Aviation Runway and Ramp Safety: Sustained Efforts to Address	 
Leadership, Technology, and Other Challenges Needed to Reduce	 
Accidents and Incidents (20-NOV-07, GAO-08-29). 		 
                                                                 
While aviation accidents in the United States are relatively	 
infrequent, recent incidents have heightened concerns about	 
safety on airport runways and ramps. As the nation's aviation	 
system becomes more crowded every day, increased congestion at	 
airports may exacerbate ground safety concerns. To safely handle 
the anticipated larger volumes of air traffic, the Federal	 
Aviation Administration (FAA) is implementing the Next Generation
Air Transportation System (NextGen) to better manage air traffic 
both in the air and on the ground. GAO was asked to evaluate (1) 
the progress being made in addressing runway safety and what	 
additional measures, if any, could be taken and (2) the factors  
affecting progress in improving ramp safety and what is being	 
done by FAA and others to address those factors. We reviewed	 
runway and ramp safety data, interviewed agency officials and	 
industry stakeholders, and surveyed experts.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-29						        
    ACCNO:   A78310						        
  TITLE:     Aviation Runway and Ramp Safety: Sustained Efforts to    
Address Leadership, Technology, and Other Challenges Needed to	 
Reduce Accidents and Incidents					 
     DATE:   11/20/2007 
  SUBJECT:   Accident prevention				 
	     Air traffic control systems			 
	     Air transportation 				 
	     Aircraft accidents 				 
	     Airports						 
	     Aviation security					 
	     Commercial aviation				 
	     Research and development				 
	     Risk assessment					 
	     Risk management					 
	     Safety standards					 
	     Strategic planning 				 
	     Transportation planning				 
	     Transportation safety				 
	     Program implementation				 
	     Next Generation Air Transportation 		 
	     System						 
                                                                 

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GAO-08-29

   

     * [1]Results in Brief
     * [2]Background

          * [3]Federal Roles in Runway and Ramp Safety

     * [4]Challenges Remain Despite Numerous Efforts to Address Runway

          * [5]FAA Uses a Layered Approach to Reduce the Risks of Runway In

               * [6]FAA Is Using Technology as a Major Part of its Risk
                 Reductio
               * [7]Infrastructure Improvements and Research Efforts Are
                 Being M
               * [8]FAA Training and Industry Outreach Includes Human Factors
                 Is
               * [9]FAA and Airports Have Improved Runway Safety Areas in
                 Case o

          * [10]Lack of Coordination and Leadership, Technology Challenges,

               * [11]FAA's Office of Runway Safety Is Not Carrying Out its
                 Coordi
               * [12]Technology Challenges Impede Progress in Improving
                 Runway Sa
               * [13]Lack of Runway Incident Data Impedes Causal Analysis
               * [14]Controller Fatigue Continues to Be a Runway Safety
                 Concern
               * [15]FAA Has Not Implemented NTSB's Runway Safety
                 Recommendations
               * [16]FAA Has Opportunities to Improve Runway Safety

     * [17]Progress in Addressing Ramp Safety Is Affected by a Lack of

          * [18]Lack of Complete Accident Data Hinders Efforts to Address Ra
          * [19]Lack of Standards for Ramp Operations Could Hinder Safety
          * [20]The Federal Government and the Aviation Industry Are Taking
          * [21]Additional Measures May Improve Ramp Safety

     * [22]Conclusions
     * [23]Recommendations
     * [24]Agency Comments
     * [25]Appendix I: Objective, Scope, and Methodology
     * [26]Appendix II: Survey Methodology
     * [27]Appendix III: Serious Incursions Involving Commercial Aircra
     * [28]Appendix IV: Status of the National Runway Safety Plan Objec
     * [29]Appendix V: Airports with Surface Surveillance Technology
     * [30]Appendix VI: Airports Where Ramp Accident Fatalities Occurre
     * [31]Appendix VII: GAO Contact and Staff Acknowledgments

          * [32]GAO Contact
          * [33]Staff Acknowledgments

               * [34]Order by Mail or Phone

Report to Congressional Requesters

United States Government Accountability Office

GAO

November 2007

AVIATION RUNWAY AND RAMP SAFETY

Sustained Efforts to Address Leadership, Technology, and Other Challenges
Needed to Reduce Accidents and Incidents

GAO-08-29

Contents

Letter 1

Results in Brief 3
Background 5
Challenges Remain Despite Numerous Efforts to Address Runway Safety 18
Progress in Addressing Ramp Safety Is Affected by a Lack of Data and
Standards, but the Industry Is Taking Action to Address these Issues 48
Conclusions 58
Recommendations 59
Agency Comments 59
Appendix I Objective, Scope, and Methodology 61
Appendix II Survey Methodology 65
Appendix III Serious Incursions Involving Commercial Aircraft 80
Appendix IV Status of the National Runway Safety Plan Objectives 81
Appendix V Airports with Surface Surveillance Technology 83
Appendix VI Airports Where Ramp Accident Fatalities Occurred 85
Appendix VII GAO Contact and Staff Acknowledgments 86

Tables

Table 1: Experts' Ranking of the Most Effective FAA Actions to Address
Runway Incursions 19
Table 2: Changes in ASDE-X Equipment Cost and Deployment Completion Dates
33
Table 3: ASDE-X Commissioned Airports as of August 2007 34
Table 4: Experts' Ranking of the Actions that FAA Could Take with the Most
Potential to Address Runway Incursions 46
Table 5: Experts' Ranking of the Most Effective Actions by FAA, OSHA,
Airports, and Airlines to Address Ramp Accidents 50
Table 6: Experts' Ranking of the Actions that FAA, OSHA, Airports, or
Airlines Could Take with the Most Potential to Address Ramp Accidents 55
Table 7: List of Organizations that GAO Visited or Contacted Regarding
Runway and Ramp Safety 63
Table 8: Serious Incursions Involving At Least One Commercial Aircraft
during Fiscal Year 2006 and Fiscal Year 2007 80
Table 9: Implementation Status of the Objectives Contained in Federal
Aviation Administration's (FAA) National Runway Safety Plan for 2002-2004
81
Table 10: Airports with Airport Surface Detection Equipment, Model 3
(ASDE-3)/Airport Movement Area Safety Systems (AMASS) or the Airport
Surface Detection Equipment, Model X (ASDE-X) or Scheduled to Receive
ASDE-X 83
Table 11: U.S. Airports at which Ramp Fatalities Occurred from 2001
through 2006 85

Figures

Figure 1: Movement and Nonmovement Areas of the General Mitchell
International Airport in Milwaukee, WI 7
Figure 2: Number and Rate of Runway Incursions from Fiscal Year 1998
through Fiscal Year 2007 9
Figure 3: Total Number of Serious Incursions, Fiscal Year 2001 through
Fiscal Year 2007 11
Figure 4: U.S. Commercial Airports that Experienced the Most Runway
Incursions from Fiscal Year 2001 through Fiscal Year 2006 12
Figure 5: Photograph of the December 2005 Runway Overrun at Chicago Midway
Airport 13
Figure 6: Example of an Accident in an Airport Ramp Area 15
Figure 7: Airport Surface Detection Equipment, Model X (ASDE-X) Deployment
Sites 20
Figure 8: Runway Status Lights System 22
Figure 9: Aircraft Taxiing Routes at the Hartsfield-Jackson Atlanta
International Airport Without Using the Perimeter Taxiway 24
Figure 10: Aircraft Taxiing Route at the Hartsfield-Jackson Atlanta
International Airport Using the Perimeter Taxiway 25
Figure 11: Example of How EMAS Can Stop an Aircraft 29
Figure 12: Annual Number of Ramp Fatalities at U.S. Airports from 2001
through 2006 49
Figure 13: Questions Asked in First Survey 68

Abbreviations

ADS-B Automatic Dependent Surveillance-Broadcast
AMASS Airport Movement Area Safety System
ASDE-3 Airport Surface Detection Equipment, Model 3
ASDE-X Airport Surface Detection Equipment, Model X
CAST Commercial Aviation Safety Team
EMAS Engineered Materials Arresting System
DOT Department of Transportation
FAA Federal Aviation Administration
ICAO International Civil Aviation Organization
JPDO Joint Planning and Development Office
NextGen Next Generation Air Transportation System
NTSB National Transportation Safety Board
OMB Office of Management and Budget
OSHA Occupational Safety and Health Administration
OSH Act Occupational Safety and Health Act

This is a work of the U.S. government and is not subject to copyright
protection in the United States. The published product may be reproduced
and distributed in its entirety without further permission from GAO.
However, because this work may contain copyrighted images or other
material, permission from the copyright holder may be necessary if you
wish to reproduce this material separately.

United States Government Accountability Office
Washington, DC 20548

November 20, 2007

The Honorable Jerry F. Costello
Chairman
Subcommittee on Aviation
Committee on Transportation and Infrastructure
House of Representatives

The Honorable Frank R. Lautenberg
United States Senate

While aviation accidents in the United States are relatively infrequent,
recent incidents have heightened concerns about safety on airport runways
and ramps.^1 On August 16, 2007, for example, at Los Angeles International
Airport--one of the nation's busiest airports--two commercial aircraft
carrying 296 people came within 37 feet of colliding, resulting in an
incident called a runway incursion. In another example, in 2005, an
aircraft departing from Seattle-Tacoma International Airport, carrying 142
people, experienced sudden cabin depressurization caused by a ramp vehicle
having punctured the aircraft fuselage while on the ramp. As the nation's
aviation system becomes more crowded every day, increased congestion at
airports may exacerbate ground safety concerns. To safely handle the
anticipated larger volumes of air traffic, the Federal Aviation
Administration (FAA) is implementing the Next Generation Air
Transportation System (NextGen) to better manage air traffic both in the
air and on the ground. At airports, FAA focuses its safety oversight on
the movement areas--runways and taxiways^212--where the chances of
catastrophic accidents are greater than other areas. By contrast, safety
oversight of operations in the ramp areas of airports is handled primarily
by airlines and airports. While aviation accidents in the United States
are relatively infrequent, recent incidents have heightened concerns about
safety on airport runways and ramps. On August 16, 2007, for example, at
Los Angeles International Airport--one of the nation's busiest
airports--two commercial aircraft carrying 296 people came within 37 feet
of colliding, resulting in an incident called a runway incursion. In
another example, in 2005, an aircraft departing from Seattle-Tacoma
International Airport, carrying 142 people, experienced sudden cabin
depressurization caused by a ramp vehicle having punctured the aircraft
fuselage while on the ramp. As the nation's aviation system becomes more
crowded every day, increased congestion at airports may exacerbate ground
safety concerns. To safely handle the anticipated larger volumes of air
traffic, the Federal Aviation Administration (FAA) is implementing the
Next Generation Air Transportation System (NextGen) to better manage air
traffic both in the air and on the ground. At airports, FAA focuses its
safety oversight on the movement areas--runways and taxiways--where the
chances of catastrophic accidents are greater than other areas. By
contrast, safety oversight of operations in the ramp areas of airports is
handled primarily by airlines and airports.

To respond to your request, our objective was to determine how well FAA
and others are addressing runway and ramp safety issues. To accomplish
this, we focused on the following questions: (1) What progress is being
made in addressing runway safety, and what additional measures, if any, To
respond to your request, our objective was to determine how well FAA and
others are addressing runway and ramp safety issues. To accomplish this,
we focused on the following questions: (1) What progress is being made in
addressing runway safety, and what additional measures, if any, could be
taken? and (2) What factors affect progress in improving ramp safety and
what is being done by FAA and others to address those factors?

^1Ramps are areas of airports where aircraft are readied for arrival and
departure.

^2Taxiways are routes that aircraft follow to and from runways.

To answer these questions, we reviewed data on runway and ramp safety
incidents and accidents from FAA, the National Transportation Safety Board
(NTSB), and the Department of Labor's Occupational Safety and Health
Administration (OSHA) and Bureau of Labor Statistics; relevant laws,
regulations, and agency policies; and federal government and aviation
industry efforts to address runway and ramp safety, including the
development of new technology. We also looked at how taxiways affect
runway safety. In addition, we interviewed FAA, NTSB, OSHA, airport, and
aviation trade organization officials reflecting various segments of the
industry, as well as pilots, air traffic controllers, and ramp workers and
their union representatives. We also surveyed experts^3 on the causes of
runway and ramp incidents and accidents, the effectiveness of measures
that are being taken to address them, and what additional measures could
be taken. A majority of the experts was selected with the assistance of
the National Academy of Sciences, and we identified additional experts
during our review. The individuals were selected on the basis of their
expertise in areas such as technology and procedures used to address
runway incursions, overruns, and ramp accidents; international aviation
safety practices; human factors issues; general aviation; airports; and
ground operations. We report the survey results in terms of actions that
are most effective or future actions that have the greatest potential.
Through our analyses, the actions that we report as being most effective
or having the greatest potential were ones that a majority of respondents
indicated were very or extremely effective for the effectiveness questions
or great or very great potential for the questions asking about potential.
Because we asked the experts to answer questions only within their areas
of expertise, a different number of responses were received for various
survey questions. Based on interviews with officials knowledgeable about
the data contained in this report, we determined that runway and ramp
safety data were sufficiently reliable for the types of analyses that we
performed for this report such as trends in runway incursions, the
incidence of fatalities in airport ramp areas, and frequency of air
traffic controller overtime. We conducted our work in Atlanta, GA;
Atlantic City, NJ; Boston, MA; Burbank, Long Beach, Los Angeles, and San
Diego, CA; Newark, NJ; Seattle and Spokane, WA; and Washington, D.C. These
locations included airports that have experienced higher rates of runway
incursions or where new aviation safety technology was being researched or
tested. We conducted our work from October 2006 through November 2007 in
accordance with generally accepted government auditing standards. Appendix
I contains additional information about our methods. Detailed information
about our survey methodology and the survey questions are contained in
appendix II.

^3The survey consisted of two phases. Twenty-five experts responded to the
first phase survey and 22 responded to the second phase survey.

Results in Brief

FAA and other aviation stakeholders have taken steps to address runway and
ramp safety, but the lack of coordination and leadership, technology
challenges, the lack of data, and human factors-related issues impede
further progress. Our analysis showed that FAA had completed or was in the
process of implementing 34 of the 39 initiatives contained in its 2002
national runway safety plan; 4 initiatives were canceled and 1 pertaining
to deploying certain technology was not met. The completed initiatives
included deploying and testing other technology designed to prevent runway
collisions and overruns; helping change airport layout, markings, signage,
and lighting; and providing training for pilots and air traffic
controllers. Of the measures that FAA is taking to address runway
incursions, the results of our survey of experts indicated that the most
effective actions were lower-cost ones, such as enhancing airport
markings, lighting, and signage. In addition, FAA has made progress in
addressing runway overruns and reported in May 2007 that 70 percent of the
runways at U.S. commercial airports substantially comply with runway
safety area standards, up from 55 percent in 2000. Runway safety areas
reduce the chance of aircraft being damaged from overruns. While the
number and rate of incursions declined after reaching a peak in fiscal
year 2001 and remained relatively constant for the next 5 years,
preliminary data for fiscal year 2007 indicate that the overall incursion
rate increased during fiscal year 2007 and is nearly as high as the fiscal
year 2001 peak. FAA's Office of Runway Safety has also not carried out its
leadership role in recent years. The office's role is to lead the agency's
runway safety efforts by coordinating and monitoring runway safety
activities to ensure that goals are met. Those goals were established in
2002 in a national runway safety plan. However, FAA has not updated the
plan, despite agency policy that such a plan be prepared every 2 to 3
years. The lack of an updated plan has resulted in uncoordinated runway
safety efforts by individual FAA offices. Moreover, runway safety
technology currently being installed, the Airport Surface Detection
Equipment, Model X (ASDE-X), which is designed to provide air traffic
controllers with the position and identification of aircraft and alerts of
potential collisions, has faced cost increases and schedule delays from
its original baselines and is experiencing operational difficulties with
its alerting function. At the same time, additional technology to prevent
runway collisions is years away from deployment. FAA also lacks reliable
runway safety data and the mechanisms to ensure that the data are
complete. Furthermore, air traffic controller fatigue, which may result
from regularly working overtime, continues to be a matter of concern for
NTSB, which investigates transportation accidents, and other aviation
stakeholders. We found that, as of May 2007, at least 20 percent of the
controllers at 25 air traffic control facilities, including towers at
several of the country's busiest airports, were regularly working 6-day
weeks. FAA could take additional measures to improve runway safety. These
measures include starting a nonpunitive, confidential, voluntary program
for air traffic controllers to report safety risks in the national
airspace system, which includes runways and taxiways, similar to a program
that FAA has already established for pilots and others in the aviation
community, and could help the agency to understand the causes and
circumstances regarding runway safety incidents. The results of our survey
of experts indicated that the action FAA could take with the greatest
potential for preventing runway incursions was encouraging the use of
lighting systems that guide aircraft on their airport taxi routes. The
results of our survey of experts also indicated that the actions with the
greatest potential that FAA could take to prevent runway overruns included
addressing the causes and circumstances of overruns, such as improving
communication of runway conditions and weather information to flight
crews, and encouraging improvements in and use of runway condition and
friction measurements, which provide data regarding the slickness of a
runway.

Efforts to improve airport ramp safety are hindered by a lack of complete
accident data and standards for ground handling. Such data could help FAA
and the aviation industry to understand the nature and extent of the
problem, as a first step to identifying what actions are needed to reduce
ramp accidents. We found no complete source of data on ramp accidents, but
reviewed ramp fatality data from 2001 through 2006 from FAA, OSHA, and
NTSB, and found that these agencies had investigated 29 fatal ramp
accidents during that time. The majority of the fatalities in these
accidents were ramp workers. We found no complete nonfatal injury data on
ramp accidents. In addition, we found no federal or industrywide standards
for ramp operations. The federal government has generally taken an
indirect role in overseeing ramp safety; airlines and airports typically
control the ramp areas using their own policies and procedures. Meanwhile,
some airlines and airports have initiated their own efforts to address
ramp safety, and aviation organizations have begun collecting ramp
accident data. We asked experts to provide their views on those industry
efforts, and they indicated that the most effective ones were being taken
mainly by airlines, for example, by setting safety targets and using ramp
towers. In addition, an international aviation association plans next year
to start a safety audit program of companies with employees who work in
airport ramp areas, which would be a step toward applying standardized
criteria to these companies. Officials from a union representing ramp
workers said that FAA should increase its safety oversight of ramp areas,
while other aviation industry officials said that FAA's resources are more
appropriately focused on the runways and taxiways, where there are greater
safety risks to passengers. The results of our survey of experts indicated
that the action FAA, OSHA, airport, or airlines could take with the
greatest potential for preventing ramp accidents was promoting a safety
culture in the ramp area.

