Aviation Safety: FAA Generally Agrees with but Is Slow in Implementing
Safety Recommendations (Chapter Report, 09/23/96, GAO/RCED-96-193).
Pursuant to a congressional request, GAO examined the Federal Aviation
Administration's (FAA) responsiveness to aviation safety-related
recommendations made by GAO, the National Transportation Safety Board
(NTSB), and the Department of Transportation's (DOT) Office of the
Inspector General (IG).
GAO found that FAA: (1) generally concurred with the recommendations on
aviation safety made by GAO, NTSB, and DOT IG and has implemented 64
percent of the 256 recommendations made between 1990 and 1994; and (2)
often did not meet the established timeframes for implementing
recommendations, did not establish completion dates for implementing
recommendations, and did not meet statutory requirements for initially
responding to GAO recommendations. GAO also found that, in response to
GAO and NTSB recommendations, FAA: (1) has taken several actions to
improve aircraft certification by revising guidance, reassessing the
responsibilities and training of certification staff and technical
specialists, and improving oversight; (2) has taken several actions to
improve its inspection program, but it has not fully implemented a
strategy to improve the quality of data used in its resource targeting
system; and (3) has not completed actions regarding critical runway
safety issues, although both it and NTSB considered several of the
recommendations closed.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: RCED-96-193
TITLE: Aviation Safety: FAA Generally Agrees with but Is Slow in
Implementing Safety Recommendations
DATE: 09/23/96
SUBJECT: Transportation safety
Interagency relations
Inspection
Airline regulation
Safety regulation
Air transportation operations
Aircraft accidents
Human resources training
IDENTIFIER: FAA National Resource Specialist Program
FAA ASAS Program Tracking and Reporting Subsystem
FAA Airport Movement Area Safety System
FAA Airport Surface Detection Equipment Radar
FAA Safety Performance Analysis System
FAA Aircraft Production Certification Program
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Cover
================================================================ COVER
Report to the Honorable
Collin C. Peterson, House of Representatives
September 1996
AVIATION SAFETY - FAA GENERALLY
AGREES WITH BUT IS SLOW IN
IMPLEMENTING SAFETY
RECOMMENDATIONS
GAO/RCED-96-193
Implementation of FAA Safety Recommendations
(341441)
Abbreviations
=============================================================== ABBREV
AMASS - Airport Movement Area Safety System
ASDE - Airport Surface Detection Equipment
DOT - Department of Transportation
FAA - Federal Aviation Administration
GAO - General Accounting Office
NTSB - National Transportation Safety Board
PTRS - Program Tracking and Reporting Subsystem
RIAT - Runway Incursion Action Teams
SPAS - Safety Performance and Analysis System
Letter
=============================================================== LETTER
B-261918
September 23, 1996
The Honorable Collin C. Peterson
House of Representatives
Dear Mr. Peterson:
In response to your request, this report examines the Federal
Aviation Administration's (FAA) responsiveness to recommendations
concerning aviation safety made by us, the National Transportation
Safety Board, and the Department of Transportation's Office of
Inspector General. This report contains recommendations to the
Secretary of Transportation for improving FAA's responsiveness.
As you requested, unless you publicly announce its contents earlier,
we plan no further distribution of this report until 30 days after
the date of this letter. We will then send copies to the Secretary
of Transportation; the Director, Office of Management and Budget; and
other interested parties. We will make copies available to others
upon request.
If you or your staff have any questions, please call me at (202)
512-2834. Major contributors to this report are listed in appendix
III.
Sincerely yours,
John H. Anderson, Jr.
Director, Transportation and
Telecommunications Issues
EXECUTIVE SUMMARY
============================================================ Chapter 0
PURPOSE
---------------------------------------------------------- Chapter 0:1
The Federal Aviation Administration (FAA), within the Department of
Transportation (DOT), is responsible for promoting safety in civil
air transportation. GAO and DOT's Office of Inspector General review
FAA's safety programs, and the National Transportation Safety Board
(NTSB) investigates aviation accidents. The three organizations make
recommendations to FAA aimed at improving the efficiency and
effectiveness of FAA's activities and functions and at improving
aviation safety. Representative Collin C. Peterson asked GAO to
determine FAA's responsiveness to such recommendations.
Specifically, this report focuses on two questions.
-- What has FAA's overall record been in responding to, agreeing
with, and implementing significant recommendations concerning
aviation safety made by GAO and DOT's Inspector General from
1990 through 1994, as well as recommendations made by NTSB or
added to NTSB's "Most Wanted" lists of safety recommendations
from 1990 through 1994?
-- To what extent have GAO's specific recommendations in the areas
of aircraft certification, airline inspections, and oversight of
foreign carriers and NTSB's recommendations concerning safety on
runways been fully implemented?
BACKGROUND
---------------------------------------------------------- Chapter 0:2
To promote aviation safety, FAA is responsible for, among other
things, certifying that aircraft are properly designed, conducting
periodic inspections of airlines to ensure their continued compliance
with safety regulations, operating the nation's air traffic control
system, and ensuring that airports provide a safe operating
environment. FAA is subject to legislative and administrative
requirements for responding to and implementing recommendations made
by the three aforesaid organizations in a timely manner. FAA is
required by law to initially respond to (1) congressional committees
on its planned actions on GAO's recommendations within 60 days and
(2) NTSB on its recommendations within 90 days. DOT's policies and
procedures require FAA to respond to the Inspector General's
recommendations within 60 days. In addition, FAA is required to
establish time frames for implementing the recommendations of all
three organizations.
The three organizations, as well as FAA, maintain systems for
tracking FAA's response to and disposition of each recommendation.
GAO's review focused on the implementation status of 256
recommendations related to aviation safety that the three
organizations had identified as particularly significant. For
example, NTSB's recommendations that GAO reviewed were classified by
NTSB as "Most Wanted." The recommendations were made from 1990
through 1994 by GAO, DOT's Inspector General, or NTSB, or were added
by NTSB to its "Most Wanted" list of safety recommendations during
this period. In addition, GAO conducted detailed field work on 18 of
GAO's and NTSB's recommendations concerning aircraft design, airline
inspections, and airport runways to ascertain whether or to what
extent they had actually been carried out in the field.
RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3
FAA generally concurred with the recommendations made by GAO, NTSB,
and DOT's Inspector General and had implemented the majority (64
percent) of them as of October 1995. However, FAA met the
established implementation time frames only about one-third of the
time for GAO's and the DOT Inspector General's recommendations. GAO
could not readily measure FAA's on-time performance for NTSB's
recommendations because FAA had not included in most of its initial
responses to NTSB the estimated time frames for implementing most of
NTSB's recommendations that GAO reviewed.
While FAA's initial responses to NTSB's and the DOT Inspector
General's recommendations were almost always made within the required
time frames, FAA never met the statutory time frames for responding
to the congressional committees on GAO's recommendations included in
this review, nor did it establish the required completion dates for
some of GAO's and the majority of NTSB's recommendations included in
this review. Delays in initially responding to recommendations may
slow FAA's progress in taking actions to resolve the issues that led
to the recommendations, and without estimated completion dates, there
are no milestones against which implementation progress can be
measured.
For the 18 specific recommendations on which GAO conducted detailed
field work, FAA has taken actions on or had actions in process on 17
of them to improve its aircraft certification process, its airline
inspections, its oversight of foreign carriers, and the safety of
airport runways. However, GAO found that the status shown in the
tracking systems for some of NTSB's recommendations did not reflect
the actual status of on-the-ground actions. Of the seven
recommendations by NTSB that GAO reviewed in the field, five were
listed in the tracking systems as closed (i.e., implemented by FAA).
But GAO found that for four of these five recommendations, actions
remained to be completed, primarily by affected airports, to fully
resolve the problems that gave rise to the recommendations.
PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4
FAA GENERALLY AGREES WITH
AND IMPLEMENTS
RECOMMENDATIONS BUT OFTEN
DOES NOT MEET ESTABLISHED
TIME FRAMES
-------------------------------------------------------- Chapter 0:4.1
FAA agreed with about 90 percent of the 256 significant
safety-related recommendations made by the three organizations.
