
that the study might have been very helpful to the NTSB in its 1990
investigation of a Boeing 737 aircraft explosion at Manila Airport in the
Philippines the explosion occurred in the aircraft s center fuel tank.
According to both officials, it is possible that, if they had received the
Boeing study by 1990, safety recommendations made as a result of the TWA
Flight 800 crash could have been issued sooner.
In August 2000, NTSB released its report on the TWA Flight 800 accident,
which included the following statement regarding the report Boeing prepared
for the Air Force on fuel tank overheating in the E4- B:
The Safety Board recognizes that the military variant of the 747 is not
directly comparable to the civilian 747 and that the focus of that study was
fuel pump functionality, not flammability. Nonetheless, it is unfortunate
that potentially relevant information about 747 center wing [ fuel ] tank
overheating and corrective measures were not provided to the FAA or to 747
operators earlier.
64 Subcommittee on Administrative Oversight and the Courts, Committee on the
Judiciary, U. S. Senate.
Page 62 GAO- 02- 77 Aviation Safety
Appendix VIII: Case Study on Strandflex Control Cable
In January 1999, a former employee of the Strandflex Company alleged in
federal court that the corporation was not conducting quality assurance
tests to ensure that its wire rope used in the assembly of aircraft control
cables met military specifications. According to the Department of Defense (
DOD) , this wire rope is critical to the safe operation of flight control
systems ( e. g. , aircraft rudders, wing flaps, brakes, and steering) on
affected aircraft. However, Federal Aviation Administration ( FAA) officials
contend that this wire rope is not always critical to flight safety because
civil federal aviation regulations require that aircraft control systems
incorporate redundancies, meaning that failure of control cables would not
cause loss of the airplane. 65
In response to the allegation against the Strandflex Company, the Defense
Criminal Investigative Service initiated an investigation and an independent
test by DOD demonstrated the wire rope did not consistently meet strength
requirements. The Department of Defense Office of Inspector General ( DODIG)
alerted the military services and FAA concurrently in May 1999. The military
services took prompt action to notify responsible officials to assess the
extent of safety hazards and correct them. FAA took just over a year to
notify the civil aviation community. FAA officials acknowledged that there
was a delay, but said that they had assessed the situation and concluded
that it did not require urgent action. However, the agency s inaction
resulted in a Department of Transportation Office of Inspector General (
DOTIG) investigation into the delay and FAA s overall process for issuing
notifications of unapproved parts. On May 30, 2001, the Strandflex Company
admitted to making false claims to the United States and falsely certifying
that its aircraft control cable wire rope met U. S. military specifications
and was ordered by a U. S. District Court judge to pay a criminal fine and
restitution.
DOTIG Has Reported That FAA Delayed Action on Strandflex Concerns
Concerned about FAA s delay in notifying air carriers of possible problems
with Strandflex cables, a June 2000 Congressional request called for the
DOTIG to investigate, among other things, the timeliness and effectiveness
of FAA s response to information about possible flaws in the Strandflex
control cable.
65 FAA officials also told us that civil aircraft cable assemblies are often
designed to be five times stronger than they need to be. Furthermore, once
aircraft control cables are assembled, they are tested in a manner that
would reveal weaknesses in the wire rope.
Page 63 GAO- 02- 77 Aviation Safety
Appendix VIII: Case Study on Strandflex Control Cable
In March 2001, the DOTIG reported that FAA did not act in a timely manner in
response to the information it received about Strandflex, confirming that
just over a year had passed between the time that the DODIG notified FAA
about possible problems with Strandflex and the date that FAA published an
Unapproved Parts Notification ( UPN) on Strandflex. A UPN disseminates
information about unapproved parts to the civil aviation community. 66
Furthermore, the DOTIG identified three primary factors that accounted for
FAA s untimely response: FAA ( 1) misfiled the initial notification,
resulting in an initial delay of approximately 3 months; ( 2) spent an
additional month forwarding a Suspect Unapproved Parts investigative request
to the New England Regional office for further investigation; ( 3) delayed
an additional 4 months because a legal challenge made it reluctant to issue
advisory field notifications about suspect unapproved parts. 67
FAA Has Taken Action to Improve Communication with DOD in Response to the
DOTIG Investigation of Strandflex
FAA notified the DODIG in August 2000 of the need for DOD to send alert
messages pertaining to suspect unapproved parts directly to FAA s Suspect
Unapproved Parts Program Office. This action was taken in response to the
DOTIG s investigation of FAA s delay in alerting the civil aviation
community about potential quality assurance problems with Strandflex wire
rope. Specifically, DOD alerts about suspect unapproved parts were being
sent to FAA s Civil Aviation Security Office 68 rather than FAA s Suspect
Unapproved Parts Program Office. While the DOTIG did not identify this as a
key contributor to the year- long delay by FAA, such simple communication
breakdowns as not sending safety notifications to all responsible officials
could lead to delays in addressing potential hazards. In its response to the
DOTIG finding of weaknesses in FAA s
66 OIG Investigation of Responses to Information About a Serious Flaw in
Aircraft Cables , U. S. Department of Transportation, Office of the
Inspector General ( Mar. 2, 2001, Report Number CC- 2000- 290) .
67 FAA attributed its reluctance to a September 1999 challenge from an
attorney representing members of the aviation community regarding the agency
s authority to issue such notifications. The attorney cited concerns that
field notifications are purely advisory in nature, that no corrective action
is mandatory, and that the companies named in field notifications are not
afforded the opportunity to respond to the issues violating their due
process rights.
68 FAA s Office of Civil Aviation Security, Internal Security Investigation
Program, often provides investigative services at the request of other FAA
organizational units on a wide range of subjects, including unapproved
aircraft parts.
Page 64 GAO- 02- 77 Aviation Safety
Appendix VIII: Case Study on Strandflex Control Cable
overall processing of UPNs, the FAA manager for the Suspect Unapproved Parts
Program Office advised the DOTIG that corrective action had been taken to
ensure that all DOD alert messages were now sent directly to FAA s Suspect
Unapproved Part Program Office. According to FAA and DOD officials, while
FAA s Office of Civil Aviation Security remains the addressee in the
official letter from DOD alerting FAA to potential problems with suspect
unapproved parts, the FAA Unapproved Parts Program Office is included on DOD
s list of facsimile recipients and receives notifications immediately after
signature.
Page 65 GAO- 02- 77 Aviation Safety
Appendix IX: Comments from the Under Secretary of Defense
Page 66 GAO- 02- 77 Aviation Safety
Appendix IX: Comments from the Under Secretary of Defense
Page 67 GAO- 02- 77 Aviation Safety
Appendix IX: Comments from the Under Secretary of Defense
Page 68 GAO- 02- 77 Aviation Safety
Appendix X: GAO Contacts and Staff Acknowledgments
GAO Contacts Peter F. Guerrero ( 202) 512- 2834 In addition to the
individual named above, Aaron Casey, Beverly Dulaney, Colin Fallon, David
Hooper, Maren McAvoy, Sara- Ann Moessbauer, Robert White, and Mario Zavala
made key contributions to this report.
( 395001) Page 69 GAO- 02- 77 Aviation Safety
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