We are recommending that FAA take several measures to enhance runway and
ramp safety, which include preparing a new national runway safety plan,
improving data collection on runway overruns and ramp accidents, and
addressing air traffic controller overtime and fatigue issues that may
affect runway safety. We provided the Department of Transportation (DOT)
and the Department of Labor with drafts of this report for their review
and comment. DOT agreed to consider the report's recommendations and
provided technical corrections and clarifications, which we incorporated
as appropriate. The Department of Labor had no comments but provided a
technical correction, which we incorporated.

Background

Demand for air travel has increased in recent years, with over 740 million
passengers flying in the United States in fiscal year 2006, and is
expected to climb to an estimated 1 billion passengers per year by 2015.
To meet this demand, the Joint Planning and Development Office (JPDO),
housed within FAA and created to plan and coordinate the transition to
NextGen, has developed a strategy to establish the needed national
airspace system infrastructure, including airports. JPDO's objectives
include providing air traffic control and airport authorities with greater
flexibility to match capacity with demand, reducing congestion, and
establishing a comprehensive safety management approach. Implementing the
plan will include deploying Automatic Dependent Surveillance-Broadcast
(ADS-B), a satellite-based technology that broadcasts aircraft
identification, position and speed with once-per-second updates, which
will provide pilots with greater situational awareness and help to keep
aircraft at safe distances from each other on the runways.

Safety at airports in the United States is a shared responsibility among
FAA, airlines, and airports. FAA air traffic controllers oversee activity
in the movement areas--runways and taxiways--but airlines and airports
provide primary safety oversight in the nonmovement areas--ramps and
gates.^4 Figure 1 shows the movement and nonmovement areas of the General
Mitchell International Airport in Milwaukee, WI.

^4Ramp towers, staffed by airline, airport, or contractor personnel, are
used to control the ramps at some airports.

Figure 1: Movement and Nonmovement Areas of the General Mitchell
International Airport in Milwaukee, WI

Runway safety is a major aviation safety concern that involves measures to
prevent runway incursions and overruns. Through September 2007, FAA
defined a runway incursion as "any occurrence in the runway environment
involving an aircraft, vehicle, person, or object on the ground that
creates a collision hazard or results in a loss of required separation
when an aircraft is taking off, intending to take off, landing, or
intending to land." On October 1, 2007, FAA began using a definition of a
runway incursion developed by the International Civil Aviation
Organization (ICAO), a United Nations specialized agency.^5 ICAO's
definition of an incursion is any occurrence at an airport involving the
incorrect presence of an aircraft, vehicle, or person on the protected
area of a surface designated for the landing or take-off of aircraft.
Runway incursion prevention has been on NTSB's list of most wanted
transportation improvements since 1990 because runway collisions can have
serious consequences. Six runway collisions have occurred in the United
States since 1990, resulting in 63 deaths. The worst runway accident in
the United States occurred at the Los Angeles International Airport in
1991, when an aircraft that was landing collided with another that was
holding on the same runway, killing 34 people. The most recent fatal
runway collision in the United States occurred in 2000, when two general
aviation aircraft collided on the runway at the Sarasota Bradenton
International Airport in Florida, resulting in 4 fatalities.^6 Other
runway incidents, which FAA did not classify as incursions, also can have
serious consequences. On August 27, 2006, for example, a Comair regional
jet crashed in Lexington, KY, after taking off from a wrong runway that
was too short for the aircraft, killing all but one of the 50 people
onboard.^7

^5Among other things, ICAO develops standards and recommended practices,
procedures, and guidance material related to all aspects of civil
aviation, including safety and security.

^6The worst accident in aviation history occurred in 1977 when a KLM
Boeing 747 collided with a Pan Am Boeing 747 on a runway in Tenerife, the
Canary Islands, killing 583 passengers and crew. The Spanish government,
which investigated the accident, determined that the accident was caused
by a miscommunication between the KLM pilot and the control tower that
take-off clearance had been provided, as well as several other factors.

^7FAA classified this accident as a surface incident, which it had defined
as any event where unauthorized or unapproved movement occurs within a
movement area associated with the operation of an aircraft that affects or
could affect the safety of flight. After adopting ICAO's definition of a
runway incursion, FAA began classifying some incidents formerly classified
as surface incidents as incursions.

The number and rate of runway incursions rose in the 1990s before peaking
in fiscal year 2001 (see fig. 2). In fiscal year 2001, there were 407
incursions at a rate of 6.1 incursions per 1 million air traffic control
tower operations, compared to fiscal year 2006, when there were 330
incursions at a rate of 5.4 incursions per 1 million tower operations. As
shown in fig. 2, the rate of incursions remained relatively constant from
fiscal year 2002 through fiscal year 2006, at an average rate of 5.2
incursions per 1 million tower operations. However, preliminary FAA data
indicate 370 incursions occurred during fiscal year 2007, representing a
rate of 6.05 incursions per 1 million air traffic control tower
operations. The preliminary rate of incursions for fiscal year 2007 is
about 12 percent higher than during fiscal year 2006 and is nearly as high
as when the rate of incursions reached a peak in fiscal year 2001.

Figure 2: Number and Rate of Runway Incursions from Fiscal Year 1998
through Fiscal Year 2007

Note: Fiscal year 2007 data are preliminary.

Since 2001, FAA has classified the severity of runway incursions into four
categories--A through D.^8 The number and rates of serious
incursions--categories A and B, where collisions were narrowly or barely
avoided--have continued to occur at about the same level from fiscal year
2002 through fiscal year 2006 at an average of about 30 serious incursions
per year and an average rate of 0.5 serious incursions per 1 million air
traffic control tower operations. Preliminary data indicate that 24
serious incursions occurred during fiscal year 2007, compared to 31 during
fiscal year 2006. The preliminary rate of serious incursions for fiscal
year 2007 is 0.39 per 1 million air traffic control tower operations,
which is about 24 percent less than during fiscal year 2006, when the rate
of serious incursions was 0.51 per 1 million tower operations.

Although most runway incursions involve general aviation aircraft,^9 about
one-third of the most serious incursions from fiscal year 2002 through
fiscal year 2007 (categories A and B)--about 9 per year--involved at least
one commercial aircraft that can carry many passengers (see fig. 3). For
example, on July 11, 2007, a collision between two aircraft carrying 172
people was narrowly averted at the Fort Lauderdale-Hollywood Airport in
Florida, when a Boeing 757 that had just touched down was able to become
airborne again to avoid hitting an Airbus A320 aircraft that was
approaching the same runway. An NTSB preliminary report indicated that the
two aircraft missed each other by less than 100 feet. According to NTSB,
it has investigated several near collisions in recent years that could
have been catastrophic if they had not been averted through pilot skill
and luck. Appendix III contains a list of serious incursions involving at
least one commercial aircraft during fiscal year 2006 and fiscal year
2007.

^8FAA defines category A as separation decreases and participants take
extreme action to narrowly avoid a collision, or the event results in a
collision; category B, separation decreases and there is a significant
potential for a collision; category C, separation decreases but there is
ample time and distance to avoid a potential collision; and category D,
there is little or no chance of collision.

^9According to FAA, 72 percent of incursions from fiscal year 2003 through
fiscal year 2006 involved at least one general aviation aircraft.

Figure 3: Total Number of Serious Incursions, Fiscal Year 2001 through
Fiscal Year 2007

Note: Fiscal year 2007 data are preliminary.

FAA officials, experts we surveyed, and officials at some airports that
have experienced the most incursions said that runway incursions were
caused by many different factors, including airport complexity, frequency
of runway crossings, the amount of air traffic, miscommunication between
air traffic controllers and pilots, a lack of situational awareness on the
airfield by pilots, and performance and judgment errors by air traffic
controllers and pilots. According to FAA, 54 percent of incursions from
fiscal year 2003 through fiscal year 2006 were caused by pilot errors, 29
percent were caused by air traffic controller errors, and 17 percent were
caused by vehicle operator or pedestrian errors.

In the United States, most runway incursions have occurred at major
commercial airports. Figure 4 shows the 10 U.S. commercial airports that
have experienced the most runway incursions from fiscal year 2001 through
fiscal year 2006 and the overall number of incursions and the number of
serious incursions that occurred at those airports during that time.

Figure 4: U.S. Commercial Airports that Experienced the Most Runway
Incursions from Fiscal Year 2001 through Fiscal Year 2006

In addition to incursions, overruns are a runway safety concern. When an
aircraft overruns the end of a runway during an aborted takeoff or while
landing, the results can be serious. In December 2005, for example, a
Southwest Boeing 737 overran the runway at the Chicago Midway Airport
during a snowstorm, ran through airport fencing, and collided with a car
on an adjacent roadway, resulting in one fatality (see fig. 5).^10 Since
2001, NTSB has investigated 12 runway overruns that resulted in 18
fatalities, usually involving smaller general aviation aircraft. NTSB
attributed the overruns primarily to pilot error, such as misjudgments of
speed and distance.

^10NTSB determined that the probable cause of that accident was the
pilots' failure to use available reverse thrust in a timely manner to
safely slow or stop the airplane after landing.

Figure 5: Photograph of the December 2005 Runway Overrun at Chicago Midway
Airport

FAA has established standards for runway safety areas, which are
unobstructed areas surrounding a runway, to enhance safety in the event
that an aircraft overruns, undershoots, or veers off a runway. FAA airport
design standards generally require commercial airports to establish, to
the extent practicable, 1,000-foot runway safety areas at both ends of a
runway.^11 In 1999, FAA established its Runway Safety Area Program,
administered by the Office of Airport Safety and Standards, to help
commercial airports meet runway safety area standards.^12 In 2005, FAA set
a goal of having commercial service airports make all practicable
improvements to runway safety areas by 2015.^13 Also in 2005, Congress
enacted legislation requiring the owner or operator of a commercial
service airport^14 to meet FAA runway safety area standards by December
31, 2015. The importance of establishing a runway safety area was
demonstrated during the crash of an American Airlines MD-82 in Little
Rock, AR, on June 1, 1999, when it overran the runway, went down a rock
embankment, and collided with a structure supporting a lighting system,
killing 11 passengers and crew. According to NTSB, the airport had a
runway safety area that was only 550 feet in length beyond the end of the
runway. Experts we surveyed said that runway overruns are caused by
factors such as pilot misjudgments about speed, altitude, or distance;
inadequate information on weather and runway conditions; and aircraft
equipment failure.

^11The 1,000-foot runway safety area standard was based on the results of
an FAA study of overruns from 1975 to 1987, which indicated that about 90
percent of overruns occurred within 1,000 feet of the runway end. FAA
runway safety area standards depend on the type of aircraft using a runway
and range from 120 feet wide by 240 feet beyond the end of the runways
used for smaller aircraft to 500 feet wide by 1,000 feet beyond the end of
the runways for larger aircraft.

^12In 2000, FAA started a program to accelerate the construction of runway
safety area improvements. Prior to 2000, FAA required that when
certificated airports undertook a major runways construction project, the
runway safety areas would be brought up to current standards to the extent
practicable.

Although not considered part of the movement area of an airport, ramp
areas can be dangerous for ground workers and passengers. Airport ramps
are typically small, congested areas in which departing and arriving
aircraft are serviced by ramp workers, including baggage, catering, and
fueling personnel. Other personnel present on ramps include airport
police, FAA officials, and other airport, airline, and vendor staff. The
presence of a large number of people utilizing equipment in a relatively
small area, often under considerable time pressure, creates an environment
in which injuries and fatalities and aircraft and equipment damage can
occur. Figure 6 shows an example of a ramp accident.

^13In a May 24, 2007, report to Congress, FAA indicated that it had hoped
that all runway safety area improvements would be complete by 2010 but
that 42 projects would not be completed until after 2010 because they are
often large and complex, requiring several years to complete.

^14The runway safety area requirement in Public Law 109-115, 119 Stat.
2401 (2005) is applicable to owners or operators of an airport that have
received an operating certificate under 49 U.S.C. S 44706.

Figure 6: Example of an Accident in an Airport Ramp Area

Activities in the ramp area can also affect the safety of air crew and
passengers once they leave the ramp area. Undetected aircraft damage from
ramp activities can cause in-flight emergencies. In December 2005, for
example, an Alaska Airlines MD-80 that had departed from Seattle to
Burbank, CA, experienced a sudden cabin depressurization. After the
aircraft safely returned to Seattle, it was discovered that a ramp vehicle
had punctured the aircraft fuselage, but the incident had not been
reported.

Aviation organizations have attempted to quantify the nature, extent, and
cost of ramp accidents. According to the experts we surveyed, these errors
occur as a result of multiple causes, such as carelessness, distractions,
confusion, and inadequate training of ramp workers; lack of supervision;
and time pressure. The Flight Safety Foundation, an aviation safety
research organization, has estimated that ground accidents worldwide cost
air carriers $10 billion annually, including costs associated with
injuries and fatalities and other indirect costs such as cancelled
flights.^15 However, these research efforts have also been hindered by a
lack of data. In a 2002 study of ramp worker accidents, FAA noted the
difficulty of obtaining nonfatality data.^16 The Flight Safety Foundation
also noted the limited amount of data available for its 2004 study of
damage and injury on airport ramps.^17

Federal Roles in Runway and Ramp Safety

FAA has primary federal responsibility for runway safety. Several FAA
offices carry out these responsibilities, including

           o the Air Traffic Organization, which manages air traffic
           control--including the hiring, training, and managing of more than
           14,300 air traffic controllers--and develops and maintains runway
           safety technology;
           o the Office of Runway Safety, created in 1999 as part of the Air
           Traffic Organization to lead and coordinate the agency's runway
           safety efforts--including developing a national runway safety plan
           and metrics for runway safety--and evaluate the effectiveness of
           runway safety activities;
           o the William J. Hughes Technical Center in Atlantic City, NJ,
           which conducts aviation safety research;^18 
           o the Office of Airports--which, as of July 2007, employed 45
           safety inspectors to check airports' compliance with
           regulations--develops standards for airport signage, markings, and
           lighting, and manages the agency's Runway Safety Area Program to
           address runway overruns;
           o the Office of Aviation Safety, which conducts safety inspections
           of airlines, audits air traffic safety issues, and administers a
           program to obtain information from pilots about the circumstances
           of runway incursions; and
           o the Civil Aerospace Medical Institute in Oklahoma City, which
           conducts aerospace medical and human factors research.
			  
^15Flight Safety Foundation officials noted that this estimate assumes 27
million departures annually, includes only International Air Transport
Association airlines, and is based mostly on foreign airline data. They
also noted that to determine injury costs, they extrapolated U.S. injury
costs across the world, perhaps resulting in injury cost estimates higher
than they actually would be.

^16FAA, Report to Congress: Injuries and Fatalities of Workers Struck by
Vehicles on Airport Aprons, (Washington, D.C.: July 2002).

^17Flight Safety Foundation, Equipment Damage and Human Injury on the
Apron: Is It a Cost of Doing Business? (Alexandria, VA: 2004).

^18Other federal agencies such as DOT's Volpe National Transportation
Systems Center and the National Aeronautics and Space Administration also
conduct runway safety research.			  

           FAA's oversight of ramp areas is provided indirectly through its
           certification of airlines and airports.^19 FAA has statutory
           authority to investigate aviation accidents including those that
           occur in ramp areas.^20 Pursuant to an FAA order, it is
           responsible for "ensuring that all facts, conditions, and
           circumstances leading to the accident are recorded and evaluated
           and action is taken to prevent similar accidents."^21 According to
           NTSB officials, that agency also investigates aviation accidents,
           including incursions and overruns that result in accidents, and
           selected runway incursions--those that are the most severe or
           those that the board believes represent the most safety benefit.
           NTSB investigates ramp accidents when someone is onboard the
           aircraft, when flight is intended or when a death or serious
           injury or substantial damage to the aircraft occurs. Under the
           Occupational Safety and Health Act (OSH Act), OSHA has statutory
           authority to govern the occupational safety and health of
           employees.^22 According to OSHA officials, the agency investigates
           ramp accidents when they involve fatalities or the hospitalization
           of three or more employees and conducts workplace inspections in
           response to complaints from workers.^23 According to a 2000
           memorandum of understanding between OSHA and FAA relating to
           coordination and enforcement of the OSH Act, OSHA does not
           investigate accidents involving crew members on aircraft in
           operation.
			  
^19Primarily through 14 C.F.R. parts 119, 121, 135, and 139.

^2049 U.S.C. S 46101(a)(2).

^21FAA Order 8020.11B.

^2229 U.S.C. SS651 et seq.

^23OSHA conducts its work pursuant to the 1970 Occupational Safety and
Health Act and the general industry safety and health standards outlined
in 29 C.F.R. part 1910; however, neither contains provisions that pertain
specifically to the aviation industry.		

           Challenges Remain Despite Numerous Efforts to Address Runway Safety	  

           FAA has undertaken a number of efforts to address runway safety
           problems involving incursions and overruns. The agency has taken a
           layered approach to meet many of the runway safety strategic
           objectives it set in 2002. However, the lack of coordination and
           leadership among FAA's runway safety efforts, technology
           challenges, the lack of data, and human factors issues impede
           further progress in addressing runway safety. Because the number
           and rate of runway incursions did not decrease from fiscal year
           2002 through fiscal year 2006 and remains at a level higher than
           any time during the 1990s, FAA could take additional
           cost-effective measures to improve runway safety. These measures
           include ensuring that FAA's Office of Runway Safety operates as a
           coordinating entity for the agency's runway safety efforts, as
           well as establishing a new voluntary safety incident reporting
           program for air traffic controllers.
			  
			  FAA Uses a Layered Approach to Reduce the Risks of Runway Incursions
			  and Overruns

           FAA's layered approach to addressing runway safety includes a
           range of actions, such as deploying, researching, and testing new
           technology; encouraging airport improvements, such as changes to
           layout, markings, signage, and lighting; and providing human
           factors training for pilots and air traffic controllers. Our
           analysis found that FAA completed or was in the process of
           implementing 34 of the 39 runway safety objectives it set in its
           most recent national runway safety plan, issued in 2002, as a
           means of reducing the severity, number, and rate of runway
           incursions^24 (see app. IV). Most of the completed objectives
           involved (1) developing and distributing runway safety education
           and training materials to controllers, pilots, and other airport
           users; (2) supporting and developing new technologies intended to
           reduce the potential for runway collisions; and (3) assessing and
           modifying procedures to enhance runway safety.^25 The results of
           our survey of experts indicated that the most effective actions
           that FAA was taking were lower-cost measures, such as enhancing
           airport markings, lighting, and signage (see table 1). Some
           experts noted that markings, lighting, and signage help keep
           aircraft from becoming lost on the airfield and accidentally
           entering an active runway. The testing of runway status
           lights--technology that is more expensive to deploy than improving
           airport markings, lighting, and signage--is another action that a
           majority of the experts rated as being most effective. Further,
           one expert noted that all of FAA's actions in addressing runway
           incursions must be continued because one fix alone will not
           improve safety.
			  