Specifically, FAA agreed with 90 percent of GAO's 113
recommendations, 97 percent of NTSB's 29 recommendations, and 89
percent of the DOT Inspector General's 114 recommendations. FAA's
on-time implementation of recommendations was 55 percent for GAO's
recommendations and 13 percent for the DOT Inspector General's
recommendations. NTSB's legislation requires that FAA's responses to
NTSB's recommendations include a time table for completing the
procedures for adopting the recommendations, and DOT and FAA orders
reinforce this requirement. GAO found, however, that FAA had not
fully complied with this requirement. Specifically, of NTSB's 29
"Most Wanted" recommendations that GAO reviewed, FAA had not included
time frames for 24 of them in its initial responses to NTSB. In the
absence of such time frames, GAO was unable to readily measure FAA's
timeliness in implementing NTSB's recommendations. In addition, FAA
had not set completion dates for 18 of GAO's recommendations, and FAA
averaged 214 days to respond to congressional committees on GAO's
recommendations rather than the 60 days mandated by law. In
contrast, FAA's initial responses were on time 93 percent of the time
for NTSB's recommendations and 88 percent of the time for the DOT
inspector General's recommendations.
FAA'S ACTIONS TO IMPLEMENT
RECOMMENDATIONS ON AIRCRAFT
CERTIFICATION, AIRLINE
INSPECTION, OVERSIGHT OF
FOREIGN CARRIERS, AND SAFETY
ON AIRPORT RUNWAYS
-------------------------------------------------------- Chapter 0:4.2
Before introducing an aircraft into commercial service in the United
States, the manufacturers must obtain FAA's certification that the
aircraft and its systems meet the agency's standards. In 1993, GAO
reported that FAA had not ensured that its staff were effectively
involved in the certification process because FAA delegated up to 95
percent of the certification activities to FAA-approved persons
employed or retained by aviation industry companies. These
designated engineering representatives act as FAA's surrogates in
analyzing, testing, and examining aircraft designs and systems. In
response to a number of GAO's recommendations, FAA has better defined
the role of its certification staff and improved its oversight of the
designated engineering representatives. In addition, FAA has
identified technical areas, such as crash dynamics and advanced
avionics, in which FAA needs technical specialists to maintain
leadership and identified key points when these technical specialists
should be involved in the certification process.
FAA regularly inspects air carriers to help ensure that their
operations comply with federal aviation safety regulations. In 1991
and 1992 reports, GAO made a number of recommendations intended to
improve the efficiency and effectiveness of FAA's inspection program.
Since that time, FAA has taken actions to address the majority of the
problems identified in those reports. For example, FAA has taken
steps to better target its inspection resources to areas posing the
greatest safety risks by developing and deploying a risk assessment
system. However, GAO reported in 1995 that data problems threatened
the effectiveness of this system, and FAA still has not completed a
strategy to address the data problems. As recommended by GAO, FAA
has increased its oversight of foreign carriers flying into the
United States and improved its program for assessing foreign
countries' compliance with international aviation standards.
The vast majority of serious commercial aviation accidents occur
during takeoff and landing. To improve safety on airport runways,
NTSB has made several recommendations to FAA over the years. NTSB
considered runway safety issues so important that since 1990, it has
placed recommendations addressing them on its "Most Wanted" list of
critical safety recommendations. Of the seven recommendations by
NTSB on runway safety that GAO examined, five are listed as having
been implemented by FAA in both NTSB's and FAA's tracking systems.
However, GAO found that in four of the five cases, the actions
necessary to address the problems that gave rise to the
recommendations had not been completed by all of the affected
airports. For example, in 1991 NTSB recommended that FAA improve its
standards for airport marking and lighting when visibility is low; in
1993, NTSB classified the recommendation as "closed" because of an
"acceptable action" when FAA issued new standards and guidance that
called for airports to develop plans for operating in low visibility
by January 1995. However, GAO found that as of July 1996, only 19 of
77 airports that need such plans under these standards had plans that
had been approved by FAA, while 23 others had not even formed a
working group to develop such a plan.
RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5
To enhance the timeliness of the implementation of recommendations
and to better track the actual implementation of all recommendations
relating to safety, GAO recommends that the Secretary of
Transportation direct the Administrator of FAA to
-- ensure that FAA's initial responses to GAO's and NTSB's
recommendations include target dates for completing actions on
them, as called for in legislation and DOT's policies;
-- respond to congressional committees on GAO's recommendations
within 60 days, as required by law; and
-- for critical safety recommendations, periodically monitor their
implementation and the actions needed to fully resolve, at the
field level, the problems that gave rise to the recommendations
and report the status to the Congress and the agency that made
the recommendations.
AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:6
GAO provided DOT with copies of a draft of this report for DOT's
review and comment. GAO met with agency officials from FAA offices
responsible for the programs and activities discussed in this report,
including the managers of the Recommendation Branch, Office of
Accident Investigation; Evaluation and Analysis Branch, Flight
Standards Service; National Runway Incursion Program, Air Traffic
Operations Service; and Airport Safety and Operations Division,
Office of Airport Safety and Standards; and the Chief of DOT's Audit
Liaison Division, Office of the Assistant Secretary for
Administration. DOT generally agreed with GAO's findings and
conclusions. However, DOT officials expressed concern about their
ability to monitor in-the-field implementation of all
recommendations, primarily because of insufficient resources, as GAO
was suggesting in its proposed recommendation.
GAO recognizes that resource and other constraints can limit the
amount of in-depth verification FAA can perform to assess the
implementation of all recommendations. However, GAO believes that at
a minimum, FAA should monitor the in-the-field implementation of
critical safety recommendations and report the results to the
Congress and the agency that made the recommendations. Thus, GAO has
modified its recommendation to allow flexibility on how FAA monitors
the implementation of actions in the field to address the problems
that gave rise to the recommendations. In addition, while FAA
officials acknowledged that time frames for implementing NTSB's
recommendations have not always been appropriately documented, they
stated that frequent dialogue occurs between FAA and NTSB on the
progress made in implementing NTSB's recommendations and that FAA
program offices establish internal target dates for implementing
them. While frequent communications between FAA and NTSB and
internal target dates are certainly useful, the absence of documented
time frames in FAA's initial responses to recommendations does not
meet established legislative and administrative requirements and
limits the ability of appropriate oversight entities, including the
Congress, to monitor the timeliness of FAA's implementation progress.
DOT also provided GAO with technical comments and updates on the
status of specific actions relating to the recommendations reviewed,
which have been incorporated into the report as appropriate.
INTRODUCTION
============================================================ Chapter 1
The Federal Aviation Administration (FAA), within the Department of
Transportation (DOT), is responsible for promoting safety in air
transportation and air commerce. To help ensure the safety of the
more than 1 million people who travel on thousands of flights
throughout the United States and to and from other countries each
day, FAA, among other things, inspects and certifies the aviation
community's compliance with FAA's regulations. GAO and the
Department of Transportation's Office of Inspector General review
FAA's implementation of safety programs, and the National
Transportation Safety Board (NTSB) investigates aviation accidents
and performs special studies on aviation safety. The reports
prepared by these three organizations often contain recommendations
to FAA aimed at improving the efficiency and effectiveness of its
activities and functions and at improving aviation safety. This
report discusses FAA's actions to respond to and implement these
recommendations.
FAA'S RESPONSIBILITIES IN
AVIATION SAFETY
---------------------------------------------------------- Chapter 1:1
Section 44701 of Title 49 of the United States Code requires FAA to
promote the safety of civil aircraft in air commerce. The United
States Code establishes that the safety of air passengers is a
responsibility of airlines, aircraft manufacturers, airports, and
ultimately, FAA. The airlines are responsible for operating their
aircraft safely, aircraft manufacturers are responsible for designing
and building aircraft that meet FAA's regulations, and airports are
responsible for providing a safe operating environment. FAA is
responsible for, among other things, certifying that aircraft and
airlines are ready to operate safely and conducting periodic
inspections to ensure their continued compliance with safety
regulations. FAA conducts these periodic inspections of both
domestic and foreign airlines. FAA is also responsible for operating
the nation's civilian air traffic control system. An essential
factor in aviation safety is the ability of the air traffic control
system to efficiently route aircraft in the air. FAA also fosters
the safe and efficient movement of aircraft on airport surfaces. To
carry out the above and other activities, FAA has about 47,000
employees.
ROLES OF GAO, NTSB, AND DOT'S
INSPECTOR GENERAL
---------------------------------------------------------- Chapter 1:2
As the legislative branch agency responsible for carrying out
independent audits and evaluations of the programs, activities, and
financial operations of executive branch departments and agencies,
GAO audits and evaluates FAA's aviation safety programs and makes
recommendations intended to help FAA carry out its responsibilities
in a more efficient, effective, and economical manner. By law,
executive agencies are required to respond to GAO's recommendations
within 60 days to congressional committees, but implementation of
GAO's recommendations is not mandatory. GAO has a follow-up system
to track agencies' actions on its recommendations and reports
annually to the Congress on open recommendations.
DOT's Inspector General audits the programs and operations of DOT.