^24FAA's 2002 national runway safety plan was developed in cooperation
with the Commercial Aviation Safety Team (CAST), a joint
government-aviation industry group formed to study aviation safety issues,
and encompassed 11 of the safety enhancements CAST identified as having
the greatest potential for improving runway safety from its Runway
Incursion Joint Safety Implementation Team.

^25Of the remaining 5 objectives not implemented, 4 were cancelled, and 1
objective concerning the deployment of technology was not met.			  

           Table 1: Experts' Ranking of the Most Effective FAA Actions to
           Address Runway Incursions

Ranking Action                                                             
1       Enhancing airport markings and lighting                            
2       Enhancing airport signage                                          
3       Approving perimeter taxiways, which provide aircraft with access   
           to gates without crossing active runways                           
4       Establishing Runway Safety Action Teams, groups of airport safety  
           stakeholders to identify and implement safety improvements         
4       Testing runway status lights, which provide a visible warning when 
           runways are not clear to enter or cross                            

           Source: GAO analysis of responses from survey of experts.

           Note: Rankings are based on responses from 22 experts and reflect
           the actions that a majority of experts indicated were "very
           effective" or "extremely effective."
			  
			    FAA Is Using Technology as a Major Part of its Risk Reduction Strategy

           Surface surveillance technology is a major part of FAA's strategy
           to improve runway safety. FAA has deployed the Airport Movement
           Area Safety System (AMASS), which uses the Airport Surface
           Detection Equipment, model 3 (ASDE-3) radar,^26 and is deploying
           the Airport Surface Detection Equipment, Model X (ASDE-X) to
           provide ground surveillance, both of which give air traffic
           controllers better visibility of activity on the airfield and
           could help prevent collisions. FAA completed the deployment of
           ASDE-3/AMASS at 34 of the nation's busiest airports (see app. V)
           in 2003, and is now deploying ASDE-X at 35 major airports (see
           fig. 7). Although ASDE-3/AMASS and ASDE-X are both radar-based,
           ASDE-X integrates data from a variety of sources, including radars
           and aircraft and vehicle transponders, to give controllers a more
           complete view of airport activities.^27 ASDE-3/AMASS and ASDE-X
           are both designed to provide controllers with alerts when the
           system detects a possible collision.
			  
^26AMASS is essentially the safety logic, which is designed to detect
potential collisions, for ASDE-3. This combined technology is usually
referred to as ASDE-3/AMASS.

^27Other sources of ASDE-X data include multilateration, which is a group
of antennas used to obtain position information on aircraft. Each ASDE-X
airport has between 10 and 20 antennas.

Figure 7: Airport Surface Detection Equipment, Model X (ASDE-X) Deployment
Sites

Note: ASDE-X-commissioned airports identified in bold.

Runway status lights, which FAA is testing at the Dallas-Ft. Worth
International Airport and the San Diego International Airport, are a
series of lights embedded in the runways that give pilots a visible
warning when runways are not clear to enter, cross, or depart on.^28 They
are a fully automatic, advisory safety system requiring no input from
controllers, and
currently consist of takeoff hold lights and runway entrance lights (see
fig. 8).^29 Ten of 17 experts^30 we surveyed indicated that FAA's testing
of runway status lights was very or extremely effective in addressing
runway incursions. Surface surveillance systems, such as ASDE-3/AMASS and
ASDE-X, provide the data needed to operate runway status lights, and the
systems' safety logic assesses any possible conflicts on the airfield and
provides alerts of potential collisions.

^28FAA is testing both takeoff hold lights and runway entrance lights with
ASDE-X at the Dallas-Ft. Worth International Airport and is testing runway
entrance lights with AMASS at the San Diego International Airport.

^29According to FAA, future additions to the runway status lights system
could include runway intersection lights and lights to warn pilots exiting
at high speeds about traffic on closely-spaced parallel runways.

^30Twenty-two experts responded to our survey, but the number of
respondents for each question varies because we asked them to answer
questions only within their areas of expertise. In addition, some
respondents answered "don't know/no basis to judge" to certain questions.

Figure 8: Runway Status Lights System

Another technology that FAA is testing, the Final Approach Runway
Occupancy Signal, is designed to provide a visible warning to aircraft on
approach. This system, which is being tested at the Long Beach (Daugherty
Field) airport in California, activates a flashing light visible to
aircraft on approach as a warning to pilots when a runway is occupied and
hazardous for landing. FAA is also testing low cost surface surveillance
systems for small to medium airports at the Spokane International
Airport.^31 FAA would need to certify a low cost surface surveillance
system before it could be used at airports in the United States. A low
cost surface surveillance system is being used at 44 airports outside of
the United States.

  Infrastructure Improvements and Research Efforts Are Being Made to Prevent the
  Risk of Collisions

Some airports are also making changes to their runways and taxiways to
reduce the risk of collisions. FAA has helped fund, for example, the
construction of perimeter taxiways (also called end-around taxiways) that
provide aircraft with access to gates without crossing active runways. As
discussed earlier in this report, the crossing of active runways is one of
the many causes of incursions. The Hartsfield-Jackson Atlanta
International Airport opened a perimeter taxiway in April 2007, and the
Dallas-Ft. Worth International Airport plans to open one in October
2008.^32 According to Atlanta airport officials, use of the perimeter
taxiway eliminates about 560 aircraft runway crossings per day, or about
one-third of the airport's total daily runway crossings.^33 Figure 9 shows
the typical route that aircraft landing on the northern runways at the
Hartsfield-Jackson Atlanta International Airport would take to taxi to the
gate without using the perimeter taxiway. Figure 10 shows that, by using
the perimeter taxiway, aircraft landing on the northernmost runway no
longer need to cross a parallel runway to reach the gates. Eleven of 16
experts we surveyed indicated that FAA's approval of perimeter taxiways
was very or extremely effective in addressing runway incursions.

^31According to an FAA official, by contrast to ASDE-X, which uses
multiple sensors, low cost surface surveillance systems collect data using
a single sensor.

^32Hartsfield-Jackson Atlanta International Airport officials said the
perimeter taxiway cost $48 million. An official from the Dallas-Ft. Worth
International Airport said its perimeter taxiway will cost about $63.8
million. FAA indicated that it provided about $26 million in Airport
Improvement Program funds for the perimeter taxiway at the
Hartsfield-Jackson Atlanta International Airport and about $47.3 million
for the perimeter taxiway at the Dallas-Ft. Worth International Airport.

^33Certain large aircraft, such as the Boeing 747, Boeing 777, Airbus
A330, and Airbus A340 cannot use the perimeter taxiway because of their
large wingspans.

Figure 9: Aircraft Taxiing Routes at the Hartsfield-Jackson Atlanta
International Airport Without Using the Perimeter Taxiway

Figure 10: Aircraft Taxiing Route at the Hartsfield-Jackson Atlanta
International Airport Using the Perimeter Taxiway

FAA has also helped fund other runway and taxiway changes at various
airports. For example, the Los Angeles International Airport, the U.S.
commercial airport that has experienced the most runway incursions in
recent years, is modifying its runway and taxiway configuration in an area
where many of the incursions have occurred.^34 FAA and airports have made
many runway safety improvements at airports that were identified by local
and regional Runway Safety Action Teams, which are groups of FAA and
airport officials, as well as other aviation safety stakeholders, which
were formed as part of the agency's runway safety program in 2002. In
addition, FAA has standardized airport signage and markings, including
issuing new standards for surface markings that require the use of glass
beads for better reflectivity, requiring new taxiway markings that alert
pilots that they are approaching runway entrances, and doubling the size
of markings indicating where aircraft should hold before proceeding onto
the runway. A majority of the experts we surveyed confirmed the measures'
effectiveness, indicating that FAA's enhancement of airport markings,
lighting, and signage was very or extremely effective.^35

FAA has funded runway safety research that has led to the testing and
deployment of new technology and other measures. During fiscal year 2006,
FAA spent about $3.5 million on runway incursion prevention research at
its William J. Hughes Technical Center on projects such as visual
guidance, including signs and lighting; and about $55,000 on research at
its Civil Aerospace Medical Institute regarding vehicle incursions and
operational errors. Also during fiscal year 2006, FAA funded about $1
million for runway safety-related research that was conducted at DOT's
Volpe National Transportation Systems Center on projects such as runway
status lights, analyses of runway incursion data, FAA's runway incursion
severity calculator, and the electronic flight bag.^36

^34This modification is being made by moving the southernmost runway 55
feet farther away from its parallel runway to accommodate the construction
of a centerfield taxiway between the two runways. According to a Los
Angeles World Airports official, the Los Angeles International Airport is
spending $333 million for the south airfield improvements, of which FAA
funded $98 million, including $29.6 million for the new center taxiway.

^35Fifteen of 22 respondents indicated that FAA's enhancement of airport
markings and lighting was very or extremely effective and 14 indicated
that FAA's enhancement of airport signage was very or extremely effective.

^36An electronic flight bag is an electronic display system that gives
pilots a variety of aviation data such as aircraft operating manuals and
navigational charts. Electronic flight bags range from laptop-like devices
that are independent of the aircraft for use on existing fleets to
displays permanently installed in the cockpits of newer aircraft.

  FAA Training and Industry Outreach Includes Human Factors Issues

Because most incursions are caused by human error, FAA is making outreach
and awareness efforts to address errors made by pilots, air traffic
controllers, and airport vehicle operators. The agency issued booklets in
2004 and 2005 for pilots that highlight communication procedures for safe
surface operations at towered and nontowered airports. In collaboration
with the aviation industry, FAA helped to create two online courses that
educate pilots on runway safety and conducts safety seminars for pilots
across the country to encourage safe practices on the airfield. To enhance
air traffic supervisor and controller education, FAA is developing for
training purposes simulated recreations of actual incursions. In addition,
in recent years, FAA developed and initiated controller training on human
factors, including skills enhancement regarding teamwork, communication,
problem solving, situational awareness, and managing workloads. FAA also
provided airline maintenance personnel operating "tug and tow" vehicles
with best practices while operating on the airport surface and requires
driver training programs for all airport workers who access the airfield
movement areas at commercial airports. Many of the items implemented as a
result of recommendations made by Runway Safety Action Teams also involved
human factors. FAA data indicated that Runway Safety Action Teams
recommended 4,441 action items for implementation between April 2001 and
mid-December 2006. Of these, 3,338 actions, or about 75 percent, were
completed, with the largest combined grouping (945 actions) relating to
pilots, air traffic controllers, and vehicle drivers regarding actions
such as training and improved procedures. Ten of 19 experts we surveyed
indicated that FAA's establishment of Runway Safety Action Teams was very
or extremely effective in addressing runway incursions. Only 5 of 22
experts we surveyed indicated that FAA's pilot educational initiatives
were very or extremely effective and 8 of 21 experts said that FAA's air
traffic controller training was very or extremely effective in addressing
runway incursions.

  FAA and Airports Have Improved Runway Safety Areas in Case of Overruns

To address runway overruns, FAA and airports have made progress in recent
years to bring runway safety areas into compliance with FAA standards.
According to FAA, as of May 2007, 70 percent of the 1,014 runways at 573
commercial airports in the United States substantially comply^37 with
runway safety area standards, up from 55 percent in 2000. Progress has
also been made in bringing runways at the nation's busiest airports into
compliance with FAA runway safety area standards pursuant to the
congressional mandate to have all airports in compliance by December 31,
2015. As of June 2007, 21 of 47 runways at the 10 busiest U.S. commercial
airports did not meet FAA runway safety area standards,^38 down from 30
runways at those airports that did not meet standards in October 2006.
Increased compliance with runway safety area standards reduces the chance
of aircraft being damaged from overruns.

^37FAA considers runway safety areas that meet 90 percent of the standards
to be in substantial compliance.

Recognizing the difficulties of meeting the runway safety area standards
at airports that do not have enough space to establish 1,000-foot runway
safety areas, FAA conducted research during the 1990s that led to the
development of the Engineered Materials Arresting System (EMAS), a bed of
crushable concrete designed to stop overrunning aircraft. In 1999, FAA
began accepting EMAS as an alternative to constructing a runway safety
area when its construction is not practicable and, in 2004, began
considering EMAS as generally equivalent to a full-length runway safety
area. As of June 2007, EMAS was installed at 24 runway ends at 19 U.S.
airports and 12 additional EMAS systems were under contract at 8 airports.
In addition, EMAS had successfully stopped four aircraft that had overrun
runways, including a Boeing 747 that overran a runway at the John F.
Kennedy International Airport in January 2005 and was traveling at an exit
speed of about 70 knots, or about 80 miles per hour. Figure 11 shows an
example of how EMAS can stop an aircraft. The effectiveness of this
measure was supported by a majority of experts we surveyed, who indicated
that FAA's acceptance of EMAS as an alternative to constructing a runway
safety area when its construction is not practical was very or extremely
effective in addressing runway overruns.^39 One expert, for example, said
that because many airports no longer have the ability to expand existing
runway safety areas, EMAS may be the only practical solution. Other
experts noted that preventive measures, such as training to improve pilot
skills, are also needed.

^38Those airports include Chicago O'Hare International Airport, with six
runways that did not meet runway safety area standards as of June 2007;
Houston's George Bush Intercontinental Airport, with five runways that did
not meet standards; and Los Angeles International Airport, with four
runways that did not meet standards. Busiest airports were identified from
preliminary 2006 enplanement data.

^39Twelve of 16 experts indicated that FAA's acceptance of EMAS as an
alternative to constructing a runway safety area when its construction is
not practical was very or extremely effective in addressing runway
overruns.

Figure 11: Example of How EMAS Can Stop an Aircraft

Since 2000, about $300 million per year from FAA's Airport Improvement
Program has been spent on runway safety area improvements, and $1.1
billion is expected to be needed to complete the remaining 207 projects.
FAA officials told us that, if the current funding levels are maintained
for the Airport Improvement Program, sufficient resources will be
available to complete the planned runway safety area improvements. An
official from an airport association said that even if sufficient airport
improvement funds are available for runway safety area improvements, all
airports will not be able to acquire the land needed to establish the
safety areas. Eleven of 14 experts we surveyed indicated that FAA's use of
airport improvement funds to construct runway safety areas was very or
extremely effective in addressing runway overruns.

Lack of Coordination and Leadership, Technology Challenges, Lack of Data, and
Human Factors Issues Impede Further Progress in Improving Runway Safety

Although FAA took many steps to address runway safety problems involving
incursions and overruns, especially since the number and rate of
incursions peaked in fiscal year 2001, its efforts have waned in recent
years, and the number and rate has remained steady. Additional measures by
FAA would enhance the coordination and leadership of runway safety issues,
technology, data collection and analysis, and human factors issues.

  FAA's Office of Runway Safety Is Not Carrying Out its Coordination and
  Leadership Functions

FAA is not following its order, issued in 2002, that directs the Office of
Runway Safety to coordinate and monitor activities throughout the agency
to ensure that runway safety goals are met.^40 The absence of coordination
and national leadership impedes further progress on runway safety because
no single office is taking charge of assessing the causes of runway safety
problems and taking the steps needed to address those problems. Under the
FAA order, FAA's Office of Runway Safety is to prepare a national runway
safety plan every 2 to 3 years and to provide updates as needed. However,
we found that the most recent national runway safety plan, issued in 2002,
is no longer being used and the status of its objectives are not being
tracked. FAA officials told us the national runway safety plan has been
replaced by the FAA Flight Plan, which is a high-level planning document
covering all of FAA's programs. However, we agree with the conclusion in a
May 2007 audit report by the DOT Office of Inspector General^41 that
replacing the national runway safety plan by the higher-level FAA Flight
Plan, with the goal of having each FAA office separately include its
runway safety initiatives in its own business plan, does not have the same
national focus and emphasis on runway safety that a national plan for
runway safety provides. In addition, although the Airports Office and the
Air Traffic Organization included runway safety objectives in their
business plans, the Office of Aviation Safety's business plan for fiscal
year 2007 did not include plans to reduce runway incursions.^42 Moreover,
the lack of a comprehensive, targeted plan has resulted in uncoordinated
efforts that may not be the most effective.

^40FAA Order 7050.1.

^41DOT Office of Inspector General, Progress Has Been Made in Reducing
Runway Incursions, but Recent Incidents Underscore the Need for Further
Proactive Efforts, Report No. AV-2007-050 (Washington, D.C.: May 24,
2007).

^42Under the 2002 national runway safety plan, 11 of the 39 objectives
were assigned to the Office of Aviation Safety's Flight Standards Service.

In addition, although FAA hired a permanent director at the Senior
Executive Service (SES) level for the Office of Runway Safety in August
2007, the Office of Runway Safety did not have a permanent director for
the previous 2 years, resulting in a lack of national program leadership,
and its staff was reduced by about 45 percent over the last 4 years.
Before 2004, the runway safety office had 66 full-time staff led by an
SES-level manager in headquarters, compared to about 37 full-time runway
safety staff led by a non-SES-level acting director as of May 2007.^43
Moreover, although contractors represented about 60 percent of the Office
of Runway Safety staff in 2004,^44 funding for the office's contract
employees was reduced from about $4 million in 2005 to about $2.5 million
per year in 2007. An FAA official told us that because the Office of
Runway Safety relied heavily on contractors for staff, it lacked a career
path for potential managers in the field and at headquarters and lost
expertise that the contractors had developed when their contracts expired.
In addition, as of May 2007, the Office of Runway Safety no longer had as
many full-time detailees from other FAA offices with runway safety
responsibilities, including FAA's Airports and Air Traffic Organization's
Terminal Service offices, as it had in the past.

Several FAA officials and others said that the lack of leadership in the
Office of Runway Safety had negatively affected the program. A regional
runway safety program manager said, for example, that having had no
permanent director for the office resulted in a lack of direction from
headquarters, leaving regions to carry out runway safety efforts in
different ways. This situation prevents FAA from identifying systemwide
causes of runway safety problems that may require coordinated solutions.
Furthermore, an official currently working on the runway safety program
said that no quarterly performance review meetings were held between the
Acting Director of Runway Safety and the regional runway safety program
managers for over a year during 2006 and 2007. These meetings had been
held, for example, to discuss regional initiatives. Such sharing of
information between regions could help address runway safety issues from a
national perspective and implement changes systematically. FAA research
officials also told us that after having completed a study for the Runway
Safety Office, they could not find anyone to give it to in FAA
headquarters. The new permanent director of the Office of Runway Safety
indicated that the office plans to restart some initiatives, including
conducting quarterly runway safety performance reviews, starting in
December 2007. However, other plans for the office are still being
developed.

^43In addition to his duties as acting director of the Office of Runway
Safety, this official was also a regional runway safety director.
Officials in the Air Traffic Organization's Office of Safety Services
assisted the acting director in carrying out his duties.

^44Contractors represented 40 of the 66 Office of Runway Safety employees
before 2004 and 21 of the 37 employees in 2007.

  Technology Challenges Impede Progress in Improving Runway Safety

FAA has faced significant challenges in deploying and developing
technology for runway safety. Technology currently being installed,
ASDE-X, has experienced cost increases and schedule delays from its
original baselines, and is encountering some operational difficulties.^45
At the same time, additional technology to prevent runway collisions is
years away from deployment. Because FAA relies heavily on technology as
part of its runway safety strategy to supplement a controller's vision of
the airfield, these challenges impede progress in addressing runway
safety.

FAA has revised its cost and schedule plans twice since 2001 to deploy
ASDE-X at 35 airports by 2011. The current program costs have increased by
about $125 million over the 2001 estimate, as FAA added nine airports to
its deployment schedule (see table 2). FAA currently estimates that the
total ASDE-X program cost will be about $806 million, including the cost
to operate and maintain the system through fiscal year 2030. This includes
facilities and equipment costs of about $550 million, which is
approximately $40 million more than what we reported in 2005, plus about
$257 million in operations and maintenance costs. As of August 2007,
ASDE-X was commissioned^46 at 11 airports. Regarding their plans to deploy
ASDE-X to the remaining 24 airports by 2011, FAA officials said that they
had focused their efforts at the beginning of the program on software
development, which is nearly complete, and on system enhancements, which
have been completed, allowing them now to concentrate on system
deployment. In addition, FAA officials said in November 2007 that ASDE-X
deployment is ahead of the agency's revised 2005 schedule and that costs
have remained consistent with its revised 2005 cost estimate. Nonetheless,
as discussed below, our concerns about the schedule plans for ASDE-X
remain.

^45We are conducting ongoing work on how FAA factors cost increases and
schedule delays for systems such as ASDE-X into its acquisition
performance measurement.

^46FAA refers to ASDE-X as being commissioned after the system has been
tested at an airport and demonstrated that the field site personnel can
fully operate and maintain it.

Table 2: Changes in ASDE-X Equipment Cost and Deployment Completion Dates

                                               2002                           
                             2001 estimate estimate 2005estimate 2007estimate 
Cost targets                     $424.3   $505.2       $549.8       $549.8 
Number of planned                    26       33           35           35 
operational systems                                                        
Deployment completion              2007     2007         2011         2011 
targets                                                                    

Source: GAO analysis of FAA data.

Note: Cost is millions of dollars.

Although it took about 4 years for ASDE-X to be commissioned at those 11
airports, FAA plans to deploy the system at the remaining 24 additional
airports in less than 4 years (see app. V). Furthermore, not all 11 ASDE-X
commissioned airports have key safety features of the system. For example,
as of August 2007, three of the ASDE-X commissioned airports did not have
safety logic, which generates a visible and audible alert to an air
traffic controller regarding a potential runway collision. Moreover, five
airports, including the three lacking safety logic, do not have a system
enhancement that allows ASDE-X to alert controllers of potential
collisions on intersecting runways or runways intersecting taxiways during
inclement weather (see table 3). Because of these issues, the DOT
Inspector General reported,^47 and we agree, that the program is at risk
of not meeting its current cost and schedule plans to deliver ASDE-X
systems at 35 airports by 2011.

^47DOT Office of Inspector General, Actions Needed To Reduce Risk with the
Next Generation Air Transportation System, CC-2007-047 (Washington, D.C.:
May 9, 2007) and FAA Needs to Improve ASDE-X Management Controls to
Address Cost Growth, Schedule Delays, and Safety Risks, AV-2008-004
(Washington, D.C.: Oct. 31, 2007).

Table 3: ASDE-X Commissioned Airports as of August 2007

                                       Commissioned     Safety System         
Airport                             date             logic  enhancements^a 
General Mitchell International      October 30, 2003 Yes    Yes            
Airport (Milwaukee, WI)                                                    
Orlando International Airport       September 30,    Yes    Yes            
                                       2004                                   
Theodore Francis Green State        May 16, 2005     No     No             
Airport (Providence, RI)                                                   
William P. Hobby Airport (Houston,  August 31, 2005  No     No             
TX)                                                                        
Seattle-Tacoma International        February 24,     Yes    No             
Airport                             2006                                   
Lambert-St. Louis International     May 24, 2006     Yes    No             
Airport                                                                    
Hartsfield-Jackson Atlanta          June 7, 2006     Yes    Yes            
International Airport                                                      
Bradley International Airport       June 21, 2006    No     No             
(Hartford, CT)                                                             
Louisville International-Standiford July 19, 2007    Yes    Yes            
Field                                                                      
Chicago O'Hare International        August 29, 2007  Yes    Yes            
Airport                                                                    
Charlotte Douglas International     August 30, 2007  Yes    Yes            
Airport (Charlotte, NC)                                                    

Source: FAA.

^aThese enhancements include rain configuration, which maintains the system
functioning during inclement weather such as moderate or heavy rain;
converging taxiway logic, which generates an alert when an aircraft or
vehicle on a taxiway is predicted to enter a runway; intersecting runway
alerts, which generate alerts when aircraft are predicted to collide at
intersecting runways; and tower configuration, which directs an alert
regarding potential conflicts on particular runways to certain
controllers.

Recent serious runway incursions at airports with fully operational runway
safety technology reveal persistent problems with their alerting
functions. For example, air traffic controllers at eight airports with
ASDE-3/AMASS told us that the alerting function does not work well during
heavy precipitation and that they disable the alerting function during
inclement weather.^48 As a result, air traffic controllers at those
airports with ASDE-3/AMASS do not have the benefit of an incursion
alerting system in poor weather conditions, when it may be most needed.
Furthermore, the ASDE-X commissioned airports are experiencing problems
with false alerts, which occur when the system incorrectly predicts an
impending collision, and false targets, which occur when the system
incorrectly identifies something on the airfield as an aircraft or vehicle
and could generate a false alert. (These problems are discussed in more
detail below.) Although FAA officials acknowledged that ASDE-X is
experiencing problems with false alerts, they said the system is operating
within specifications. An April 2007 FAA internal audit of the
ASDE-3/AMASS and ASDE-X safety logic systems concluded that the runway
safety logic system was not providing consistent information to
controllers, creating a lack of confidence in the system.^49 Furthermore,
NTSB, after several investigations of incursions at airports equipped with
ASDE-3/AMASS, determined that the alerting process was ineffective because
the delay was too long before pilots would receive the alert relayed by
controllers. As a result, NTSB asked that FAA develop a system that
provides a direct warning to the cockpit.^50

^48FAA officials said that due to the nature of radar, heavy rain has the
potential to degrade system performance, but that all radar systems have
similar limitations. However, they also said that ASDE-X performs much
better in all levels of rain than the ASDE-3/AMASS system.

Of the 11 ASDE-X commissioned airports, the control tower at the
Seattle-Tacoma International Airport reported the most problems with false
targets.^51 In addition, of the eight ASDE-X commissioned airports with
the alerting function, the control tower at the Hartsfield-Jackson Atlanta
International Airport reported the most problems with false alerts.^52
When an ASDE-3/AMASS or ASDE-X alert sounds, air traffic controllers are
required to instruct landing aircraft to follow a go-around procedure,
sending the aircraft back into the airspace for another landing attempt,
even if nothing is visible on the runway that could cause a collision.^53
The controllers said the effect of this practice is to increase air
traffic and flight times. Officials from the ASDE-X manufacturer said an
elevated number of false targets, on average, at the Seattle-Tacoma
International Airport is caused primarily by the location of the surface
movement radar relative to the airport facility structures, the movement
area, and the airport's configuration. The location of these structures is
determined by FAA and the airports. Officials from the manufacturer also
said ASDE-X at the Hartsfield-Jackson Atlanta International Airport is
experiencing an elevated number of nuisance alerts, which are caused by
real conditions that are not safety threats, such as a vehicle on a
runway, but landing aircraft are far enough from the airport not to
constitute a threat. They said the nuisance alerts being experienced at
the Hartsfield-Jackson Atlanta International Airport are caused by the
site-specific configuration parameters of the system, and that they are
working with air traffic controllers, FAA engineers, and the ASDE-X
program office to adjust the parameters of the system to minimize the
nuisance alerts while maintaining the required performance. The officials
noted the difference between nuisance alerts and false alerts, which are
issued after the system detects potential threats that are not real. The
officials said they examine false alerts very closely with FAA and
determine whether to make design modifications to the system to ensure
that they are minimized.

^49Audit of Runway Safety Logic Systems, FAA Air Traffic Safety Oversight
Service, Audit Project Number: ADT-FY-07-001 (Washington, D.C.: April 16,
2007).

^50According to NTSB, simulations of ASDE-3/AMASS performance using data
from actual incursions showed that alerts may occur as little as 8 to 11
seconds before a potential collision.

^51The air traffic control tower at the Seattle-Tacoma International
Airport reported 306 false targets from January 27, 2006, though May 17,
2007. According to FAA, 261 of these false targets have been addressed by
an adaptation or software change, and very few were related to system
malfunctions.

^52We reviewed the daily records of air traffic control tower operations
at the Hartsfield-Jackson Atlanta International Airport and found that 41
false alerts were recorded from June 7, 2006, to May 16, 2007.

^53FAA Order 7110.65R.

FAA ASDE-X program officials said that the problems with false alerts and
false targets are site-specific, rather than systemic issues, relating to
the location of sensors and radar towers. The officials said they are
working to address the problems by adjusting the sensitivity of the
systems, which they described as a time-consuming, continuous process with
no single fix. For example, they said that at the Seattle-Tacoma
International Airport, the system's level of sensitivity was increased at
the site's request because of its experience with heavy fog, and that a
certain number of false targets cannot be eliminated without sacrificing
the sensitivity. At the same time, FAA officials acknowledged that the
location of the ASDE-X surface movement radar at the Seattle-Tacoma
International Airport has affected system performance much more than
originally anticipated. FAA also noted that all radar systems experience
false targets as a function of detection and that the majority of false
targets at the Seattle airport occurred on taxiways near the terminal.
They also said that new software being deployed at airports starting in
September 2007 would help address the problems involving false alerts and
that with the addition of the new software, ASDE-X is operating under
system requirements not to generate more than two false alerts within 24
hours. This software enhancement was deployed at the Hartsfield-Jackson
Atlanta International Airport in September 2007, and FAA program officials
said they believe it has resulted in improved ASDE-X system performance.
We were not able to confirm this information.

Only 3 of 17 experts we surveyed indicated that FAA's deployment of
ASDE-3/AMASS was very effective,^54 and 4 of 17 experts said that ASDE-X
was very or extremely effective in addressing runway incursions.^55 One
expert, for example, said that ASDE-X appears to be a great technology to
aid controllers, but is not trustworthy at this point because the rate of
false alerts is somewhat high. In addition, this expert said that because
ASDE-X has been deployed only to a few airports, it is not doing much to
address runway incursions within the national airspace system as a whole.
Another expert said that ASDE-X and runway status lights would greatly
enhance both pilot and air traffic controller awareness, particularly at
complex airports.

Most airports in the United States have no runway safety technology to
supplement a controller's vision of the airfield and will not have such
technology even after FAA completes its plan to deploy ASDE-X at 35 major
airports. FAA's original plans called for 34 airports to receive
ASDE-3/AMASS and 35 airports to receive ASDE-X. In total, 59 airports^56
were to receive either technology, but this number was reduced to 44 in
August 2006 after FAA canceled plans to deploy ASDE-X at 15 of the
originally scheduled airports.^57 The 35 major airports to receive ASDE-X
handle 70 percent of the enplanements at U.S. airports but represent only
6 percent of all U.S. commercial airports,^58 leaving most airports
without this type of technology. Six of 12 experts who indicated that they
had knowledge of or experience with the deployment of ASDE-X indicated
that, considering the benefits and problems with ASDE-X, including false
alerts and false targets, deployment of the system at the remaining 27
airports^59 by 2011 should be kept as planned, 4 said that deployment
should be accelerated, and 2 said that deployment should be slowed down.
One expert, for example, who indicated that the deployment of ASDE-X
should be kept as planned, said that the problems with the system will be
worked out as the system is deployed.

^54Of the 17 respondents, 3 said ASDE-3/AMASS was very effective, 9
moderately effective, 4 slightly effective, and 1 not at all effective.

^55Of the17 respondents, 1 said ASDE-X was extremely effective, 3 said it
was very effective, 10 said it was moderately effective, and 3 said it was
slightly effective.

^56Ten airports that were scheduled to receive ASDE-X already had
ASDE-3/AMASS.

^57FAA's rebaseline of the ASDE-X program, which was approved by the
agency's Joint Resources Council, was conducted on the basis of analyzing
the safety and efficiency benefits of deploying the system at the 59
top-tier airports. The analysis assumed that maximum benefit was derived
from deploying ASDE-X at airports with larger traffic counts and/or more
complex operations. Sunk costs, such as site preparation that was already
underway, were also considered. However, we found that FAA's ASDE-X
business case did not include year-by-year estimates of benefits and costs
or a sensitivity analysis, as required for all investment decisions by
Office of Management and Budget (OMB) Circular A-94. A sensitivity
analysis is a quantitative assessment of the effect that a change in an
assumption--the numerical value of a single parameter--will have on net
present value. In commenting on a draft of this report, FAA officials said
that they had computed year-by-year analyses and conducted a sensitivity
analysis. However, this information was not included in FAA's business
case for ASDE-X for the entire 30-year lifecycle investment, as required
by OMB.

^58There were approximately 570 airports used by commercial service
aircraft in 2006.

FAA is testing additional runway safety technology, but these systems are
still years from being deployed in the United States. Runway status
lights, which warn pilots when runways are unsafe to enter or cross, have
had positive preliminary test evaluations, but need a surface surveillance
system such as ASDE-3/AMASS or ASDE-X to operate. FAA officials expect to
decide in 2007 whether to deploy runway status lights at the 35 ASDE-X
airports at an estimated cost of $300 million but do not expect to make a
final investment decision on another runway safety lighting technology,
the Final Approach Runway Occupancy Signal, which provides a visible
warning to aircraft on approach, for another 2 years. In addition, an FAA
official said the agency is still exploring the capabilities of the low
cost surface surveillance system and does not yet have a deployment
schedule. Only 2 of the experts we surveyed indicated that FAA's testing
of the low cost surface surveillance system was very effective in
addressing runway incursions.^60 FAA announced in March 2007 that it was
changing the certification process to enable the use of electronic flight
bags (electronic display systems that give pilots a variety of aviation
data such as aircraft operating manuals and navigational charts) and
airport moving maps,^61 which can show an aircraft's position on an
airfield, but a system that shows the location of other aircraft on the
airfield is still under development. In addition, although officials from
the Hartsfield-Jackson Atlanta International Airport cited the benefit of
reducing aircraft runway crossings from using the airport's new perimeter
taxiway, FAA officials said that few U.S. airports have the space to
construct perimeter taxiways and noted that they are expensive to
construct.

^59At the time the survey was administered, ASDE-X had not yet been
commissioned at 27 of the 35 airports.

^60Of 8 respondents, 2 said it was very effective, 3 moderately effective,
and 3 slightly effective.

^61Most electronic flight bags contain moving maps, which help pilots
identify and anticipate an airplane's location on runways and taxiways.

  Lack of Runway Incident Data Impedes Causal Analysis

In addition to its technological challenges, FAA lacks reliable runway
safety data and the mechanisms to ensure that the data are complete. FAA's
tabulation of the number of incursions does not reflect the actual number
of incidents that occur. FAA only counts incursions that occur at airports
with air traffic control towers, so the actual number of incursions,
including those that occurred at airports without air traffic control
towers, is higher than FAA reports. In addition, FAA's information on
incursions that occurred at towered airports may not be complete,
according to some experts we surveyed. For example, one expert said that
the airline industry's reporting of runway incursions is higher than FAA's
data and that most or all air carriers are aware of significant events
that controllers failed to report. Although the airline industry provides
data to FAA on safety incidents that may involve runway incursions, the
information lacks sufficient specificity for FAA to use in its tabulation
of incursions.

Furthermore, although FAA requires errors^62 that may result in incursions
to be reported, the information collected does not always contain complete
data on the causes and circumstances involved. Without more complete data,
FAA cannot conduct in-depth analyses to ensure that the most effective
corrective measures that address the causal factors are being implemented.
An FAA program to obtain detailed information about the circumstances
regarding runway incursions by administering questionnaires to pilots
involved in incursions--the Runway Incursion Information and Evaluation
Program--could help to identify root causes of pilot deviations and
provides a mechanism to obtain information that may not otherwise be
reported. However, only 19 percent of pilots involved in runway incursions
and surface incidents participated in the program during 2004 through
2006, and FAA did not provide any evidence that it analyzed the data that
were collected.

^62These errors include operational errors, which FAA defines as an action
by an air traffic controller that results in less than the required
minimum separation between two or more aircraft, or between an aircraft
and an obstacle (e.g., vehicles, equipment, personnel on runways);
operational deviations, which are defined as an occurrence attributable to
an element of the air traffic system in which applicable separation minima
were maintained, but an aircraft, vehicle, equipment, or personnel
encroached upon a landing area that was delegated to another position of
operation without prior coordination or approval; pilot deviations, which
are defined as actions by pilots that violate any Federal Aviation
Regulation; and vehicle/pedestrian deviations, which are defined as
vehicles, pedestrians, or other objects interfering with aircraft
operations by entering or moving on the movement area without
authorization from air traffic control.

Certain FAA efforts that are in the early stages have the potential to
improve runway safety data. For example, FAA plans to start a nonpunitive,
confidential, voluntary reporting program for air traffic controllers,
similar to the Aviation Safety Action Program^63 as part of the FAA safety
management system.^64 The program will enable air traffic controllers to
report anything that they perceive could contribute to safety risks in the
national airspace system. The benefit of such program is that the
information obtained might not be reported otherwise, and could increase
the amount of data collected on the causes and circumstances of runway
incursions. Many industry stakeholders such as the National Air Traffic
Controllers Association, the Air Transport Association, the Air Line
Pilots Association, and the Air Safety Foundation, support establishing
such a program, which could also help reduce any underreporting of
incidents. FAA has been working on establishing such a program since 2004,
and indicated at a runway incursion meeting with the aviation community in
August 2007 that it would implement a short-term runway safety plan that
included implementing such a voluntary self-reporting program. According
to FAA, it signed a partnership agreement with the National Air Traffic
Controllers Association regarding the program in October 2007; however,
the agency did not indicate when the plan would be implemented.