The results of the Inspector General's audits of FAA's aviation
safety programs are contained in reports to FAA, which usually
contain recommendations. FAA is required by DOT guidance to respond
to the Inspector General's final reports within 60 days, but
implementation of the recommendations is not mandatory. The
Inspector General has established a system for following up on
recommendations made to FAA until final actions are completed. The
Secretary of Transportation sends to the Congress semiannual reports
that include recommendations that have not been resolved or on which
corrective actions have not been completed.
NTSB is an independent agency that investigates transportation
accidents and promotes transportation safety through recommendations.
NTSB investigates all civilian aviation accidents, conducts studies
on safety, and evaluates the effectiveness of government agencies'
safety programs. NTSB's recommendations can be made to FAA and to
other parties, including federal, state, and local governments and
private aviation companies, but most of NTSB's recommendations
concerning air safety are directed at FAA. According to NTSB,
recommendations on safety are NTSB's most important product.
Although the implementation of NTSB's recommendations is not
mandatory, the Congress has required that DOT send its response to
each recommendation to NTSB within 90 days. NTSB has established an
Office of Safety Recommendations and a follow-up program to track the
implementation of its recommendations. In addition, NTSB developed
in 1990 a "Most Wanted" list of important safety recommendations
identified for special attention and intensive follow-up; this list
is revised annually. NTSB reports on the safety recommendations made
and the Secretary of Transportation's responses to its
recommendations annually to the Congress.
DOT'S AND FAA'S POLICIES AND
PROCEDURES FOR RESPONDING TO
AVIATION SAFETY RECOMMENDATIONS
---------------------------------------------------------- Chapter 1:3
The Office of Management and Budget's Circular A-50, Revised,
provides the policies and procedures that all executive agencies are
to use when considering reports issued by GAO and the Inspectors
General when follow-up is necessary. The circular requires agencies'
responses to audit reports to include planned corrective actions,
and, where appropriate, dates for achieving those actions. The
circular also requires executive agencies to establish a follow-up
system to ensure the prompt and proper resolution and implementation
of recommendations. Section 1135 of Title 49 of the United States
Code requires that DOT respond to NTSB's recommendations. DOT and
FAA have established policies and procedures for tracking, responding
to, and implementing the recommendations made by GAO, NTSB, and the
Inspector General.\1
DOT's Office of the Assistant Secretary for Administration has
responsibility for ensuring that departmental commitments to GAO and
the Inspector General are implemented promptly and effectively.
Within FAA, the Office of the Associate Administrator for
Administration serves as the control point for FAA's relationships
with GAO and DOT's Inspector General on audit matters. This office
is also responsible for administering a follow-up system to ensure
that FAA's commitments to GAO and the Inspector General are promptly
and effectively carried out.
DOT's Office of the Assistant Secretary for Transportation Policy
ensures that DOT and its agencies respond to and act on NTSB's
recommendations in accordance with DOT's policies and procedures.
Within FAA's Office of the Associate Administrator for Regulation and
Certification, the Office of Accident Investigation serves as the
control point for all NTSB recommendations on aviation and is
responsible for following up on NTSB's recommendations until
appropriate action has been taken.
--------------------
\1 These policies and procedures implement provisions found in
applicable laws and circulars, such as 49 U.S.C. � 1101 et seq., the
"Inspector General Act Amendments of 1988" (P.L. 100-504), the
"Legislative Reorganization Act of 1970" (P.L. 91-510), and the
Office of Management and Budget Circular A-50, Revised.
OBJECTIVES, SCOPE, AND
METHODOLOGY
---------------------------------------------------------- Chapter 1:4
At the request of Representative Collin C. Peterson, we examined
FAA's responsiveness to recommendations concerning aviation safety
from GAO, NTSB, and DOT's Inspector General. This report focuses on
two questions.
-- What has FAA's overall record been in responding to, agreeing
with, and implementing significant recommendations concerning
aviation safety made by GAO and DOT's Inspector General from
1990 through 1994 as well as recommendations made by NTSB or
added to NTSB's "Most Wanted" list of safety recommendations
from 1990 through 1994?
-- To what extent have GAO's specific recommendations made on
aircraft certification, airline inspections and oversight of
foreign carriers, and NTSB's recommendations concerning safety
on runways been fully implemented?
To address these questions, we first established a universe of
significant recommendations related to aviation safety made by GAO,
NTSB, and DOT's Inspector General primarily from 1990 through 1994.
We selected this period in accordance with Representative Peterson's
request and also because some recommendations, such as those dealing
with regulatory change and new equipment, cannot normally be
implemented in a short time frame because they often require thorough
study as well as extensive consultation with the aviation community
and cost-benefit analyses. For this reason, we did not review the
implementation of recommendations made in calendar years 1995 and
1996. We also included 10 recommendations dating from 1986 that NTSB
considered particularly significant and added to its "Most Wanted"
list during the 1990-94 period. We reviewed listings of aviation
safety reports and recommendations on aviation safety by GAO, NTSB,
and DOT's Inspector General for the period 1990 through 1994. To
determine the major areas in which GAO, NTSB, and the DOT Inspector
General had made significant recommendations, we consulted with the
officials who were responsible for these reports and recommendations
and reviewed various agency documents that identified and discussed
significant reports and recommendations, including NTSB's "Most
Wanted" lists from 1990 through 1994. Through this process, we
identified 256 significant recommendations (113 from GAO; all 29 of
the aviation safety recommendations included in NTSB's 1990-1994
"Most Wanted" lists, including the 10 recommendations dating back to
1986; and 114 from DOT's Inspector General). We gathered data on
their status from the tracking systems maintained by GAO, NTSB, DOT's
Inspector General and FAA. We did not verify the accuracy of the
overall data in the tracking systems.
We then selected from this list 11 GAO and 7 NTSB recommendations for
which we conducted detailed audit work and determined the status of
the recommendations' actual implementation, including the status of
actions necessary to fully correct the problems that gave rise to the
recommendations, at specific FAA locations and airports. We did not
perform any such detailed field work on recommendations by DOT's
Inspector General because that office was performing a similar audit
of the implementation of several of its recommendations on aviation
safety that were classified as "closed and fully implemented" because
of concerns about the actual implementation of the recommendations in
the field offices. A more detailed discussion of our objectives,
scope, and methodology is presented in appendix I, and the list of
locations where we performed detailed field work is presented in
appendix II.
We discussed a draft of this report with officials from FAA offices
responsible for the programs and activities discussed in this report.
We have incorporated their comments where appropriate. Additional
details on their comments and our response appear at the end of
chapters 2 and 5. We conducted our review from January 1995 through
August 1996 in accordance with generally accepted government auditing
standards.
FAA'S RESPONSIVENESS TO
SIGNIFICANT RECOMMENDATIONS
CONCERNING SAFETY
============================================================ Chapter 2
FAA generally concurred with the recommendations on aviation safety
made by GAO, NTSB and DOT's Inspector General and has implemented the
majority of them. These recommendations were made by GAO and DOT's
Inspector General from 1990 through 1994. These recommendations were
also made by NTSB or were added to NTSB's "Most Wanted" lists of
safety recommendations from 1990 through 1994. Nevertheless, FAA
often did not meet the time frames established for implementing these
recommendations. FAA implemented 55 percent of GAO's recommendations
and 13 percent of the DOT Inspector General's recommendations as of
October 1995. We were unable to readily measure FAA's timeliness in
implementing NTSB's recommendations because FAA had not established
time frames in its initial responses to NTSB for implementing 24 of
NTSB's 29 "Most Wanted" recommendations that we reviewed. In
addition, FAA had not established completion dates for implementing
18 of GAO's recommendations.
The first step toward the timely implementation of recommendations is
for FAA to make its initial response to agencies' recommendations
within the time required. However, while FAA usually met the
statutory requirement to make an initial response to NTSB's
recommendations within 90 days and DOT's requirement to respond to
the DOT Inspector General's recommendations within 60 days, FAA did
not meet the statutory requirement to respond to GAO's
recommendations within 60 days for any of the recommendations
included in this review.
FAA GENERALLY CONCURRED WITH
RECOMMENDATIONS AND HAS
IMPLEMENTED THE MAJORITY OF
THEM
---------------------------------------------------------- Chapter 2:1
FAA usually agreed with the recommendations made by the three
organizations (GAO, NTSB, and DOT's Inspector General). For the
recommendations we reviewed, FAA either concurred with or concurred
in part with 90 percent of GAO's 113 recommendations, concurred with
97 percent of NTSB's 29 "Most Wanted" recommendations, and concurred
with 89 percent of the DOT Inspector General's 114 recommendations.
FAA had implemented 64 percent of the 256 recommendations that we
reviewed, according to the information in the three organizations'
tracking systems as of October 1995. However, FAA had not completed
actions to implement the remaining 36 percent of the recommendations.