We also found that FAA's categorization of the severity of runway
incursions involves a level of subjectivity, raising questions about the
accuracy of the data. An internal FAA audit of 2006 runway incursion data
found that the subjectivity of the severity classifications has the
potential to affect the accuracy of the classifications. The audit found
that incursion severity classifications were subjective and partially
incomplete. In addition, 18 percent of the incursion severity
classifications for 2006 were found not to be in compliance with FAA
severity classification requirements or could not be classified
accurately.^65 The audit also found that since August 31, 2006, the Office
of Runway Safety has been using a computer program called Runway Incursion
Severity Classification to calculate initial assessments of severity.^66
FAA indicated that use of the computer program ensures consistent ratings
based on available data. However, most of the information regarding
incursions, which is entered into the computer model, is based on
observations of incidents, rather than instrument readings, because many
airports do not have the technology needed to collect such information or
the information is not available to FAA, according to agency officials.^67
Observations regarding matters such as how close two aircraft came to
colliding on a runway may be less accurate than instrument readings and,
therefore, raise questions about the accuracy of the severity assessments.
These findings were supported by the experts we surveyed. The majority of
the experts who responded to a question about the accuracy of FAA's
incursion severity classifications indicated that, based on their
knowledge of specific incidents, FAA classified the incidents as being
less severe than they actually were.^68

^63This program seeks to improve aviation safety through the voluntary
self-reporting of safety incidents. Participants include employees of air
carriers and repair stations that have entered into a memorandum of
understanding with FAA. FAA does not take enforcement action against
employees who voluntarily self-reported safety violations for reports that
are sole-source and will pursue administrative action only for reports
that are not sole-source. Incidents that involve alcohol, drugs, criminal
activity, or intentional disregard for safety are not eligible for
self-reporting under the program. See GAO, Aviation Safety: FAA's Safety
Oversight System Is Effective but Could Benefit from Better Evaluation of
Its Programs' Performance, [35]GAO-06-266T (Washington, D.C.: Nov. 17,
2005) and Aviation Safety: Better Management Controls are Needed to
Improve FAA's Safety Enforcement and Compliance Efforts, [36]GAO-04-646
(Washington, D.C.: July 6, 2004).

^64Safety management is a systematic, explicit, and comprehensive approach
for managing safety risk at all levels and throughout the entire scope of
an operation and lifecycle of a system.

^65Auditors found that 82 percent of the runway incursion assessments
complied with the severity classifications, 4 percent were not in
compliance, and that 13 percent of the incursions could not be accurately
classified due to insufficient guidance contained in FAA Order 7050.1,
which defines the severity classification categories.

^66The current method of evaluation is for the program to assign a
severity rating and then have the Air Traffic Organization assessment team
members vote to reach a consensus. If the assessment team's rating is
different from the program, then the Air Traffic Organization's Director
of Operational Services will make the final determination of severity. FAA
plans to complete its validation of the computer program in fiscal year
2008.

^67An FAA official said, for example, that the agency usually does not
receive information from aircraft flight recorders for its runway
incursion assessments.

^68Seven of 11 experts questioned the classifications and 4 said that the
incidents tended to be correctly classified.

Furthermore, FAA does not have complete information on ASDE-3/AMASS and
ASDE-X system abnormalities, which could be used to analyze the
performance of the systems' alerting functions. An internal FAA audit^69
concluded that 54 percent of all alerts--false and real--from the
ASDE-3/AMASS and ASDE-X systems and 40 percent of instances when the
systems' alerting functions were disabled were not recorded.^70 The audit
also found no evidence of alerting standards for the runway safety logic
systems, which limits the systems' capability of assessing risks and
providing timely alerts to air traffic controllers.

We also found that FAA does not systematically collect data on the number
of runway overruns that do not result in damage or injury that could be
used for analytical purposes to study trends and causes of these
incidents. FAA officials said it would be useful to collect such data
because it would help them tailor standards to what has actually occurred,
for example, how far an aircraft overran a runway before stopping.

  Controller Fatigue Continues to Be a Runway Safety Concern

Air traffic controller fatigue continues to be a human factors issue
affecting runway safety. In April 2007, for example, NTSB recommended that
FAA mitigate concerns about air traffic controller fatigue by (1) working
with the National Air Traffic Controllers Association to revise controller
work-scheduling policies and practices so controllers would have enough
sleep and to modify shift rotations to minimize disrupted sleep patterns
for controllers, and (2) developing a fatigue awareness and
countermeasures training program for controllers and for the personnel
involved in scheduling their work. In supporting its recommendation, NTSB
cited four instances from 2001 through 2006 when tired controllers made
errors while performing their duties that resulted in serious incursions.
NTSB said that although FAA regulations and policies place limits on
controller work schedules, for example, by requiring that controllers be
provided at least one full 24-hour day off per week, they do not
adequately consider the potential effect of work scheduling on fatigue and
performance. FAA officials said they were analyzing NTSB's recommendations
on air traffic controller fatigue but that implementing them would require
renegotiating the agency's contract with the union representing the
controllers.

^69Audit of Runway Safety Logic Systems, FAA Air Traffic Oversight
Service, Audit Project Number: ADT-FY-07-001 (Washington, D.C.: April 16,
2007).

^70FAA Order 7210.3 requires that when the safety logic system generates
any alert or is offline, it should be documented on the facility's air
traffic log.

According to FAA data, as of May 2007, at least 20 percent of the
controllers at 25 air traffic control facilities, including towers at
several major airports, were working 6-day weeks,^71 which could cause
fatigue. FAA officials said that it may take 2 to 3 years before
controller overtime can be reduced at some facilities, as the agency acts
to replace retiring controllers. In the meantime, the agency officials
indicated that they had no plan to mitigate the effects of air traffic
controller fatigue.

While FAA has taken some actions to address controller fatigue, problems
have been identified with some efforts. For example, an FAA human factors
initiative, the National Air Traffic Professional Program, is aimed at
identifying how controllers' performance can be affected by factors such
as fatigue and distraction. The program consists of training designed to
sharpen and maintain controllers' mental skills most closely associated
with visual attention and scanning. However, the DOT Inspector General
reported in May 2007^72 that the program had not been implemented at
towers where visual attention and scanning are key factors in preventing
runway incursions. Although FAA has taken some steps to address human
factors issues through the educational initiatives that were discussed
earlier, progress on addressing runway safety will be impeded until the
human factors issues involving fatigue are addressed.

^71FAA identified 25 facilities with 20 percent or greater of the
employees working a 6-day week and 4 percent or greater of the hours were
covered by overtime. The 25 facilities included 21 control towers and 4
terminal radar approach control facilities. Of 25 facilities, 12 had
between 20 and 29 percent of their controllers working 6-day weeks, 7 had
between 30 and 39 percent of their staff working 6-day weeks, and 6
facilities had between 40 to 52 percent of their controllers working 6-day
weeks. The 25 facilities included 7 control towers at airports that were
ranked among the 50 busiest FAA air traffic control towers in the country,
including Hartsfield-Jackson Atlanta International Airport, which is the
busiest airport in the country and had 52 percent of its controllers
regularly working 6-day weeks.

^72DOT Office of Inspector General, Progress Has Been Made in Reducing
Runway Incursions, but Recent Incidents Underscore the Need for Further
Proactive Efforts, Report No. AV-2007-050 (Washington, D.C.: May 24,
2007).

  FAA Has Not Implemented NTSB's Runway Safety Recommendations

FAA has not implemented any of NTSB's six runway incursion prevention
recommendations, made in 2000,^73 that FAA

           o require all airports with scheduled passenger service to deploy
           a ground movement safety system that will prevent runway
           incursions and provide a direct warning capability to flight
           crews;
           o require that all runway crossings be authorized by specific air
           traffic control clearance;
           o require that, when aircraft need to cross multiple runways, air
           traffic controllers issue an explicit crossing instruction for
           each runway;
           o discontinue the practice of allowing departing aircraft to hold
           on active runways at night or at any time when visibility
           conditions preclude arriving aircraft from seeing traffic on the
           runway in time to initiate a safe go-around maneuver;
           o adopt an ICAO landing clearance procedure that forbids multiple
           landing clearances for the same runway; and
           o require the use of ICAO phraseology for airport surface
           operations, and periodically emphasize to controllers the need to
           use this phraseology and to speak at reasonable rates when
           communicating with flight crews.

           Since NTSB made these recommendations 7 years ago, FAA has made
           some efforts to address them, but NTSB has not accepted FAA's
           responses. Regarding NTSB's recommendation that a direct incursion
           warning capability be developed for flight crews, FAA indicated in
           2006 that, among other efforts, it had successfully completed
           promising initial field tests of runway status lights at the
           Dallas-Ft. Worth International Airport but that additional tests
           would be needed to determine if the system could be deployed to
           airports throughout the country. An NTSB official told us that the
           board would need to evaluate the runway status lights system
           before it could determine whether the system would satisfy this
           recommendation. Regarding NTSB's recommendations that FAA change
           certain air traffic control procedures, FAA said that implementing
           the recommendations could possibly transfer the risk to another
           segment of the operation by increasing pilot and controller
           workload and radio frequency congestion, and causing unexpected
           and unnecessary go-around procedures. However, NTSB disagreed,
           indicating that it remained concerned about situations where
           pilots may be lost, or believed they have received permission to
           move to different positions other than those that air traffic
           controllers intended and that air traffic controllers should not
           clear aircraft to land on runways that are occupied by other
           aircraft.
			  
^73On August 28, 2007, NTSB made five additional runway safety
recommendations to FAA and others. These recommendations included (1)
requiring crewmembers on the flight deck to positively confirm and
cross-check the airplane's location at the assigned departure runway
before crossing the hold short line for takeoff, (2) requiring aircraft
operators install on their aircraft cockpits moving map displays or an
automatic system that alert pilots when a takeoff is attempted on a
taxiway or a runway other than the one intended, (3) requiring airports
implement enhanced taxiway centerline markings and surface painted holding
position signs at all runway entrances, (4) prohibiting the issuance of a
takeoff clearance during an airplane's taxi to its departure runway until
after the airplane has crossed all intersecting runways, and (5)
suggesting that controllers refrain from performing administrative tasks,
such as the traffic count, when moving aircraft are in the controller's
area of responsibility.

           Regarding NTSB's recommendation that FAA adopt ICAO phraseology,
           FAA indicated in 2004 that adopting certain ICAO phraseology would
           create inconsistency and nonstandardization throughout the
           national airspace system. However, NTSB noted that by not adopting
           the ICAO phraseology, FAA has not harmonized its phraseology with
           the rest of the world. Two of our survey respondents also
           suggested that FAA adopt ICAO phraseology in communications
           between the air traffic controllers and pilots. In August 2007,
           FAA announced that it plans to assess whether it needs to change
           the phraseology of taxi clearances given by controllers to better
           align with ICAO standards, among other planned actions.
			  
			    FAA Has Opportunities to Improve Runway Safety

           The results of our survey of experts indicated that the actions
           that FAA could take with the greatest potential to prevent runway
           incursions, considering costs, technological feasibility, and
           operational changes, were measures to provide information or
           alerts directly to pilots (see table 4). For example, the actions
           that FAA could take with the most potential were lighting systems
           that guide pilots as they taxi at the airport and technology that
           provides enhanced situational awareness on the airfield and alerts
           of potential incursions.

           Table 4: Experts' Ranking of the Actions that FAA Could Take with
           the Most Potential to Address Runway Incursions
			  
Ranking Action                                                             
1       Encourage the use of a taxi guidance lighting system               
2       Encourage the development of runway incursion warnings in the      
           cockpit                                                            
2       Encourage the development of cockpit moving maps that show the     
           location of other aircraft and vehicles on the airfield            
2       Encourage the use of yellow embedded lights for hold short lines^a 
3       Encourage the use of Runway Awareness and Advisory System          
           technology, which provides aural situational advisories to pilots  
           on the airfield                                                    
3       Improve airport markings                                           

           Source: GAO analysis of responses from survey of experts.

           ^aHold short lines are markings indicating where aircraft should
           hold before receiving permission from air traffic control to enter
           a runway.

           Note: Rankings are based on responses from 22 experts and reflect
           actions that a majority of experts indicated had "great potential"
           or "very great potential." Although other actions also received a
           majority of positive responses, this table reports those that
           received the highest number of positive responses.

           Our survey respondents and international aviation safety experts
           also said that certain runway safety procedures in other countries
           have the potential, if adopted, to improve runway safety in the
           United States. International aviation organization officials said
           that there is some benefit to having air traffic controllers clear
           aircraft to holding points--a practice being followed at some
           airports outside of the United States--rather than directly to
           runways but that it would increase already-busy radio
           communications between pilots and the air traffic control tower.
           In addition, some experts suggested that because of the safety
           risks involved, FAA should stop using land and hold short
           procedures, which are mainly used in the United States and involve
           instructing landing aircraft to land and hold on their runway
           before crossing an intersection or another runway. Officials from
           an international aviation organization said that U.S. carriers are
           generally comfortable with land and hold procedures and understand
           that they are necessary to manage the large volume of traffic at
           certain airports. However, they added that the procedures would be
           greatly improved if they could be agreed upon and promulgated
           internationally. An expert also suggested that FAA consider
           deploying progressive taxiway lights that activate as aircraft
           taxi to or from the runway to help keep aircraft from making wrong
           turns or entering the runway environment. However, other experts
           said that progressive taxiway lights are difficult to see in the
           daytime.

           Recognizing the need for additional actions to improve runway
           safety, on August 15, 2007, FAA met with the aviation community
           and agreed on a short-term plan, which included some measures that
           our experts had also recommended. The participants decided to take
           the following actions during the subsequent 60 days: (1) conduct
           safety reviews at the airports where runway incursions and wrong
           runway departures are the greatest concern, (2) disseminate runway
           safety information and training across the entire aviation
           industry, (3) accelerate the deployment of improved airport
           signage and markings at the top 75 airports, and (4) review
           cockpit and air traffic control procedures, which could include
           changing cockpit procedures to minimize pilot activities and
           distractions while an aircraft is moving on the ground and to make
           air traffic control procedures more precise. On October 22, 2007,
           FAA announced that among the actions taken, (1) safety reviews at
           20 airports had been completed, (2) 104 of 112 air carriers
           provided pilots with simulator and other training incorporating
           runway scenarios, (3) runway markings had been upgraded at 52 of
           75 medium- and large-sized airports, and (4) 101 of 112 air
           carriers had reviewed cockpit procedures to identify and develop a
           plan to address pilot distractions when taxiing to runways. In
           addition, FAA indicated that it had completed analyzing air
           traffic control procedures regarding taxi clearances and found
           that more explicit taxi instructions were needed.

           The experts we surveyed also provided suggestions to prevent
           runway overruns. They said the actions that FAA could take with
           the greatest potential, considering costs, technological
           feasibility, and operational changes, included improving
           communication of runway conditions and weather to flight crews and
           encouraging improvements in and use of runway condition and
           friction measurements (data regarding the slickness of a runway).
           Regarding overseas practices to help prevent overruns, some survey
           respondents said that more detailed information about runway
           conditions is provided to pilots in some other countries, which
           could be communicated to pilots in the United States as they
           prepare to land. Furthermore, on October 4, 2007, NTSB recommended
           that FAA require pilots to conduct landing distance assessments
           before every landing on the basis of existing aircraft performance
           data, actual conditions, and incorporating a minimum 15 percent
           safety margin. FAA has not yet responded to this recommendation.
			  
			  Progress in Addressing Ramp Safety Is Affected by a Lack of Data
			  and Standards, but the Industry Is Taking Action to Address these
			  Issues

           The aviation industry has made efforts in recent years to address
           the incidence of ramp accidents. However, these efforts have been
           hindered by a lack of data on the nature, extent, and cost of ramp
           accidents and the absence of industrywide ground handling
           standards. In response, the federal government and the aviation
           industry have undertaken additional steps to collect data and
           develop standards as a means of understanding the problem and
           reducing the number of accidents.
			  
			  Lack of Complete Accident Data Hinders Efforts to Address Ramp Safety

           We found no source of comprehensive data on airport ramp
           accidents. Various aviation entities collect ramp accident data,
           but they are not complete enough to be useful for industrywide
           analyses, and, in many cases, the entities were not willing for
           competitive reasons to publicly disclose the data. Many industry
           stakeholders indicated to us that they lack complete ramp accident
           data. Without such data, it will be difficult for the aviation
           industry to understand the nature, extent, and cost of ramp
           accidents and to allocate appropriate resources and methods to
           improve ramp safety.

           We found that data on ramp fatalities was more readily available
           than data on nonfatal injuries and accidents without injuries. We
           reviewed FAA, NTSB, and OSHA ramp fatality data^74 from 2001
           through 2006 and determined that these agencies investigated 29
           fatal ramp accidents during that time. (See fig. 12.) These
           accidents occurred at airports of various sizes--from large hubs
           to small general aviation airports.^75 No airport experienced more
           than 2 fatalities during this time period. (See app. VI.) Of the
           29 fatalities, 17 were ground workers, 8 were passengers, and 4
           were pilots. The ramp fatalities generally occurred when these
           employees were struck by objects (such as vehicles), were crushed,
           or fell. Most aviation safety officials told us that ramp
           accidents represent little or no danger to passengers, although a
           potential danger exists if, for example, damage to an aircraft is
           left unreported. Of the 8 passengers who were killed in ramp
           accidents from 2001 through 2006, 5 were struck by propellers.
           Although we obtained data on fatal accidents, it is difficult to
           determine the true nature and extent of all ramp accidents,
           including those that result in injuries, because OSHA, the primary
           source of ramp fatality data, does not collect or report data on
           occupational injuries other than fatalities that occur in ramp
           areas. Furthermore, because FAA and NTSB only investigate certain
           ramp accidents, as discussed earlier, they do not have complete
           ramp accident data.
			
^74FAA, NTSB, and OSHA have the authority to investigate accidents that
occur on the ramp.

^75Primary commercial service airports are categorized based on the
percentage of total annual passenger boardings (enplanements) for all
operations of U.S. carriers within the United States. General aviation
airports are small airports that do not receive scheduled commercial
service.			  

           Figure 12: Annual Number of Ramp Fatalities at U.S. Airports from
           2001 through 2006
			  
			  Lack of Standards for Ramp Operations Could Hinder Safety

           We found no federal or industrywide standards for ramp operations.
           Each airport authority has its own rules and regulations, which
           may be based on local ordinances or state laws. In the United
           States, airlines typically control the ramp areas, and each
           operates its ramps with its own specific set of policies and
           procedures. In addition, in recent years, more airlines have been
           contracting out some or all of these services, and often one
           ground handling company services the aircraft of several airlines
           at an airport. In this situation, ground handling companies must
           carry out their duties in accordance with each airline's policies
           and procedures, and, because there is no standard for ramp
           operations, this could lead to confusion about operating
           procedures and safety rules and increases the likelihood of
           accidents.
			  