(See fig. 2.1.) "Implemented" means that GAO, NTSB, or DOT's
Inspector General has classified the recommendation as closed because
action on the recommendation is considered complete. "Not
implemented" means that the organization closed the recommendation
because (1) FAA disagrees with the recommendation and does not intend
to implement it or (2) the recommendation is no longer applicable.
Recommendations are classified as "open" if actions to implement the
recommendation have not been initiated or are in process, or intended
actions are not fully resolved.
Figure 2.1: FAA's
Implementation Rate for GAO's,
NTSB's, and the DOT Inspector
General's Aviation Safety
Recommendations Included in
This Review, as of October 1995
(See figure in printed
edition.)
Note: The total number of recommendations is 256.
The percentage of recommendations that had been implemented varies
somewhat by agency. Specifically,
-- of GAO's 113 recommendations, 61 percent had been implemented,
15 percent had not been implemented, and 24 percent were
considered open;
-- of NTSB's 29 "Most Wanted" recommendations, 59 percent had been
implemented, 17 percent had not been implemented, and 24 percent
were considered open; and
-- of the DOT Inspector General's 114 recommendations, 69 percent
had been implemented, and 31 percent were considered open.
Recommendations that deal with issues such as regulatory changes,
developing and acquiring new equipment, and providing needed training
cannot be accomplished in a short time frame by FAA because they
often require thorough study, extensive consultation with the
aviation community, and cost-benefit analyses. Therefore, the
implementation rates cited here would be expected to increase as time
goes by. In fact, FAA's implementation rate for GAO's and the DOT
Inspector General's recommendations is higher for those issued early
in the 1990-94 period than in the later years. FAA's implementation
rate for GAO's recommendations ranged from 87 percent for those made
in 1990 to 24 percent for those made in 1994; for the DOT Inspector
General's recommendations, the rate ranged from 100 percent for those
made in 1990 to 23 percent for those made in 1994. All of NTSB's 29
recommendations were added to the "Most Wanted" list from 1990
through 1992. FAA's implementation rate was highest for the
recommendations added in 1990--82 percent.
FAA OFTEN DID NOT MEET
ESTABLISHED TIMES FOR
IMPLEMENTING RECOMMENDATIONS
---------------------------------------------------------- Chapter 2:2
DOT's orders call for FAA to establish estimated time frames for
implementing recommendations in FAA's initial response to the
recommendations made by GAO and the DOT's Inspector General. NTSB's
legislation requires that FAA's initial responses to NTSB's
recommendations include a time table for completing the procedures to
adopt NTSB's recommendations, and DOT's and FAA's orders reinforce
this requirement. Our comparison of estimated and actual dates for
completing actions on recommendations showed that FAA usually did not
meet its estimated time frames for implementing these
recommendations. FAA's record in meeting these implementation goals
varied significantly--55 percent for GAO and 13 percent for the DOT
Inspector General's recommendations.
FAA had not established time frames in its initial responses for 24
of NTSB's 29 recommendations that we reviewed, and thus we could not
readily measure the timeliness of FAA's implementation actions. In
addition, FAA had not set implementation dates for 18 of GAO's
recommendations.
COMPLETION DATES WERE
SOMETIMES NOT ESTABLISHED
AND OFTEN WERE NOT MET FOR
GAO'S RECOMMENDATIONS
-------------------------------------------------------- Chapter 2:2.1
DOT's order for following up on GAO's recommendations states that if
action has not been completed at the time that DOT replies to
recommendations in a GAO report, estimated target completion dates
are to be included in DOT's response. However, we found that of
GAO's 113 recommendations, FAA provided completion dates for only 45.
No dates were provided for 18, for which DOT and FAA officials agreed
that completion dates should have been established. FAA did not
provide estimated completion dates for the 50 final recommendations
because the agency either considered implementation already completed
or did not agree with the recommendation or because establishing a
date would not be expected owing to the continuous nature of the
implementation action. In our May 1992 report to DOT,\1 we stated
that DOT's modal administrations had not included estimated
completion dates for about one-fourth of the recommendations included
in that review. DOT replied that corrective actions were being taken
to ensure that completion dates were included, where necessary.
Implementation had slipped for some of the 45 recommendations for
which estimated completion dates had been established in the initial
response. Only 25 of these recommendations had an actual completion
date in the FAA tracking information system that could be compared
with the original estimated completion date. Of these, only seven
met their original estimated completion date--slippage ranged from 1
to 26 months. Of the 69 recommendations that were implemented and
closed, 7 met their original completion date, and FAA reported in its
initial response that 31 other recommendations had already been
implemented. Thus, 55 percent of the recommendations were
implemented on time.
--------------------
\1 DOT's Recommendation Response System (GAO/RCED-92-164R, May 5,
1992).
COMPLETION DATES WERE
ESTABLISHED BUT NOT USUALLY
MET FOR RECOMMENDATIONS FROM
DOT'S INSPECTOR GENERAL
-------------------------------------------------------- Chapter 2:2.2
DOT's policy guidance calls for the Department's management officials
to provide the Inspector General with estimated target dates for
completing actions on recommendations that they agree with. The
guidance also calls for the Inspector General to maintain a database
of recommendations and to track both the planned and the actual
completion dates. This automated database is used by both the
Inspector General and FAA to track the status of recommendations.
For recommendations that FAA does not implement within 1 year after
agreement was reached between FAA and the Inspector General's staff
regarding the implementation actions, the Secretary of Transportation
is required to report semiannually to the Congress. The Secretary's
report also includes information on final actions taken by DOT to
implement the Inspector General's recommendations during the
reporting period.
While data from the Inspector General's tracking system show that
target dates for completion were established by FAA for the
recommendations covered in this review, those target dates were
seldom met. Of the 79 recommendations that were implemented and
closed, only 10 (or 13 percent) met their original or revised target
dates for implementation. The slippage for implementing the other 69
recommendations ranged up to 18 months; 3 of these slipped from 12 to
18 months. Most of the others were behind their implementation
schedule by 6 months or less, according to the tracking data.
Audit liaison officials at FAA headquarters pointed out that after a
year passes, contacts will be made with the field program offices
about the status of corrective actions. FAA's and the Inspector
General's field staff who are closest to the work are the ones to
whom the headquarters staff look to for both the completion and
interpretation of the tracking information.
IMPLEMENTATION TIME FRAMES
FOR NTSB'S RECOMMENDATIONS
OFTEN NOT DOCUMENTED IN
INITIAL RESPONSES
-------------------------------------------------------- Chapter 2:2.3
Section 1135 of Title 49 of the United States Code provides for a
90-day response period for NTSB's recommendations addressed to the
Department of Transportation. This legislation also requires that
the response include a time table for adopting NTSB's
recommendations, and DOT and FAA orders reinforce this requirement.
We found, however, that FAA had not fully complied with this
requirement. Specifically, of NTSB's 29 "Most Wanted"
recommendations that we reviewed, FAA had not included time frames
for 24 of them in its initial response to NTSB. In the absence of
such time frames, we were unable to readily measure FAA's timeliness
in implementing NTSB's recommendations. FAA and NTSB officials told
us that the dates for taking action on NTSB's recommendations are
often discussed between FAA and NTSB staff. In addition, FAA
officials stated that they maintain internal target dates for
completing actions on NTSB's recommendations. However, these dates
were seldom documented in correspondence between FAA and NTSB. Our
review of correspondence between FAA and NTSB revealed that for the
29 recommendations, 21 did not have documented implementation time
frames in either the initial response or any subsequent
correspondence.
NTSB officials were concerned about the length of time that FAA takes
to implement some of NTSB's recommendations. These officials
acknowledge that because of such things as regulatory rule making and
purchasing new equipment along with training for its use,
implementation can take years. Nevertheless, because of their
concerns over timeliness of implementation, they are considering
revising the NTSB internal order for following up on and closing
recommendations. The proposed changes would require NTSB staff to
review actions taken on recommendations at 1-, 3-, and 5-year
intervals and determine if the required action could have been
completed within those time frames. If so, the recommendation may be
classified as a "Closed-Unacceptable Action" because its
implementation was not timely.
On the basis of NTSB's internal guidelines for timeliness, our
analysis of FAA's timeliness for implementing NTSB's 29 "Most Wanted"
recommendations included in this report helps explain NTSB's concern
about the time that FAA takes to implement some NTSB recommendations.
While not required of or used by FAA, the following timeliness goals
are used by NTSB for following up on and closing its recommendations
in effect during the 5-year period covered by our review.
-- Class I, urgent actions, to be closed in 1 year on the basis of
the response provided.
-- Class II, priority actions, to be closed in 2 years on the basis
of the response provided.