			  The Federal Government and the Aviation Industry Are Taking Some
			  Measures to Address Ramp Safety

           FAA, OSHA, airports, and airlines are taking various measures to
           address ramp accidents. According to experts we surveyed, three of
           the four most effective actions are being taken by airlines, for
           example, by setting safety targets and using ramp towers (see
           table 5).

           Table 5: Experts' Ranking of the Most Effective Actions by FAA,
           OSHA, Airports, and Airlines to Address Ramp Accidents
			  
Ranking Action                                                             
1       Airlines setting safety targets for reducing injuries in ramp      
           areas                                                              
1       FAA's use of Runway Safety Action Teams                            
2       Airlines' use of ramp towers                                       
2       Airlines entering into safety alliances with OSHA                  

           Source: GAO analysis of responses from survey of experts.

           Note: Rankings are based on responses from 15 experts and reflect
           the actions that received the highest number of responses
           indicating that they were "very effective" or "extremely
           effective." However, none of these actions received a majority of
           positive responses.

           The federal government has generally taken an indirect role in
           addressing ramp safety. Since August 2000, FAA and OSHA have
           operated under a memorandum of understanding that gives FAA
           responsibility for investigating occupational accidents involving
           flight attendants; in the memorandum, OSHA agreed to continue its
           enforcement efforts on behalf of other aviation employees, such as
           ramp workers. However, neither agency has developed a plan or
           policy to reduce ramp accidents and address ramp safety in a
           strategic, coordinated manner. FAA's primary tool for enhancing
           ramp safety is the promotion of a safety management system for
           aviation service and airport operators through advisory circulars
           issued in 2006 and 2007.^76 FAA defines a safety management system
           as the application of a systematic, proactive approach to
           identifying and mitigating safety risks. The use of safety
           management systems increases the likelihood that safety problems
           would be detected and corrected before they result in an accident.
           However, advisory circulars are voluntary in nature. Although FAA
           expects to issue a Notice of Proposed Rulemaking in 2008, which
           would make this guidance mandatory for airport operators,
           rulemakings often take years to complete.
			  
^76Advisory Circular 120-92 (June 22, 2006) and Advisory Circular
150/5200-37 (February 28, 2007).

           According to an official with the Air Transport Association, a
           trade organization representing the airline industry, the safety
           management system concept invites FAA's acceptance of the
           continuous improvement process adopted by the carrier and its
           airport stakeholders. The official added that measuring the
           effectiveness of mitigation efforts is an essential part of safety
           management systems. However, only two of the experts we surveyed
           indicated that FAA's issuance of advisory circulars on safety
           management systems for airport operators and aviation service
           providers was very effective in addressing ramp accidents.^77 One
           expert said that FAA's issuance of an advisory circular does not
           prompt change, but is a way to reduce the agency's inspection
           workload. However, another expert said that when safety management
           systems are required, airports and air carriers will assume a
           larger role in oversight, data collection, and safety assurance.

           OSHA uses industry participation in its voluntary programs to
           promote ramp safety while also conducting workplace inspections
           and taking enforcement actions when needed. Twelve^78 airlines and
           the National Safety Council, a nonprofit, nongovernmental, public
           service organization dedicated to protecting life and promoting
           health, maintained a national alliance addressing ergonomic issues
           associated with customer checked baggage handling with OSHA from
           November 2002 to November 2006. This alliance resulted in several
           tools for enhancing ramp safety, including an OSHA e-Tool on
           baggage handling safety and an OSHA Web page detailing the
           agency's assistance for the airline industry. The Air Transport
           Association has initiated discussions with OSHA about forming an
           alliance to address ramp vehicle safety. Three of 13 experts we
           surveyed indicated that airlines entering into safety alliances
           with OSHA to address ramp accidents was very or extremely
           effective.^79 One expert, for example, said that OSHA safety
           alliances are an extremely effective way for air carriers to
           develop mitigation strategies in concert with OSHA. However,
           another expert said that airlines entering into alliances with
           OSHA have no real effect on ramp safety because OSHA's focus is on
           preventing personal injury, not aircraft damage.
			  
^77Of the 14 respondents to the question regarding the effectiveness of
FAA's issuance of advisory circulars on safety management systems for
airport operators, 2 said that it was very effective, 3 moderately
effective, 7 slightly effective, and 2 not at all effective. Of the 13
respondents to the question regarding the effectiveness of FAA's issuance
of advisory circulars on safety management systems for aviation service
providers, 2 said it was very effective, 3 moderately effective, 7
slightly effective, and 1 not at all effective.

^78Thirteen airlines originally entered into this alliance with OSHA. When
the alliance was renewed, 12 airlines participated in the alliance.

           OSHA's workplace inspections--which are initiated in response to
           fatalities or serious injuries, such as amputations, complaints,
           or data indicating that an industry is experiencing a high rate of
           illness or injury--may result in OSHA proposing that the employer
           be fined. For example, on July 25, 2007, OSHA proposed fines
           totaling about $72,500 against an airline for alleged violations
           of workplace safety standards in its ramp area at one airport.^80
           According to OSHA safety enforcement officials, proposed fines are
           intended to serve as a deterrent to unsafe practices in the
           workplace and are sometimes reduced after the employers take
           corrective actions, show good faith, or have a favorable safety
           history.^81 However, as we reported in 2005 on FAA's safety
           enforcement efforts, reductions in proposed fines may weaken any
           deterrent effect that would be expected from sanctions.^82 Only 2
           of 13 experts we surveyed indicated that OSHA's safety enforcement
           actions were very effective in addressing ramp accidents.^83
			  
^79Of the 13 respondents, 1 said it was extremely effective, 2 very
effective, 3 moderately effective, 6 slightly effective, and 1 not at all
effective.

^80OSHA's inspection of this airline's worksite was done as part of the
agency's Site-Specific Targeting Program. The worksites that OSHA inspects
under this program are identified from data on employee illness and
injuries that the agency collects each year from about 80,000
nonconstruction employers.

^81OSHA does not routinely maintain data on the number of safety
inspections conducted in airport ramp areas or the amount of fines that it
proposed regarding violations in those areas. At our request, OSHA
officials broke out how much the fine indicated above pertained to
violations in the ramp area. According to the 2005 Bureau of Labor
Statistics' Survey of Occupational Injuries and Illnesses, scheduled air
transportation industry employees had the eighth highest rate compared to
other industries, but the data are not broken out to identify the portion
represented by ramp workers.

^82GAO, FAA's Safety Oversight System is Effective but Could Benefit from
Better Evaluation of Its Programs' Performance, [37]GAO-06-266T
(Washington, D.C.: Nov. 17, 2005).

^83Of the 13 respondents, 2 said it was very effective, 4 moderately
effective, 3 slightly effective, and 4 not at all effective.			  

           Several airport officials we interviewed had initiated efforts to
           improve ramp safety at their airports, even though their ramp
           areas are typically under the control of one or more airlines. For
           example, a Massachusetts Port Authority official said that ramp
           accidents at the Boston Logan International Airport were reduced
           by 50 percent during a 6-month period during 2004 and 2005 after
           they implemented a ramp safety program. Other airport officials
           said they had used their local Runway Safety Action Teams as
           forums or initiated their own efforts for addressing ramp safety
           issues. In addition, the Seattle-Tacoma International Airport uses
           a ramp tower and ASDE-X surface movement radar to monitor ramp
           activities. Of 15 survey respondents, 4 experts indicated that the
           use of Runway Safety Action Teams was very or extremely effective
           in addressing ramp accidents, and 2 indicated that surface
           surveillance technology was very effective.^84 One expert
           indicated that Runway Safety Action Teams are an extremely
           important venue that can involve all airport stakeholders in a
           collaborative process to identify hazards, perform a risk
           assessment, and develop mitigation strategies and measure their
           effectiveness. Of 15 survey respondents, 2 experts indicated that
           airports' use of ramp towers was very or extremely effective in
           addressing ramp accidents,^85 and 3 indicated that airlines' use
           of ramp towers was very effective.^86 One expert said that ramp
           towers improve operational safety but that all operations are
           still not completely visible.

           We spoke with officials from two U.S. airlines about measures they
           were taking to improve ramp safety. One of those airlines is using
           and the other plans to use a Web-based surface surveillance system
           at certain hubs to track the movements of ground vehicles and
           aircraft. Although the airline's purpose for purchasing the system
           was for greater efficiencies in its ground operations, an official
           from that airline said he believed that increased safety was an
           additional benefit of the system because it significantly improved
           situational awareness. Although not specifically tracked, the
           airline believes it has had fewer ground accidents and incidents
           since implementing the system. Officials at another airline said
           they were addressing ramp safety further by incorporating a safety
           management system into the ramp procedures in the airline's
           operations manual, including specific ground safety training as a
           component of recurrent training required annually. In addition,
           the airline has established annual goals for reducing employee
           injuries and ground damage. The airline reported the setting of a
           goal appears effective and has resulted in a significant decrease
           in employee injuries and ground damage over the prior year.
           Officials from this airline also said that the airline had formed
           a safety action team to share best practices with its ground
           handling partners and to review their safety performance,
           resulting in an incident rate for the airline's partners that has
           been greatly reduced in the last two years and continues to
           improve. The experts we surveyed had mixed views on the
           effectiveness of airlines setting safety targets for reducing
           injuries in ramp areas in addressing ramp accidents. Four of 15
           experts indicated that it was very effective, 6 said it was
           moderately effective, and 5 indicated it was slightly or not at
           all effective. One expert said that airlines have set safety
           targets for reducing injuries in ramp areas for years and failed
           to achieve discernable results.
			  
^84Of the 15 respondents, 1 said the use of Runway Safety Action Teams was
extremely effective, 3 very effective, 7 moderately effective, and 4
slightly effective. In addition, of 15 respondents, 2 said that airports'
use of surface surveillance was very effective, 8 moderately effective,
and 5 slightly effective.

^85Of the 15 respondents, 1 said it was extremely effective, 1 very
effective, 7 moderately effective, 4 slightly effective, and 2 not at all
effective.

^86Of the 15 respondents, 3 said it was very effective, 7 moderately
effective, 3 slightly effective, and 2 not at all effective.			  

           Aviation industry groups also have efforts under way to address
           the lack of data for ramp accidents as well as the lack of
           standards for ramp operations. In 2003, the Flight Safety
           Foundation, an international nonprofit membership organization
           that researches and promotes aviation safety, started the Ground
           Accident Prevention Program to "analyze equipment damage and human
           injuries and develop methods of preventing such accidents." The
           program is now in its third phase, in which it will identify and
           encourage technical solutions to ramp safety problems along with
           continued data collection and analysis. Next year, the
           International Air Transport Association, an international airline
           association, plans to start a safety audit program of ground
           handling companies with the aim of improving operational safety by
           establishing a "worldwide ground operational safety benchmark and
           standard." The program will be available to all ground service
           providers, who, after successfully completing the audit, will be
           placed on a registry for an agreed-upon period. In addition, the
           National Air Transportation Association, which represents
           companies that own, operate, and service aircraft primarily for
           the general aviation community, has launched an industry-wide
           effort to collect ramp incident data and has goals of identifying
           best practices, reducing insurance claims, and lowering insurance
           costs. The Airports Council International, an organization that
           represents airports worldwide, publishes the Airside Safety
           Handbook as one component of its efforts to help airports operate
           more safely. Finally, the Air Transport Association collects,
           aggregates, and shares ground incident damage and injury data to
           its members. The data are reviewed at the association's quarterly
           Ground Safety Committee meetings and form a basis for assessing
           risk, developing mitigation strategies, and measuring
           effectiveness. According to the association, airlines freely share
           best practices concerning safety and many airlines perform ground
           servicing of aircraft (fuel, potable water, baggage handling,
           etc.) for one another.
			  
			  Additional Measures May Improve Ramp Safety

           The results of our survey of experts indicated that the actions
           that FAA, OSHA, airports, or airlines could take with greatest
           potential of preventing ramp accidents, considering costs,
           technological feasibility, and operational changes, included
           promoting a safety culture, standardizing airport ramp markings,
           improving or increasing training of ramp workers, increasing the
           supervision of ramp workers, and developing safer equipment
           designs (see table 6).

           Table 6: Experts' Ranking of the Actions that FAA, OSHA, Airports,
           or Airlines Could Take with the Most Potential to Address Ramp
           Accidents
			  
Ranking Action                                         
1       Promote a safety culture in ramp areas         
2       Standardize airport ramp markings              
2       Improve or increasing training of ramp workers 
2       Increase supervision of ramp workers           
3       Develop safer designs of ramp equipment        

           Source: GAO analysis of responses from survey of experts.

           Note: Rankings are based on responses from 15 experts and reflect
           the actions that a majority of respondents indicated had "great
           potential" or "very great potential."

           One expert said that as part of an improved safety culture--which
           experts in our survey indicated was the most effective action to
           address ramp accidents--management must recognize the connection
           between the occurrence of ramp incidents and accidents and its
           demand for quick aircraft turnaround times. Turnaround times are
           an important cost factor for airlines. Another expert said that
           standardizing ramp markings would be beneficial because the
           markings can be confusing for pilots. One of the experts
           indicated, however, that while improving and increasing the
           training of ramp workers would be beneficial, high job turnover
           among ramp employees is also part of the problem. Furthermore, a
           report prepared by an aviation industry group in 2004^87 cited
           inadequate training and high turnover of ramp workers,
           particularly aircraft fuelers, as contributing factors in ramp
           accidents. The report also indicated that low wages contributed to
           high rates of employee turnover. One of the experts we surveyed
           indicated that poor pay attracts a group of ramp workers that
           exhibit high turnover rates, language issues, and work ethic
           challenges. Similarly, in reports that we issued before the
           September 11, 2001, terrorist attacks, we cited high turnover and
           low wages among airport security screeners as factors affecting
           the effectiveness of performing their security duties.^88

           Some aviation industry officials and experts said that ramp safety
           in the United States might be improved through the use of new
           technology. One example is a ground pop-up system^89 to handle
           aircraft fueling and other ramp services, which is used at
           airports in Zhuhai, China, and Stockholm, Sweden. An expert said
           that a ground pop-up system reduces ramp congestion and the chance
           of vehicle collisions and injuries. In addition, some aviation
           officials said that new baggage loading technology could help make
           the ramp environment safer for ramp workers. New baggage loading
           technologies include the sliding carpet^90 and RampSnake(R).^91
           However, an international aviation safety official said that
           although these new baggage loading devices could improve working
           conditions and effort required by baggage loaders, it is not
           readily apparent how such devices could help prevent ramp
           accidents. This official also noted the high cost of a ground
           pop-up system and that it is inflexible to accommodate changed
           aircraft parking arrangements and different aircraft types. The
           potential effectiveness of safer designs of ramp equipment was
           supported by the experts we surveyed, the majority of whom said
           that developing safer designs of ramp equipment had great or very
           great potential in addressing ramp accidents.^92 An International
           Air Transport Association official also indicated that
           high-density airports outside of the United States typically have
           a higher degree of control and coordination between the ramp and
           air traffic controllers, which can contribute to safety.
			  
^87Airport Operations Safety Panel, Reducing Accidents and Improving
Safety on the Ramp (Palm Beach Gardens, FL: June 15, 2004).

^88GAO, Aviation Security: Long-Standing Problems Impair Airport
Screeners' Performance, [38]GAO/RCED-00-75 , (Washington, D.C.: June 28,
2000) and Aviation Security: Vulnerabilities Still Exist in the Aviation
Security System, [39]GAO/T-RCED/AIMD-00-142 (Washington, D.C.: April 6,
2000).

^89Equipment to service aircraft pops up from beneath the ramp when needed
and returns below afterwards.

^90The sliding carpet is an aircraft-based system for positioning cargo
once it is placed in the hold of a commercial aircraft.

^91The RampSnake(R) is a ramp-based system that delivers cargo into the
cargo hold and is capable of turning 90 degrees once inside the aircraft.			  

           Aviation industry stakeholders expressed diverse views about
           whether the federal government should increase ramp safety
           oversight and if so, which agency should carry out that increased
           oversight. Officials from a union representing ramp workers
           favored increased FAA and OSHA oversight of ramp operations
           because they felt this would lead to more and better training for
           ramp workers, the implementation of standardized procedures, and a
           focus on ramp safety equal to that provided to runway safety.
           However, an airport association official said that increasing
           FAA's oversight in the ramp area would not be the best use of the
           agency's resources because the safety risks are greater on the
           airfield, where an aircraft collision could result in many
           fatalities. In addition, a Flight Safety Foundation official said
           that additional FAA ramp safety oversight is not needed because
           FAA's focus is on passenger safety and that the agency would have
           difficulty identifying additional resources to oversee ramps. An
           author of reports on ramp accidents issued by an aviation industry
           group said that OSHA should do more to regulate safety on the ramp
           because, in his view, FAA lacks knowledge of industrial safety
           issues. However, an airline association official said that
           increased OSHA oversight of ramp operations would have little
           potential until OSHA develops national standards and appropriate
           regulations for airport ramp operations. This airline association
           official also said that the lack of a voluntary disclosure
           reporting program for OSHA-regulated incidents impedes improving
           safety in the ramp area. OSHA officials, however, said that very
           few industries have their own workplace safety standards, and that
           the agency is devoting the appropriate amount of resources for
           inspecting airport ramps because its safety inspections overall
           are selected largely on the basis of injury and illness data and
           complaints. However, they were not able to identify how many
           inspections of ramp areas were prompted by data. FAA officials
           said that they do not have responsibility for ramp safety and that
           their jurisdiction is limited to the movement areas. They also
           noted that ramp areas are normally under the jurisdiction of state
           and local authorities but that ultimately the airport operator has
           responsibility for ramp safety unless the area is leased to an air
           carrier or fixed-base operator.
			  
^92Of 15 respondents, 10 said that it had great or very great potential, 3
moderate potential, and 2 little potential.