-- Class III, longer-term actions, to be closed in 5 years on the
basis of the response provided.
Twenty-seven of the 29 "Most Wanted" recommendations are in the Class
II category and two are in the Class III category.
We determined that as of October 1995, of the 17 recommendations
closed by NTSB as having acceptable actions taken by FAA, only 6 were
implemented within NTSB's timeliness goals of 2 to 5 years as stated
above. The other 11 significantly missed NTSB's goals; the time
taken ranged up to 5 years behind NTSB's goals. The average time was
2.1 years behind these time frames for completion.
All of the remaining 12 recommendations not closed with acceptable
actions had also missed NTSB's 2- 5-year timeliness goals. For
example, of the seven recommendations that were still open, (1) five
with acceptable responses were open an average of 3 years after their
Class II goal of 2 years; (2) an open Class III recommendation with
an acceptable response was open more than 3 years after its 5-year
time goal; and (3) an open Class II recommendation with an
unacceptable response was open nearly 2 years after the Class II goal
of 2 years. The remaining five Class II recommendations were
ultimately closed by NTSB, which considered the alternative actions
taken by FAA to be unacceptable.
FAA DID NOT MEET ESTABLISHED
TIME FRAMES FOR INITIAL
RESPONSE TO GAO'S
RECOMMENDATIONS
---------------------------------------------------------- Chapter 2:3
FAA is required to make timely initial responses to recommendations
from all three organizations. Section 1135 of Title 49 of the United
States Code requires the Secretary of Transportation to make its
initial response to NTSB's recommendations within 90 days, and the
Legislative Reorganization Act of 1970 requires FAA to report to
congressional committees on actions taken or actions it plans to take
on GAO's recommendations within 60 days. For the DOT Inspector
General recommendations, DOT and FAA orders call for FAA to respond
to recommendations within 60 days. For NTSB's "Most Wanted"
recommendations that we reviewed, FAA met NTSB's time frames for 93
percent of the 29 recommendations and met the DOT Inspector General's
time frames for 88 percent of the 16 reports that contained the 114
recommendations; however, FAA did not meet the time frames for
responding to any of GAO's 34 products that contained the 113
recommendations.\2 (See fig. 2.2.) FAA's lack of timeliness in
making an initial response to GAO's recommendations may slow progress
in taking actions to resolve the problems that led to the
recommendations.
Figure 2.2: Comparison of the
Timeliness of FAA's Initial
Responses to GAO, NTSB and
DOT's Inspector General
(See figure in printed
edition.)
FAA officials told us that a number of factors can help explain the
difference in the time that FAA took to respond to the three
organizations. According to these officials, FAA's process for
responding to GAO's recommendations is lengthy and cumbersome,
requiring comments and approval at the program level and approval
from the Office of the FAA Administrator. By contrast, DOT expects
early consultation between its agencies and its Inspector General on
draft reports, and agreement is often reached at this stage on the
action that FAA will take. When such agreements are reached at this
draft stage they become part of the Inspector General's final report.
Regarding NTSB's recommendations, FAA often works closely with NTSB
during an accident investigation and is therefore already familiar
with the resulting recommendations when they are made.
In a 1992 report, we brought to DOT's attention the fact that FAA and
other DOT administrations were not meeting the requirement to make an
initial response to GAO's products within 60 days.\3 We reported that
FAA's response time was averaging 219 days for recommendations in
products issued from January 1985 through October 1990. To address
this problem, DOT began in 1994 to conduct concurrent reviews of
GAO's products and their recommendations within the Office of the
Secretary and the FAA Administrator whenever possible. However, the
problem has not been resolved. FAA averaged 214 days to respond to
the 34 GAO products included in this review. Because the concurrent
policy review was implemented near the end of our 1990-94 analysis
period, we also reviewed 12 other reports, not included in our
initial universe, issued to FAA from February 1994 through February
1996. FAA averaged 177 days to respond to the recommendations in
these products, and during this period, FAA only met the requirement
to respond within 60 days for two of these products.
--------------------
\2 For GAO's and the DOT Inspector General's recommendations, FAA
responds in a single reply to the report or product containing the
recommendations. For NTSB's recommendations, FAA may respond
separately to individual recommendations or all the recommendations
contained in an accident or special report.
\3 DOT's Recommendation Response System (GAO/RCED-92-164R, May 5,
1992).
CONCLUSIONS
---------------------------------------------------------- Chapter 2:4
The establishment of estimated completion dates brings a certain
rigor to the implementation of recommendations and provides
milestones against which progress can be measured; the absence of
milestones can hinder the timely implementation of recommendations.
However, FAA has not consistently established in its initial
responses estimated completion dates for implementing GAO's and
NTSB's recommendations with which it agrees. Furthermore, FAA rarely
meets the legislatively mandated requirement to respond to
congressional committees on recommendations in GAO products within 60
days. FAA's lack of timeliness in making an initial response to
GAO's recommendations may slow progress in taking actions to resolve
the problems that led to the recommendations.
RECOMMENDATIONS
---------------------------------------------------------- Chapter 2:5
To enhance the timeliness of FAA's implementation of GAO's and NTSB's
recommendations, we recommend that the Secretary of Transportation
(1) direct the Administrator, FAA, to ensure that initial responses
to GAO and NTSB include the expected target dates for completion of
actions to implement recommendations with which FAA agrees and (2)
take the necessary steps, in conjunction with the Office of the
Secretary, to ensure that responses to congressional committees on
GAO products are made within the 60 day time frame required by law.
AGENCY COMMENTS AND OUR
EVALUATION
---------------------------------------------------------- Chapter 2:6
In commenting on a draft of this report, DOT officials--including the
Chief of the Audit Liaison Division, Office of the Assistant
Secretary for Administration, and the Manager of the Recommendation
Branch, Office of Accident Investigation--generally agreed with the
above recommendations. However, they disagreed with our statement
that we could not readily measure FAA's on-time performance for
implementing NTSB's recommendations because there were no dates in
most of FAA's initial responses to NTSB. They stated that FAA's
tracking system contains dates for virtually all of the
recommendations and that this information was available to GAO. They
added that FAA's program offices establish internal target dates for
implementing NTSB's recommendations.
We recognized in our draft report that FAA's target dates are often
discussed with NTSB officials. However, the dates in the tracking
system can be periodically changed by the program offices. Thus,
they do not constitute a benchmark against which on-time
implementation can be measured. As discussed in the draft report,
target dates were not included in the initial responses for 24 of the
29 recommendations that we reviewed. Thus, we were not able to
readily measure FAA's on-time performance using an established
benchmark. While frequent communications between FAA and NTSB and
internal target dates are certainly useful, the absence of documented
time frames in FAA's initial responses to recommendations does not
meet established legislative and administrative requirements and
limits the ability of appropriate oversight entities, including the
Congress, to monitor the timeliness of FAA's implementation progress.
FAA HAS TAKEN STEPS TO IMPROVE
AIRCRAFT CERTIFICATION
============================================================ Chapter 3
Aviation safety begins with the design and certification of new
aircraft. Before introducing a new aircraft into commercial service
in the United States, aircraft manufacturers must obtain FAA's
certification that the aircraft and its systems meet the agency's
standards. FAA has taken several actions to address the
recommendations made in our 1993 report relating to its aircraft
certification program.\1 Specifically, FAA has better defined the of
role of its certification staff, improved its oversight of designated
engineering representatives, reassessed the need for technical
specialists and begun hiring them, issued guidance on the involvement
of these specialists, and improved the technical training of its
certification staff.
--------------------
\1 Aircraft Certification: New FAA Approach Needed to Meet
Challenges of Advanced Technology (GAO/RCED-93-155, Sept. 16, 1993).
GAO'S RECOMMENDATIONS
CONCERNING AIRCRAFT
CERTIFICATION
---------------------------------------------------------- Chapter 3:1
Section 44701 of Title 49 of the United States Code requires FAA to
promote the safety of civil aircraft in air commerce. The United
States Code mandates that FAA certify aircraft as meeting minimum
safety standards before the aircraft can be operated in the United
States. FAA carries out this mandate by setting standards and
certificating manufacturers and by verifying that aircraft conform to
certified designs and production processes.
Recognizing that with limited resources, FAA could not fulfill this
mission alone, the United States Code also authorizes the agency to
delegate certification activities, as necessary, to FAA-approved
persons appointed as either company- or consultant-designated
engineering representatives. These designated engineering
representatives act as FAA's surrogates in analyzing, testing, and
examining aircraft designs and systems. The company-designated
engineering representatives are permanently employed as part of a
company, while consultant engineering representatives are outside
representatives hired by the company. FAA staff are responsible for
overseeing the engineering representatives' activities and making the
final determination as to whether a design meets FAA's safety
requirements. For aircraft imported into the United States, FAA
relies on foreign authorities to conduct many of the necessary
certification activities, but FAA is responsible for certifying that
the aircraft meet its requirements.