           Conclusions

           FAA took a number of actions to address runway safety since the
           number and rate of incursions reached a peak in fiscal year 2001.
           However, as runway safety incidents declined, FAA's runway safety
           efforts subsequently waned. During that period of decreased
           attention, the number and rate of incursions remained relatively
           constant and at a level higher than any time during the 1990s.
           Moreover, preliminary data for fiscal year 2007 indicate the
           overall incursion rate increased to a level nearly as high as the
           2001 peak. In addition, serious incursions, where collisions were
           narrowly or barely avoided, continue to occur--about 30 per year
           since fiscal year 2002--suggesting a high risk of a catastrophic
           runway collision occurring in the United States. Furthermore, in
           recent years, FAA's Office of Runway Safety has not been
           fulfilling its mission to coordinate and lead the agency's runway
           safety efforts. The absence of national leadership and a current
           national runway safety plan impede further progress on runway
           safety because no single office is taking charge of assessing the
           causes of runway safety problems. This situation has resulted in
           uncoordinated runway safety efforts by individual FAA offices. FAA
           recently hired a runway safety director, which is a good first
           step. However, other plans for the program are still being
           developed, and it is too early to know if the office will provide
           sustained attention to runway safety problems.

           FAA's runway safety program also lacks certain data on the causes
           and circumstances of incursions and overruns. FAA has planned
           since 2004 to develop a voluntary reporting system for air traffic
           controllers, which would increase the amount of data available on
           runway incursions, but it is not clear when such a program will be
           established. Without additional data, FAA cannot conduct
           additional analysis of the causes and circumstances of runway
           incidents to ensure that the most effective corrective measures
           that address the causal factors are used. In addition, the fact
           that air traffic controllers at some of the nation's busiest
           airports are regularly working 6-day weeks due to staffing
           shortages raises questions about the extent to which regularly
           working overtime may cause fatigue, which NTSB has cited as a
           contributing factor in air traffic control errors. Furthermore,
           the nature and scope of ramp accidents are unknown. FAA is not
           working with the aviation industry and OSHA to help collect and
           analyze ramp accident data, which could identify the causes and
           circumstances of ramp accidents, and identify corrective actions.
           Without such data, FAA and the aviation industry will be hindered
           in understanding the nature and extent of ramp accidents, which
           would help identify measures to improve ramp safety.
			  
			  Recommendations

           To advance efforts to improve runway safety, we recommend that the
           Secretary of Transportation direct the FAA Administrator to take
           the following five actions:

           o Implement the FAA order establishing the Office of Runway Safety
           to lead the agency's runway safety efforts, including preparing a
           new national runway safety plan. The plan should include goals to
           improve runway safety; near- and longer-term actions designed to
           reduce the severity, number, and rate of runway incursions;
           timeframes and resources needed for those actions; and a
           continuous evaluative process to track performance towards those
           goals. The plan should also address the increased runway safety
           risk associated with the expected increased volume of air traffic.

           o Develop an implementation schedule for establishing a
           nonpunitive voluntary safety reporting program for air traffic
           controllers.
           o Develop and implement a plan to collect data on runway overruns
           that do not result in damage or injury for analyses of trends and
           causes such as the locations, circumstances, and types of aircraft
           involved in such incidents.
           o Develop a mitigation plan for addressing controller overtime
           that considers options such as shift changes and incentives to
           attract controllers to facilities with high volumes of air traffic
           and high rates of controller overtime.
           o Work with the aviation industry and OSHA to develop a mechanism
           to collect and analyze data on ramp accidents and, if the analysis
           shows it is warranted, develop a strategic plan aimed at reducing
           accidents involving workers, passengers, and aircraft in the ramp
           area. The plan should include a discussion of roles and
           responsibilities, performance measures, data collection and
           analysis, and milestones, and consider ramp safety practices being
           followed in other countries.
			  
			  Agency Comments

           We provided DOT and the Department of Labor with drafts of this
           report for their review and comment. FAA agreed to consider the
           report's recommendations and provided technical corrections and
           clarifications, which we incorporated as appropriate. The
           Department of Labor had no comments but provided a technical
           correction, which we incorporated.

           As arranged with your offices, unless you publicly announce its
           contents earlier, we plan no further distribution of this report
           until 30 days after the date of this letter. At that time, we will
           send copies of this report to interested congressional committees
           and to the Secretary of Transportation and the Secretary of Labor.
           We will make copies available to others upon request. In addition,
           this report will be available at no charge on our Web site at
           http://www.gao.gov.

           If you or your staff have any questions about this report, please
           contact me on (202) 512-2834 or at [email protected]. Contact
           points for our Offices of Congressional Relations and Public
           Affairs may be found on the last page of this report. Key
           contributors to this report are listed in appendix VII.

           Gerald L. Dillingham, Ph.D.
			  Director, Physical Infrastructure Issues
			  
			  Appendix I: Objective, Scope, and Methodology

           Our objective was to review how well the Federal Aviation
           Administration (FAA) and others are addressing runway and ramp
           safety issues. To accomplish this, we established the following
           questions: (1) What progress is being made in addressing runway
           safety, and what additional measures, if any, could be taken? and
           (2) What factors affect progress in improving ramp safety and what
           is being done by FAA and others to address those factors?

           For background information on runway and ramp safety issues, we
           reviewed reports prepared by FAA, the National Transportation
           Safety Board (NTSB), the Department of Transportation's (DOT)
           Inspector General, and others; FAA orders, advisory circulars, and
           regulations; and applicable laws. We also determined the roles and
           responsibilities involving runway and ramp safety of FAA, NTSB,
           the Occupational Safety and Health Administration (OSHA),
           airports, and airlines. Regarding runway incursions, we obtained
           data on the number and rates of incursions from fiscal year 1998
           through fiscal year 2007 and reviewed NTSB accident reports on
           incursions that resulted in collisions during that time. We also
           obtained runway incursion data from fiscal year 2001 through
           fiscal year 2006 broken down by severity, error types, and
           frequency of incursions involving general aviation and commercial
           aircraft. Regarding runway overruns, we collected data on overruns
           that NTSB investigated from fiscal year 2001 through fiscal year
           2006. Regarding ramp accidents, we obtained information on ramp
           accident fatalities that were investigated by FAA, NTSB, and OSHA
           from 2001 through 2006. Based on interviews with officials
           knowledgeable about the data contained in this report, we
           determined that runway and ramp safety data were sufficiently
           reliable for the types of analyses that we performed for this
           report such as trends in runway incursions, the incidence of
           fatalities in airport ramp areas, and frequency of air traffic
           controller overtime.

           To determine what progress is being made in addressing runway
           safety and what additional measures could be taken, we reviewed
           the status of FAA's implementation of objectives contained its
           2002 national runway safety plan and the status of the runway
           safety recommendations that NTSB made to FAA. We also evaluated
           FAA's compliance with orders establishing the agency's runway
           safety and runway safety area programs; FAA's collection and
           analysis of runway safety data, including the process that the
           agency follows to assess the severity of runway incursions; and
           findings made by FAA's Air Traffic Safety Oversight Service on the
           agency's runway incursion severity classification process and
           runway safety technology. We also looked at how taxiways affect
           runway safety. To help identify the causes of runway incursions
           and measures being taken to prevent them, we interviewed FAA and
           airport officials at five airports that have experienced more
           runway incursions than other airports in recent years.^1 Because
           technology is a major part of FAA's strategy to improve runway
           safety, we discussed the agency's efforts to develop and deploy
           technology with program officials, visited five airports where new
           technology was being tested and used to observe their operation,
           reviewed data on the systems' performance, and interviewed FAA air
           traffic controllers and managers and aviation industry officials
           about their views on the effectiveness of the technology. In
           addition, we reviewed the implementation status of Public Law No.
           109-115, which requires commercial service airports to bring their
           runway safety areas into compliance with FAA standards by 2015. We
           also interviewed officials from FAA's William J. Hughes Technical
           Center, DOT's Volpe National Transportation Systems Center, and
           the National Aeronautics and Space Administration's Ames Research
           Center about their runway safety research projects. In addition,
           we interviewed officials from international aviation organizations
           about runway safety practices and technologies being used overseas
           that could be used in the United States.

           To determine the factors affecting progress in improving ramp
           safety and what is being done by FAA and others to address those
           factors, we interviewed officials from FAA, airports, and aviation
           industry organizations; members of the Airport Operations Safety
           Panel, an aviation industry group that issued reports on ramp
           accidents in 2004 and 2005; union officials representing ramp
           workers and pilots; and other individuals knowledgeable about ramp
           safety. In addition, we interviewed OSHA officials about the
           agency's industry alliance program and enforcement efforts. We
           also interviewed officials from international aviation
           organizations about ramp safety practices and technologies being
           used overseas that could be used in the United States.

           Table 7 lists the organizations that we visited or contacted
           regarding runway and ramp safety.
			  
^1They included Los Angeles International Airport, Boston Logan
International Airport, Dallas-Ft. Worth International Airport,
Hartsfield-Jackson Atlanta International Airport, and Newark Liberty
International Airport. These five airports were among the 10 U.S. airports
that experienced the most runway incursions from fiscal year 2001 through
fiscal year 2006.			  

           Table 7: List of Organizations that GAO Visited or Contacted
           Regarding Runway and Ramp Safety

Industry category          Organization interviewed                        
U.S. government agencies   Department of Labor Bureau of Labor Statistics  
                              Department of Labor Occupational Safety and     
                              Health Administration                           
                              Department of Transportation Volpe National     
                              Transportation Systems Center                   
                              Federal Aviation Administration                 
                              Joint Planning and Development Office           
                              National Aeronautics and Space Administration   
                              National Transportation Safety Board            
FAA regional runway safety Eastern Region                                  
program managers                                                           
                              New England Region                              
                              Southeast Region                                
                              Western Region                                  
FAA air traffic control    Bob Hope Airport, Burbank, CA                   
personnel                                                                  
                              Bradley International Airport, Hartford, CT     
                              Dallas-Ft. Worth International Airport          
                              General Mitchell International Airport,         
                              Milwaukee, WI                                   
                              Hartsfield-Jackson Atlanta International        
                              Airport                                         
                              Lambert-St. Louis International Airport         
                              Long Beach Airport, Long Beach, CA              
                              Los Angeles International Airport               
                              Newark Liberty International Airport            
                              Orlando International Airport                   
                              San Diego International Airport                 
                              Seattle-Tacoma International Airport            
                              Spokane International Airport, Spokane, WA      
                              Theodore Francis Green State Airport,           
                              Providence, RI                                  
                              William P. Hobby Airport, Houston, TX           
Airports                   Bob Hope Airport, Burbank, CA                   
                              Boston Logan International Airport              
                              Dallas-Ft. Worth International Airport          
                              Hartsfield-Jackson Atlanta International        
                              Airport                                         
                              Long Beach Airport, Long Beach, CA              
                              Los Angeles International Airport               
                              Newark Liberty International Airport            
                              San Diego International Airport                 
                              Spokane International Airport, Spokane, WA      
Industry organizations     Air Line Pilots Association                     
                              Air Safety Foundation                           
                              Air Transport Association                       
                              Airports Council International                  
                              International Air Transport Association         
                              International Association of Machinists and     
                              Aerospace Workers                               
                              National Air Traffic Controllers Association    
                              National Air Transportation Association         
                              Regional Airline Association                    
Others                     Airport Operations Safety Panel                 
                              Boeing                                          
                              Commercial Aviation Safety Team                 
                              Continental Airlines                            
                              Flight Safety Foundation                        
                              International Civil Aviation Organization       
                              Northwest Airlines                              
                              Robinson Aviation                               
                              Sensis Corporation                              

           Source: GAO.

           We conducted our work from October 2006 through November 2007 in
           accordance with generally accepted government auditing standards.
			  
			  Appendix II: Survey Methodology Appendix II: Survey Methodology

           We administered a 2-phase Web-based survey to gather the
           professional views of experts on runway incursions, runway
           overruns, and ramp safety. The structured survey questions ensured
           that all individuals had the opportunity to provide information in
           response to the same questions and enabled us to quantify the
           results. Moreover, the iterative nature of the 2-phase survey
           provided the experts with the opportunity to identify future
           actions that could be taken to prevent incursions, overruns, and
           ramp accidents and then to evaluate the potential of the future
           actions that they and the other experts identified.

           We contracted with the National Academy of Sciences to identify
           experts to participate in our survey. Using criteria to ensure
           adequate representation across the criteria that we had specified,
           the National Academy identified 19 experts and we identified ten.
           The criteria ensured that we achieved

           o balance in terms of the type and depth of expertise (i.e.,
           pilots, airline officials, aircraft manufacturing officials,
           association representatives, academics, foreign civil aviation
           authorities, unions representing airlines, air traffic
           controllers, ramp workers, Federal Aviation Administration (FAA)
           maintenance and safety inspectors, professors and researchers
           involved in aviation safety);
           o balance of knowledge across relevant content areas (i.e.,
           effectiveness of measures being used to address runway incursions,
           overruns, and ramp accidents; technology research, testing, and
           use; FAA air traffic control practices and procedures;
           international aviation safety practices, human factors issues;
           general aviation; airports; and ground operations); and
           o balance in representing relevant organizations (i.e., academia,
           business, government, and professional organizations).

           The survey responses represent the professional views of the
           experts. Their expertise can be derived from formal education,
           professional experience, or both. The experts were identified by
           the National Academy and us as individuals who are recognized by
           others who work in the same subject matter area as having
           knowledge that is greater in scope or depth than that of most
           people working in the area.

           We recognize that it is likely that no one individual possessed
           complete knowledge in each of the content areas addressed in the
           survey: runway incursions, runway overruns, and ramp accidents.
           However, through our selection criteria, we attempted to identify
           a set of individuals who, when their responses were considered in
           the aggregate, could be viewed as representing the breadth of
           knowledge in each of the areas addressed in the survey.

           We identified the information to collect in our surveys based on
           our congressional request, Internet and literature searches,
           professional conferences we attended, and background interviews. A
           social science survey specialist collaborated with staff with
           subject matter expertise on the development of the surveys.

           We developed a 2-phase Web-based survey. The first survey
           contained open-ended questions asking respondents to identify the
           primary causes of runway incursions, runway overruns, and ramp
           accidents; overseas practices and technologies that could be used
           in the United States; and future actions, including the
           development of new technology that FAA could take in the future to
           prevent incursions, overruns, and ramp accidents. The responses to
           the questions on future actions were analyzed and coded into
           categories that were then used as the basis for the questions on
           future actions in the second survey. A reviewer checked the
           resulting categories and coded responses and, where
           interpretations differed, agreement was reached between the
           initial coder and the reviewer. As an extra step to check the
           completeness of the list of future actions that was generated by
           the experts we corroborated the list with other evidence we had
           collected as a part of our study and found that many of the same
           actions the experts identified were also identified through our
           other study efforts.

           The same set of respondents was also sent the second survey. As
           mentioned above, the second survey contained closed-ended
           questions asking respondents to evaluate the potential of the
           future actions that could be taken to prevent runway incursions,
           runway overruns, and ramp accidents. Other closed-ended questions
           addressed the effectiveness of specific actions that FAA and
           others are taking to address runway incursions, runway overruns,
           and ramp accidents; the accuracy of FAA reporting on runway
           incursions that have occurred since January 1, 2001; and whether
           the deployment schedule of the Airport Surface Detection
           Equipment, Model-X (ASDE-X) at 27 additional airports by 2011
           should be kept as planned or changed, considering some of the
           benefits and problems associated with the system.

           Both surveys were pretested to ensure that the questions
           appropriately addressed the topics, were clearly stated, easy to
           comprehend, unbiased, and did not place undue burden on
           respondents. We also evaluated the usability of the Web-based
           surveys. Based on the pretest results, we made necessary changes
           to the surveys prior to implementation.

           We administered the Web-based surveys between June and September
           2007. We used e-mail to inform the respondents of the survey
           administration, and provided them with the Web link for the survey
           and their log-in name and password. In the e-mail message, we
           informed respondents that our report will not contain individual
           survey responses; instead, it would present the aggregated results
           of all participants. To maximize the response rate, we sent follow
           up e-mail reminders and followed up by telephone as necessary to
           encourage survey participation.

           The first survey was sent to 27 experts. Two experts did not
           respond and were not included in the second survey. As a result,
           25 of 27 experts responded to the first survey for a response rate
           of 93 percent.

           The second survey was sent to the 25 experts who responded to the
           first survey. Twenty-two of the 25 experts responded for a
           response rate of 88 percent.

           The number of responses varied for each of the survey content
           areas--runway incursions, runway overruns, and ramp
           accidents--because we asked the experts to answer questions only
           within their areas of expertise. In addition, the number of
           responses may vary by question because we do not report the number
           of experts who responded "Don't know" or "No basis to judge." We
           report the survey results in terms of actions that are most
           effective or future actions that have the most potential. For
           tables 1 and 6, the actions that we report as being the most
           effective or having the most potential were the ones that a
           majority of respondents indicated were very or extremely effective
           for the effectiveness questions or great or very great potential
           for the questions asking about potential. For table 4, the actions
           that we report as having the most potential reflect the ones that
           a majority of experts indicated as having great potential or very
           great potential. Although other actions also received a majority
           of positive responses, this table reports the ones that received
           the highest number of positive responses. For table 5, the actions
           that we report received the highest number of responses indicating
           that they were very effective or extremely effective. However,
           none of these actions received a majority of positive responses.

           The first survey, which was administered via the Web, included 12
           questions shown in figure 13.

           Figure 13: Questions Asked in First Survey
			  
      1. Do you have expertise in runway incursions to be able to answer the  
      following three questions on the causes of runway incursions, overseas  
      practices and technology, and future actions to prevent runway          
      incursions?                                                             
      2. In your opinion, what are the primary causes of runway incursions?   
      3. What practices or technologies that are currently being used         
      overseas could be used in the United States to prevent runway           
      incursions?                                                             
      4. What actions, including the development of new technologies, could   
      FAA take in the future to prevent runway incursions?                    
      5. Do you have expertise in runway overruns to be able to answer the    
      following three questions on the causes of runway overruns, overseas    
      practices and technology, and future actions to prevent runway          
      overruns?                                                               
      6. In your opinion, what are the primary causes of runway overruns?     
      7. What practices or technologies that are currently being used         
      overseas could be used in the United States to prevent runway overruns? 
      8. What actions, including the development of new technologies, could   
      FAA take in the future to prevent runway overruns?                      
      9. Do you have expertise in ramp accidents to be able to answer the     
      following three questions on the causes of ramp accidents, overseas     
      practices and technology, and future actions to prevent ramp accidents? 
      10. In your opinion, what are the primary causes of ramp accidents?     
      11. What practices or technologies that are currently being used        
      overseas could be used in the United States to prevent ramp accidents?  
      12. What actions, including the development of new technologies, could  
      FAA take in the future to prevent ramp accidents?                       

           Source: GAO.

           The second phase of the survey was also administered via the Web
           and is reproduced as a graphic image on the following pages.