In our 1993 report, we concluded that FAA had not ensured that its
staff were effectively involved in the certification process. We
reported that FAA had delegated up to 95 percent of the certification
activities to manufacturers without defining (1) critical activities
in which FAA staff should be involved and (2) guidance on the
necessary level and quality of the oversight of the engineering
representatives. We also reported that FAA had neither provided its
staff with the technical assistance and training needed to ensure
competence in new technologies nor identified critical points in the
certification process that required specialists' involvement.
To address these concerns, we recommended that FAA
-- define a minimum effective role in the certification process for
its work force by identifying critical activities requiring the
agency's involvement or oversight,
-- establish guidance on the necessary level and quality of the
oversight of the engineering representatives and develop
measures through which staff members' performance and
effectiveness could be evaluated,
-- formally examine the need to hire specialists in areas of
advanced technology,
-- require specialists' involvement early in the certification
process and at other key junctures, and
-- establish specific training requirements for its certification
staff and identify training in new technologies that is
available at universities, companies in private industry, and
other government agencies.
FAA'S ACTIONS TO IMPLEMENT
RECOMMENDATIONS
---------------------------------------------------------- Chapter 3:2
FAA has taken actions to implement all of the above recommendations.
Specifically, FAA has better defined the role of its certification
staff, improved its oversight of designated engineering
representatives, reassessed the need for technical specialists and
begun hiring them, issued guidance on the involvement of these
specialists, and improved the technical training of its certification
staff. As discussed below, many of these actions were recently
taken, and it is too early to determine how effectively they will be
implemented. Also, funding constraints could limit FAA's ability to
provide its certification staff with the planned technical training.
FAA HAS BETTER DEFINED ITS
ROLE IN THE CERTIFICATION
PROCESS
-------------------------------------------------------- Chapter 3:2.1
We reported that in response to a dramatically escalating work load,
FAA had delegated certification duties without defining a clear role
for its staff to ensure that they were effectively involved in the
certification process. As a result, FAA's involvement in the process
had diminished to the point where the agency's ability to understand
and certify new technologies was threatened. We reported that
although FAA had developed general guidance defining its directorate
structure,\2 the agency had not established guidance to ensure its
effective involvement in the process. To ensure that FAA staff were
effectively involved in the certification process, we recommended
that FAA define a minimum effective role for its staff by identifying
critical activities requiring FAA's involvement or oversight.
In its April 1994 reply to our recommendation, FAA stated that it did
not fully concur because a structured approach to the certification
process was already defined in FAA's orders, notices, and other
guidance material. Nevertheless, during our current review, we found
that FAA has issued additional guidance clarifying its role and
degree of involvement in the certification process. In May 1995, FAA
revised its handbook containing guidance, procedures, technical
guidelines, and limitations of authority for designated engineering
representatives. The handbook establishes a framework for delegating
functions to these representatives. Among other things, the handbook
lists typical functions that designated engineering representatives
may approve and functions to be referred to FAA for approval. FAA
also issued a job aid in May 1996 that describes the roles and
responsibilities and critical steps in the certification process.
The job aid also lays out functions that must be carried out by FAA
and cannot be delegated. Taken together, these actions address the
thrust of our recommendation.
--------------------
\2 FAA manages its certification activities through its Aircraft
Certification Service in Washington, D.C. The service comprises four
directorates that certify the airworthiness of transport airplanes,
small airplanes, engines, and rotorcraft.
FAA HAS ESTABLISHED A SYSTEM
TO OVERSEE ACTIVITIES OF
DESIGNATED ENGINEERING
REPRESENTATIVES
-------------------------------------------------------- Chapter 3:2.2
We reported that the rapid increase in the number of engineering
representatives and in the number of duties delegated to them had
reduced the amount of supervision that FAA could provide and may have
reduced the quality of that supervision. We recommended that FAA
establish guidance on the necessary level and quality of the
oversight of the representatives and develop measures through which
staff members' performance and effectiveness can be evaluated. In
response, FAA developed guidance on a standardized process for
overseeing the representatives and for annually renewing their
appointments. The new process (effective, Oct. 1995) is intended to
ensure that (1) FAA directly contacts every representative, (2) FAA's
accountability for making that contact is tracked, (3) the
representatives' performance is acceptable, and (4) the quality of
FAA's oversight is measured. FAA's actions appear to fully address
the intent of our recommendation.
FAA HAS REASSESSED THE NEED
TO HIRE TECHNICAL
SPECIALISTS
-------------------------------------------------------- Chapter 3:2.3
We reported that FAA had not fully implemented its National Resource
Specialist Program, whereby recognized experts provide FAA's
certification staff with technical assistance and advice.
Specifically, FAA had identified a need for expertise in 23 areas,
including crash dynamics, fuel and landing gear systems, advanced
materials, and advanced avionics. However, only 11 positions were
authorized, and only 8 of them were actually filled. We recommended
that FAA formally examine the need to hire specialists in areas of
advanced technology. FAA completed a formal assessment of this
program in January 1995 and identified the need for 18 such
specialists. FAA was authorized to begin recruiting qualified
specialists in early 1996 to fill vacant positions, and as of July
1996, it had hired two additional specialists.
FAA HAS ISSUED GUIDANCE
EMPHASIZING THE USE OF
SPECIALISTS
-------------------------------------------------------- Chapter 3:2.4
We reported that FAA's guidance was silent on when and to what extent
specialists should be involved in the certification process and that
this lack of direction had limited the potential of the National
Resource Specialists Program. The specialists were not required to
involve themselves in the certification process nor were
certification staff required to use them, even though the specialists
are full-time FAA employees. Rather, decisions about involvement
were left to the discretion of the staff and specialists involved.
We found that the staff sometimes did not seek the specialists'
advice and that the specialists were often involved in the process
too late to be most effective. For example, during FAA's
certification of the Airbus A330 and A340 aircraft, participation by
the specialist on composite materials apparently came too late for
his concerns to be addressed. According to the specialist, FAA staff
said they considered the composite materials technology being used on
these aircraft to be "old technology," and therefore they did not
need his involvement. When he pressed to be involved and eventually
examined the plans, he found that Airbus's use of composites was at
the highest stage of technological advancement. He stated that his
review of the plans and Airbus's testing came too late, however, for
the company to take his concerns into account in its testing for
compliance with safety standards.
On the basis of these findings, we recommended that FAA require the
specialists' involvement early in the certification process and at
other key junctures. While FAA agreed that specialists should be
involved at appropriate junctures in the certification process, FAA
disagreed with the need for further guidance on their involvement.
During our current work, we found that while there is no formal
requirement to involve the specialists early in the certification
process, FAA Aircraft Certification Service officials said that
management has reemphasized to Aircraft Certification office managers
the need to involve the specialists early in the certification
process and to make arrangements for using their skills.
Specifically, in May 1996, FAA issued a job aid that sets out the
role of the specialists and points when the specialists should be
involved in the process, such as at early meetings. FAA's Aircraft
Certification Services officials added that the specialists are to be
notified at the start of a new certification and that the specialists
can determine the extent of their involvement. These actions address
the thrust of our recommendation, and FAA officials stated that they
plan to monitor the new procedures to ensure that specialists are
effectively involved in the certification process.
FAA HAS TAKEN ACTION TO
IMPROVE STAFF'S TECHNICAL
TRAINING
-------------------------------------------------------- Chapter 3:2.5
We reported that (1) most training courses taken by certification
staff dealt with such nontechnical subjects as supervision and
writing or with subjects that were outside their certification
responsibilities and (2) the lack of technical training was
accompanied by a declining level of experience among the
certification staff as a whole. We recommended that FAA establish
specific training requirements for each certification discipline,
ensure that each staff member meets those requirements, and keep the
training as current as possible by identifying the training in new
technologies that is available at universities, companies in private
industry, and other government agencies.
At the time of our 1993 audit work, FAA had efforts under way to
improve training. Since then, FAA has (1) issued a strategic plan
for certification training that describes how the agency will develop
and carry out its training program, (2) developed training profiles
for all disciplines among the certification staff, (3) developed and
offered several new training courses, and (4) developed a technical
training catalog to inform the certification work force about the
technical training available outside FAA. FAA also established a
technical career path for nonsupervisory engineers in order to have a
core group of individuals with in-depth technical knowledge and to
retain competent engineers. Budget reductions, however, could affect
the implementation of some of these initiatives. For example, FAA's
fiscal year 1996 training budget is less than the amount the agency
said it needed for operationally essential training, and the budget
shortfall could delay initial and recurrent training for the test
pilots who certify new aircraft.
CONCLUSIONS
---------------------------------------------------------- Chapter 3:3
Since we issued our report in September 1993, FAA has taken actions
to implement all of our five recommendations. FAA's actions address
the problems that we previously reported and should improve the
agency's certification process. However, it is too early to
determine how effective these actions will be because many of FAA's
actions have occurred too recently to evaluate their actual
implementation. In addition, funding constraints could limit FAA's
ability to provide its certification staff with planned technical
training.
FAA HAS TAKEN SEVERAL ACTIONS TO
IMPROVE ITS INSPECTION PROGRAM,
BUT RESOURCE TARGETING SYSTEM IS
NOT COMPLETE
============================================================ Chapter 4
FAA inspects domestic and foreign air carriers that fly into the
United States to help ensure that their operations comply with
federal and international aviation safety regulations. In response
to recommendations made in GAO reports issued in November 1991 and
November 1992,\1 FAA has taken several steps to make its inspection
program more effective and efficient. However, some of FAA's actions
have not yet been fully implemented. Specifically, FAA's
resource-targeting system is still not fully operational nor has FAA
completed and implemented a strategy to improve the quality of the
data in the databases used in the targeting system.
--------------------
\1 Aviation Safety: Problems Persist in FAA's Inspection Program
(GAO/RCED-92-14, Nov. 20, 1991) and Aviation Safety: Increased
Oversight of Foreign Carriers Needed (GAO/RCED-93-42, Nov. 20,
1992).
GAO'S RECOMMENDATIONS
CONCERNING INSPECTIONS
---------------------------------------------------------- Chapter 4:1
FAA develops the federal aviation regulations that airlines must
follow and prepares guidance on how FAA's safety inspectors should
perform inspections. FAA also inspects commercial and general
aviation aircraft, aircraft repair stations, schools for training
pilots and maintenance staff, and pilots. These inspections serve as
part of an early warning system to identify potential safety
problems.
We reported in November 1991 that numerous deficiencies in FAA's
inspection program impeded the agency's ability to ensure that
airlines were operating safely. Specifically, FAA was unable to
effectively evaluate airlines' safety conditions because it did not
(1) have adequate guidance for properly classifying the airlines'
problems and (2) know whether the airlines were correcting identified
problems. Without complete and accurate information, FAA could not
determine whether inspection priorities were achieved, inspection
follow-up activities were adequate and timely, and inspection
resources were being used effectively. We also reported that FAA did
not have a system for assessing the relative safety risks among
airlines.
Furthermore, we reported in November 1992 that (1) FAA's assessments
of foreign countries' oversight of their air carriers to ensure that
they were operating in accordance with international standards were
not giving priority attention to assessing the oversight of countries
whose carriers have serious safety problems, (2) FAA had not defined
the nature or frequency of the comprehensive inspections that its
field offices should perform when a country did not provide the
required oversight or when serious safety problems were identified
with a specific foreign air carrier, and (3) FAA was not promptly
notifying all relevant field offices of serious safety concerns about
foreign carriers. We concluded that these gaps in the safety
coverage of foreign carriers increased the potential for unsafe
aircraft to enter or operate in the United States.
To address these concerns, we recommended that FAA
-- complete its efforts to provide inspectors with clear and
distinctive definitions of the comment codes that they use to
classify the airlines' problems into broad categories;
-- require inspectors to record the corrective actions taken for
identified problems;
-- give priority to developing a risk-assessment system, including
a plan and milestones for implementation;
-- give priority to assessing the oversight capabilities of those
countries that FAA determines have one or more carriers with
serious safety problems;
-- require its field offices to perform comprehensive inspections
of foreign air carriers that fly into the United States when FAA
finds that these carriers' home government does not comply with
international standards and/or becomes aware that the carriers
have serious safety problems; and
-- promptly notify all relevant field offices of serious safety
concerns about foreign carriers.
FAA'S ACTIONS TO IMPLEMENT
RECOMMENDATIONS
---------------------------------------------------------- Chapter 4:2
FAA recently revised its guidance to inspectors for recording the
results of inspections by providing additional guidance and
procedures on selecting the proper comment code and for preparing the
narrative relating to the code, and FAA has efforts under way to
better define the codes. FAA also recently revised its guidance for
recording corrective actions on identified problems. FAA has
developed and is deploying a risk assessment system for targeting its
resources, and the agency expects to have this system fully
operational by 1999. FAA is still in the formative stages for
developing a strategy to improve the quality of data used by this
system. Finally, FAA has taken several actions to improve its
oversight of foreign carriers serving the United States by improving
its program for assessing the oversight capabilities of countries
with carriers serving the United States, increasing its surveillance
and the comprehensiveness of its inspections of foreign carriers, and
promptly notifying field offices of problems with foreign carriers.
FAA HAS TAKEN ACTIONS TO
IMPROVE THE USE OF CODES FOR
CLASSIFYING INSPECTION
RESULTS
-------------------------------------------------------- Chapter 4:2.1
In November 1991, we reported that the data in FAA's Program Tracking
and Reporting Subsystem (PTRS)\2 were unreliable for providing
information on the performance of FAA's inspection program and were
inadequate for ensuring the accomplishment of key elements of the
inspection program. Among PTRS' features are about 200 comment codes
that inspectors use to classify inspection results into 15 broad
categories, such as records, flight conduct, maintenance, and
management. We reported that FAA did not provide inspectors with
adequate definitions of the comment codes. Because of ambiguities in
the codes' descriptions, inspectors had difficulty determining how to
classify identified problems and could record the same problems
differently, thus making it hard to accumulate consistent results and
spot trends. Therefore, we recommended that FAA provide inspectors
with clear and distinctive definitions of the comment codes.
At the time of our 1991 report, FAA agreed that these codes could be
made clearer and stated that PTRS' instructions and job aids for
inspectors would be included in the inspectors' handbooks.
Subsequently, FAA developed instructions with job aids showing
examples of properly used comment codes for some inspections. While
FAA had taken some steps to clarify the use of the comment codes used
in PTRS, its actions did not fully resolve the problems that we
previously reported. During our current review, 35 of the 67
inspectors we interviewed said that a safety problem could be
recorded under several codes, and 16 of the 67 said that they had
difficulty choosing the correct code.
Subsequent to our field audit work, FAA revised its PTRS Procedures
Manual in June 1996. The revised manual contains procedures and
guidance to be used by inspectors in recording PTRS activities
including the results of inspections. The revision includes an
extensive discussion on selecting the proper comment codes as well as
guidance on preparing the narrative portion of inspection reports.
The manual also points out that national efforts are in progress to
redesign PTRS to, among other things, reduce the number of comment
codes and better define them. Although FAA's actions address our
recommendation, it is too early to determine how effective they will
be in addressing the previously identified problems.
--------------------
\2 FAA developed this computer-based system to provide data for
planning and overseeing its inspection program. Inspectors record
inspection results in PTRS. FAA's local, regional, and headquarters
officials use information from PTRS to track inspection activities
and results as well as to plan additional surveillance activities.
FAA HAS REVISED ITS NATIONAL
GUIDANCE FOR RECORDING
CORRECTIVE ACTIONS
-------------------------------------------------------- Chapter 4:2.2
In our 1991 report, we stated that although corrective actions are
essential to ensure that airlines are operating safely, FAA did not
know whether inspectors follow up on identified problems. As a
result, FAA had no assurance that airlines were taking corrective
actions. Therefore, we recommended that FAA require inspectors to
record the corrective actions taken for identified problems.
FAA agreed with the recommendation that a comprehensive data system
containing all corrective actions would be ideal. However, FAA
stated that given its limited available resources, it believed the
greatest safety benefit could be achieved by recording corrective
actions only for significant problems. Furthermore, FAA believed
that current guidance in the PTRS handbook required inspectors to
record corrective actions taken for identified problems. Therefore,
FAA did not plan to implement our recommendation.
Although FAA stated during our current field work that the existing
guidance requires inspectors to record corrective actions, FAA's
headquarters officials and field inspectors were unable to provide us
with documentation of a national requirement to record corrective
actions. In addition, in reviewing the FAA inspectors' handbooks and
PTRS guidance in effect during our field work, we found no
requirement that inspectors record corrective actions. However, the
FAA field office managers and inspectors whom we spoke with stated
that recording corrective actions was encouraged or required by their
local office. Thus, all of the field offices we visited were
attempting to achieve the intent of our recommendation.