Appendix III: Serious Incursions Involving Commercial Aircraft


Table 8: Serious Incursions Involving At Least One Commercial Aircraft
during Fiscal Year 2006 and Fiscal Year 2007

                                            Airline(s) and      Number of air 
Date          Airport                    aircraft involved   passengers    
October 13,   Gulfport-Biloxi            Northwest Airlines  N/A           
2005          International, MS          DC9 and Cessna C172               
March 21,     Chicago O'Hare             Lufthansa Airbus    78            
2006          International              A319 and Chautauqua               
                                            Embraer E145                      
April 29,     Phoenix Sky Harbor         US Airways Airbus   N/A           
2006          International              A320 and pedestrian               
May 25, 2006  Miami International        Boeing 747 and      N/A           
                                            American Eagle                    
                                            Aerospatiale AT43                 
July 18, 2006 Chicago O'Hare             American Eagle      N/A           
                 International              Canadair CRJ7 and                 
                                            US Airways Boeing                 
                                            737                               
July 23, 2006 Chicago O'Hare             ATLAS Boeing 747    131           
                 International              and United Airlines               
                                            Boeing 737                        
July 26, 2006 Los Angeles International  Mesa Canadair CRJ2  N/A           
                                            and Skywest Embraer               
                                            E120                              
August 8,     Southwest Florida          Southwest Boeing    N/A           
2006          International, Ft. Myers,  737 and vehicle                   
                 FL                                                           
September 30, Los Angeles International  Gulfstream GLF5 and N/A           
2006                                     Skywest Canadair                  
                                            CRJ7                              
January 5,    Denver International       Key Lime Air        50            
2007                                     Swearingen SW4 and                
                                            Frontier Airbus                   
                                            A319                              
February 2,   Denver International       United Boeing 737   101           
2007                                     and snowplow                      
May 4, 2007   Cyril E. King Airport,     American Airlines   N/A           
                 Charlotte Amalie, VI       Boeing 757 and                    
                                            Cessna C208                       
May 6, 2007   Los Angeles International  Skywest Embraer 120 N/A           
                                            and Virgin Air A346               
May 26, 2007  San Francisco              Republic Airlines   27            
                 International              Embraer 170,                      
                                            Skywest Airlines                  
                                            Embraer 120                       
July 11, 2007 Fort Lauderdale-Hollywood  Delta Air Lines     172           
                 International, FL          Boeing 757 and                    
                                            United Airlines                   
                                            Airbus A320                       
July 19, 2007 Chicago O'Hare             United Airlines     N/A           
                 International              Boeing 737 and US                 
                                            Airways Boeing 737                
August 16,    Lost Angeles International WestJet Boeing 737  296           
2007                                     and Northwest                     
                                            Airlines Airbus                   
                                            A320                              

Source: GAO analysis of Federal Aviation Administration and NTSB data.

Note: N/A indicates that the information was not contained in the National
Transportation Safety Board (NTSB) incident reports.

Appendix IV: Status of the National Runway Safety Plan Objectives

Table 9: Implementation Status of the Objectives Contained in Federal
Aviation Administration's (FAA) National Runway Safety Plan for 2002-2004

Runway Safety Objective                                          Status    
1. Develop new training courses or informational briefings for   Complete  
controllers to reduce operational errors.                                  
2. Facilitate use of surface operations training for air         Complete  
carriers and general aviation.                                             
3. Distribute mechanic runway safety taxi training to major      Complete  
airlines.                                                                  
4. Complete over 1,000 safety seminars per year, including       Ongoing   
runway safety topics.                                                      
5. Publish airport vehicle surface operations advisory circular  Complete  
with best practices and standard operating procedures.                     
6. Conduct research on improving controller training related to  Complete  
memory limitations. Review existing course materials.                      
7. Require all tower controllers to complete training            Ongoing   
emphasizing team effectiveness and situational awareness.                  
8. Develop course material and conduct training for aviation     Complete  
safety inspectors and enhance awareness of certified flight                
instructors and pilot examiners on pilot surface operations.               
9. Develop and implement enhanced training for tower             Complete  
controllers.                                                               
10. Implement a foreign air carrier pilot training program.      Cancelled 
11. Expand role of flight service station specialists to provide Complete  
runway safety information for general aviation at towered and              
nontowered airports.                                                       
12. Publish series of letters to all pilots discussing runway    Cancelled 
safety.                                                                    
13. Provide airport diagrams for towered airports to pilots via  Complete  
a link or other means.                                                     
14. Conduct at least one annual media emphasis project with      Complete  
trade or association periodicals.                                          
15. Assess selected air traffic control procedures to enhance    Ongoing   
runway safety.                                                             
16. Implement national standardized requirements for tower       Complete  
positions.                                                                 
17. Implement standardization of national equipment and          Cancelled 
procedures for runway incursion devices.                                   
18. Publish and disseminate best practices and standard          Complete  
operating procedures as appendixes to pilot surface movement               
advisory circulars.                                                        
19. During inspectors, ensure that pilots have current surface   Complete  
movements charts available and are being used.                             
20. Develop advisory circulars addressing procedures, best       Complete  
practices, and standard operating procedures for airline                   
maintenance taxi operators and tug and tow vehicles on airport             
surface.                                                                   
21. Disseminate and provide training to all safety inspectors    Ongoing   
for the Runway Incursion Information Evaluation Program.                   
22. Improve runway safety data collection, storage retrieval,    Ongoing   
and distribution.                                                          
23. Improve collection and analysis of operational error data    Cancelled 
with human factors tool, using technique to identify root                  
causes.                                                                    
24. Complete and publish results from phraseology workgroup.     Complete  
25. Evaluate and, if appropriate, implement national procedures  Complete  
requiring pilot read-backs to controllers for certain clearances           
or instructions.                                                           
26. Publish guidance on standard surface operations phraseology  Complete  
for pilots and mechanics moving aircraft.                                  
27. Issue guidance on vehicle operations near active runways.    Complete  
28. Complete airport paint marking study and revise advisory     Complete  
circular standards, if appropriate.                                        
29. Complete airport design and operations study. Enhance design Complete  
standards and improve procedures as appropriate.                           
30. Ensure towered airports have current airport diagrams.       Complete  
Clarify process, roles, and responsibilities for development and           
maintenance of airport diagrams.                                           
31. Maintain the published ASDE-3/AMASS deployment waterfall     Complete  
schedule.                                                                  
32. Develop high-level requirements for runway status lights and Ongoing   
validate implementation methods through field demonstrations.              
33. Conduct evaluations of existing low-cost technologies.       Complete  
34. Meet published ASDE-X milestones.                            Not met   
35. Evaluate moving map technologies in an operational           Complete  
environment, using either aircraft or surface vehicles.                    
36. Develop and evaluate visual signal for direct warning to     Ongoing   
aircraft on final approach when the runway is occupied.                    
37. Develop a surface "road map" for low-cost technology         Complete  
architecture and issue Broad Agency Announcements to solicit               
industry ideas.                                                            
38. Create and accomplish periodic regional runway safety plans  Ongoing   
for each FAA region, including Runway Safety Action Team site              
visits to airports in each region.                                         
39. Implement an aggressive runway safety "special emphasis"     Ongoing   
program at selected airports that results in reducing runway               
incursions.                                                                

Source: GAO analysis of FAA data.

Appendix V: Airports with Surface Surveillance Technology

Table 10: Airports with Airport Surface Detection Equipment, Model 3
(ASDE-3)/Airport Movement Area Safety Systems (AMASS) or the Airport
Surface Detection Equipment, Model X (ASDE-X) or Scheduled to Receive
ASDE-X
Table 10: Airports with Airport Surface Detection Equipment, Model 3 
(ASDE-3)/Airport Movement Area Safety Systems (AMASS) or the Airport 
Surface Detection Equipment, Model X (ASDE-X) or Scheduled to Receive 
ASDE-X:

Airport: Baltimore Washington International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: {Empty; 
Scheduled ASDE-X Deployment[A]: June 2010.

Airport: Boston Logan International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: July 2009.

Airport: Bradley International, Hartford, CT; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Camp Springs Andrews Air Force Base; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Charlotte Douglas International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty].

Airport: Chicago Midway; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: July 2010.

Airport: Chicago O'Hare International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty].

Airport: Cleveland Hopkins International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Covington/Cincinnati Northern Kentucky International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Dallas-Ft. Worth International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: April 2010.

Airport: Denver International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: November 2009.

Airport: Detroit Metro Wayne County; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: June 2008.

Airport: Ft. Lauderdale/Hollywood; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: April 2009.

Airport: General Mitchell International, Milwaukee, WI; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty].

Airport: George Bush Intercontinental; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: November 2009. 

Airport: Hartsfield-Jackson Atlanta International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Honolulu International - Hickam Air Force Base; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: August 2010. 

Airport: John F. Kennedy International, New York, NY; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: July 2009. 

Airport: John Wayne-Orange County, Santa Ana, CA; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: February 2010. 

Airport: Kansas City International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Lambert-St. Louis International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Las Vegas McCarran International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: December 2009. 

Airport: Los Angeles International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: June 2009. 

Airport: Louis Armstrong New Orleans International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Louisville International-Standiford Field; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Memphis International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: January 2011. 

Airport: Miami International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: August 2010. 

Airport: Minneapolis-St. Paul International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: February 2010. 

Airport: New York LaGuardia; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: December 2010. 

Airport: Newark International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: July 2009. 

Airport: Orlando International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Philadelphia International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: December 2009. 

Airport: Phoenix Sky Harbor International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: December 2008. 

Airport: Pittsburgh International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Portland International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Ronald Reagan Washington National; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: December 2010. 

Airport: Salt Lake City International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: May 2010. 

Airport: San Diego International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: January 2011. 

Airport: San Francisco International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Seattle-Tacoma International; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Ted Stevens Anchorage International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Theodore Francis Green State, Providence, RI; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Airport: Washington Dulles International; 
ASDE-3/AMASS: Check; 
ASDE-X Commissioned: [Empty]; 
Scheduled ASDE-X Deployment[A]: July 2008. 

Airport: William P. Hobby, Houston, TX; 
ASDE-3/AMASS: [Empty]; 
ASDE-X Commissioned: Check; 
Scheduled ASDE-X Deployment[A]: [Empty]. 

Source: FAA. 

[A] Represents when the facility first declares the system ready for 
conditional use. Once the system is formally accepted by the facility, 
the system is commissioned. 

Note: As indicated above, 28 airports currently have ASDE-3/AMASS. Six 
additional airports (Seattle-Tacoma International, Lambert-St. Louis 
International, Hartsfield-Jackson Atlanta International, Louisville 
International-Standiford Field, Chicago O'Hare International, and 
Charlotte Douglas International) originally had ASDE-3/AMASS, but the 
equipment has since been upgraded to ASDE-X. 

Appendix VI: Airports Where Ramp Accident Fatalities Occurred Appendix VI:
Airports Where Ramp Accident Fatalities Occurred

Table 11: U.S. Airports at which Ramp Fatalities Occurred from 2001
through 2006

Table 11: U.S. Airports at which Ramp Fatalities Occurred from 2001 
through 2006: 

Airport: Addison; 
Location: Dallas, TX; 
Type[A]: Reliever; 
Number of fatalities: 1. 

Airport: Burke Lakefront; 
Location: Cleveland, OH; 
Type[A]: Reliever; 
Number of fatalities: 1. 

Airport: Logan International; 
Location: Boston, MA; 
Type[A]: Large hub; 
Number of fatalities: 1. 

Airport: Baltimore/Washington International; 
Location: Baltimore, MD; 
Type[A]: Large hub; 
Number of fatalities: 1. 

Airport: Casa Grande Municipal; 
Location: Casa Grande, AZ; 
Type[A]: General aviation; 
Number of fatalities: 1. 

Airport: Cincinnati/Northern Kentucky International; 
Location: Covington, KY; 
Type[A]: Large hub; 
Number of fatalities: 1. 

Airport: Ronald Reagan Washington National; 
Location: Arlington, VA; 
Type[A]: Large hub; 
Number of fatalities: 2. 

Airport: Denver International; 
Location: Denver, CO; 
Type[A]: Large hub; 
Number of fatalities: 1. 

Airport: Detroit Metropolitan Wayne County; 
Location: Detroit, MI; 
Type[A]: Large hub; 
Number of fatalities: 1. 

Airport: El Paso International; 
Location: El Paso, TX; 
Type[A]: Small hub; 
Number of fatalities: 1. 

Airport: Newark Liberty International; 
Location: Newark, NJ; 
Type[A]: Large hub; 
Number of fatalities: 2. 

Airport: Forrest City Municipal; 
Location: Forrest City, AR; 
Type[A]: General aviation; 
Number of fatalities: 1. 

Airport: Hayward Executive; 
Location: Hayward, CA; 
Type[A]: Reliever; 
Number of fatalities: 1. 

Airport: Chicago O'Hare International; 
Location: Chicago, IL; 
Type[A]: Large hub; 
Number of fatalities: 2. 

Airport: Norfolk International; 
Location: Norfolk, VA; 
Type[A]: Medium hub; 
Number of fatalities: 1. 

Airport: Philadelphia International; 
Location: Philadelphia, PA; 
Type[A]: Large hub; 
Number of fatalities: 2. 

Airport: Richmond International; 
Location: Richmond, VA; 
Type[A]: Small hub; 
Number of fatalities: 1. 

Airport: Louisville International-Standiford Field; 
Location: Louisville, KY; 
Type[A]: Small hub; 
Number of fatalities: 1. 

Airport: Scappoose Industrial Airpark; 
Location: Scappoose, OR; 
Type[A]: General aviation; 
Number of fatalities: 1. 

Airport: Nut Tree; 
Location: Vacaville, CA; 
Type[A]: General aviation; 
Number of fatalities: 1. 

Airport: Total; 
Number of fatalities: 24[B]. 

Source: GAO analysis of Federal Aviation Administration, National 
Transportation Safety Board, and Occupational Safety and Health 
Administration data. 

[A] Primary commercial service airports are categorized based on the 
percentage of total annual passenger boardings (enplanements) for all 
operations of U.S. carriers within the United States. General aviation 
airports are small airports that do not receive scheduled commercial 
service. 

[B] Five additional fatalities occurred from 2001 through 2006, but the 
data sources did not specify the airports. 

Appendix VII: GAO Contact and Staff Acknowledgments

GAO Contact

Gerald Dillingham, Ph.D., (202) 512-2834 or [email protected]

Staff Acknowledgments

In addition to the individual named above, Teresa Spisak (Assistant
Director), Ashley Alley, Nancy Boardman, Colin Fallon, Evan Gilman, Bob
Homan, Dave Hooper, Richard Hung, Rosa Leung, Sara Ann Moessbauer, Josh
Ormond, and Pamela Vines made key contributions to this report.

(540139)

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Highlights of [47]GAO-08-29 , a report to congressional requesters

November 2007

AVIATION RUNWAY AND RAMP SAFETY

Sustained Efforts to Address Leadership, Technology, and Other Challenges
Needed to Reduce Accidents and Incidents

While aviation accidents in the United States are relatively infrequent,
recent incidents have heightened concerns about safety on airport runways
and ramps. As the nation's aviation system becomes more crowded every day,
increased congestion at airports may exacerbate ground safety concerns. To
safely handle the anticipated larger volumes of air traffic, the Federal
Aviation Administration (FAA) is implementing the Next Generation Air
Transportation System (NextGen) to better manage air traffic both in the
air and on the ground. GAO was asked to evaluate (1) the progress being
made in addressing runway safety and what additional measures, if any,
could be taken and (2) the factors affecting progress in improving ramp
safety and what is being done by FAA and others to address those factors.
We reviewed runway and ramp safety data, interviewed agency officials and
industry stakeholders, and surveyed experts.

[48]What GAO Recommends

GAO recommends that FAA take several measures to enhance runway and ramp
safety, such as updating its national runway safety plan, collecting data
on runway overruns, and working with OSHA and industry to collect and
analyze better information on ramp accidents. DOT agreed to consider the
report's recommendations.

FAA and aviation stakeholders have taken steps to address runway and ramp
safety, including deploying and testing technology designed to prevent
runway incursions, which occur when aircraft enter the runway without
authorization, and overruns, which occur when aircraft run off the ends of
runways; helping to change airport layout, markings, signage, and
lighting; and providing training for pilots and air traffic controllers.
In addition, FAA has made progress in addressing runway overruns and
reports that 70 percent of the runways at U.S. commercial airports
substantially comply with runway safety area standards, up from 55 percent
in 2000. However, the rate of runway incursions has not decreased over the
last 5 years. In addition, FAA has not prepared a national runway safety
plan since 2002, despite agency policy that it be updated every 2 to 3
years, resulting in uncoordinated efforts within the agency. Runway safety
technology currently being installed is experiencing some operational
difficulties with its alerting function, while additional technology to
prevent runway collisions is years away from deployment. FAA also lacks
data on runway overruns that could be used to analyze the causes and
circumstances of such incidents. Air traffic controller fatigue, which may
result from regularly working overtime, continues to be a matter of
concern for the National Transportation Safety Board (NTSB), which
investigates transportation accidents, and other aviation stakeholders.

Efforts to improve safety in airport ramp areas, where departing and
arriving aircraft are serviced by baggage, catering, and fueling
personnel, are hindered by a lack of complete accident data and standards
for ground handling, but the aviation industry is taking steps to address
these problems with the goal of reducing ramp accidents. Data from 2001
through 2006 from the Occupational Safety and Health Administration
(OSHA), which investigates occupational accidents, NTSB, and FAA indicated
that these agencies had investigated 29 fatal ramp accidents during that
time. The majority of the fatalities in these accidents were ramp workers.
GAO found no comprehensive nonfatal injury data on ramp accidents and
neither federal nor industrywide standards for ramp operations. The
federal government has generally taken an indirect role overseeing ramp
safety; airlines and airports typically control the ramp areas using their
own policies and procedures. Meanwhile, some airlines and airports have
initiated their own efforts to address ramp safety, and aviation
organizations have begun collecting ramp accident data.

References

Visible links
  35. http://www.gao.gov/cgi-bin/getrpt?GAO-06-266T
  36. http://www.gao.gov/cgi-bin/getrpt?GAO-04-646
  37. http://www.gao.gov/cgi-bin/getrpt?GAO-06-266T
  38. http://www.gao.gov/cgi-bin/getrpt?GAO/RCED-00-75
  39. http://www.gao.gov/cgi-bin/getrpt?GAO/T-RCED/AIMD-00-142
  40. http://www.gao.gov/
  41. http://www.gao.gov/
  42. http://www.gao.gov/fraudnet/fraudnet.htm
  43. mailto:[email protected]
  44. mailto:[email protected]
  45. mailto:[email protected]
  46. http://www.gao.gov/cgi-bin/getrpt?GAO-08-29
  47. http://www.gao.gov/cgi-bin/getrpt?GAO-08-29
*** End of document. ***