However, at each location, we found some inconsistencies in the
degree to which corrective actions were being recorded. Of the 67
inspectors whom we spoke with, 24 stated that they do not always
record corrective actions taken. For example, eight inspectors told
us that if a problem is identified during an inspection and corrected
in their presence, this corrective action is sometimes not recorded.
Two inspectors stated that they did not record any problems in PTRS
until corrective action is taken, regardless of how long it takes.
Ten inspectors said that they do not always have the time to record
corrective actions.
Subsequent to our field work, FAA revised the PTRS Procedures Manual
in June 1996. An FAA official told us that the June 1996 revision
addresses our prior recommendation. Specifically, FAA stated that
under the new manual, additional information must be recorded when a
potential problem requiring follow-up action is identified during an
inspection. It is too early to determine the effectiveness of this
revision and whether it will resolve the inconsistencies we observed.
FAA IS CONTINUING TO
IMPLEMENT A RISK-ASSESSMENT
SYSTEM
-------------------------------------------------------- Chapter 4:2.3
As early as 1987, we identified the need for FAA to develop criteria
for targeting safety inspections to airlines with characteristics
that may indicate safety problems. Again, we reported in 1991 that
although FAA maintained numerous databases with information
concerning safety, the agency did not integrate information on, among
other things, accidents, pilot deviations, and inspection results to
assess an airline's overall risk and to determine how the agency
could best use its limited inspection resources. Rather, FAA
assigned its inspection resources on the basis of the size of the
airlines' fleet. We recommended that to make more effective use of
its limited inspection resources, FAA give priority to developing a
risk-assessment system, including a plan and milestones for the
system's implementation. FAA agreed with our recommendation and
stated that it was developing the Safety Performance and Analysis
System (SPAS) for this purpose.
Although FAA has taken steps to better target its inspection
resources to areas with the greatest safety risks, these efforts have
taken several years and are not expected to be completed until 1999.
SPAS, which FAA began developing in 1991, is intended to analyze data
from up to 25 existing databases that contain such information as the
types and results of airline inspections and the number and nature of
aircraft accidents. This system is expected to produce indicators of
an airline's safety performance, which FAA will use to identify
safety risks and to establish priorities for inspections. FAA
completed the development and installation of the initial SPAS
prototype in 1993, and as of April 1996, had installed SPAS in 59
locations. FAA expects to have SPAS operational nationwide by 1999.
In February 1995, we reported that although FAA had done a credible
job in analyzing and defining the system's user requirements, SPAS
could potentially misdirect FAA's resources away from the higher-risk
aviation activities if the quality of its source data is not
improved.\3 To improve the quality of the data to be used in SPAS
analyses, we recommended that FAA develop and implement a
comprehensive strategy to improve the quality of all of the data used
in its source databases. In its July 10, 1995, response to this
recommendation, FAA concurred with the need for this comprehensive
strategy and said that it planned to complete such a strategy by the
end of 1995. FAA hired a contractor in November 1995 to develop a
plan for this strategy and an additional contractor was hired in 1996
to develop a more comprehensive strategy. FAA's target date for
completing the plan and FAA's internal review is October 1996. Until
FAA completes its strategy, the extent and the impact of the problems
with the quality of the system's data will remain unclear.
--------------------
\3 See Aviation Safety: Data Problems Threaten FAA Strides on Safety
Analysis System (GAO/AIMD-95-27, Feb. 8, 1995). Although this
report was issued outside the 1990-94 time frame covered in this
review, we mention it here because it provides information directly
related to the recommendation in our 1991 report.
FAA HAS IMPROVED ITS
ASSESSMENTS OF OVERSIGHT
CAPABILITIES OF COUNTRIES
WITH CARRIERS SERVING THE
UNITED STATES
-------------------------------------------------------- Chapter 4:2.4
In our November 1992 report, we said that FAA was identifying
problems in its inspections of foreign carriers that were flying into
the United States, thus raising questions about the oversight
capability of the foreign countries' civil aviation authorities.
Therefore, we recommended that FAA (1) give priority to assessing the
oversight capability of those countries that the agency determined
had one or more carriers with serious safety problems and (2) work
with these countries to ensure that their oversight capabilities were
sound. FAA began assessing foreign civil aviation authorities in
August 1991 to determine whether they met their responsibilities to
ensure that their carriers comply with international safety
standards. As of July 1996, FAA had assessed the civil aviation
authorities of 61 of the 104 countries or territories that have air
carriers with operating rights or that have requested operating
rights to the United States. FAA is scheduled to assess the
remaining 43 countries or territories by the end of calendar year
1996. To set the order of assessment, FAA is ranking these remaining
inspections according to the rate at which a country's foreign
carriers fly into the United States and the results of FAA's
inspections of carriers from that country.
FAA HAS INCREASED ITS
SURVEILLANCE AND
COMPREHENSIVE INSPECTIONS OF
FOREIGN AIR CARRIERS
-------------------------------------------------------- Chapter 4:2.5
We reported in 1992 that when FAA found that foreign countries were
not providing adequate oversight of their air carriers, the agency
attempted to fill the void by performing increased inspections of
some carriers. However, we found that (1) FAA's inspections of these
foreign aircraft were limited primarily to examining aircraft
markings, pilot licenses, and airworthiness certificates and (2) FAA
had not defined the nature or frequency of the inspections that its
field offices should perform when a country does not provide the
required oversight and when a foreign air carrier has serious safety
problems. We recommended that FAA require its field offices to
perform comprehensive inspections of foreign air carriers that fly
into the United States when FAA finds that their home government does
not comply with international standards and/or becomes aware that a
carrier has serious safety problems.
In September 1993, FAA developed a quarterly special emphasis list of
foreign carriers that merit additional inspection on the basis of its
inspection results as well as information from FAA's country
assessment program. FAA has also established a minimum standard for
the number and type of inspections of foreign carriers. This
guidance specifies, for example, that each foreign carrier with
scheduled flights to the United States should receive one ramp
inspection per year.\4 Beginning in fiscal year 1997, FAA plans to
increase the surveillance of these foreign carriers by requiring two
ramp inspections for each carrier. However, if a foreign carrier
appears on the quarterly special emphasis list, FAA headquarters
recommends that inspectors conduct an additional ramp inspection
monthly. Additionally, as of January 1996, if a country is ranked as
"conditional" because of FAA's assessment, all of that country's
carriers will be placed on FAA's quarterly special emphasis list for
increased inspection in the United States. Finally, FAA has expanded
its inspections to examine logbooks, flight and maintenance manuals,
minimum equipment lists, fuel records, emergency medical kits, and
the flight crew's licenses.
--------------------
\4 The primary objective of a ramp inspection is to provide
inspectors with the opportunity to evaluate an air carrier's
operation while the crew members and aircraft are on the ground. It
is a method for evaluating an operator's ability to prepare both the
aircraft and crew for a flight.
FAA IS PROMPTLY NOTIFYING
FIELD OFFICES OF PROBLEMS
WITH FOREIGN CARRIERS
-------------------------------------------------------- Chapter 4:2.6
We reported in 1992 that FAA was not acting promptly to notify its
field offices to increase surveillance of foreign carriers when it
became aware of serious safety concerns and recommended that it do
so. FAA concurred with our recommendation and stated that it planned
to use its special emphasis quarterly list as a mechanism for
notifying its field offices. However, we did not consider this
action fully responsive because the list is only published quarterly,
and relying on the list would not ensure prompt notification of the
field offices. During our current work, we found that FAA has taken
steps to promptly notify inspectors of problems identified with
foreign carriers. Specifically, we found that FAA was informing its
field offices of problems between the issuance of the quarterly
lists. Most of the 22 inspectors of foreign carriers we spoke with
believed that they were receiving sufficiently prompt notification.
CONCLUSIONS
---------------------------------------------------------- Chapter 4:3
FAA's actions to implement our recommendations should improve its air
carrier inspections and oversight of foreign carriers. These actions
include improving guidance on using comment codes to record
inspection results, developing and deploying a system to better
target its inspection resources to the areas with the greatest safety
risks, and increasing its emphasis on foreign carriers flying into
the United States. However, problems with the quality of data in the
SPAS databases could adversely affect FAA's ability to accumulate
reliable data, spot trends, and target FAA's resources. FAA's
ongoing effort to develop a strategy to improve the quality of data
used in SPAS is a step that if properly implemented should enhance
the value of SPAS as a resource-targeting tool.
RUNWAY SAFETY PROBLEMS NOT FULLY
CORRECTED
============================================================ Chapter 5
The vast majority of serious commercial aviation incidents and
accidents occurs during takeoff and landing. NTSB has made numerous
recommendations to FAA over the years to improve safety on airport
runways. NTSB officials considered runway incursions\1 so serious
that they placed 16 recommendations addressing incursions on NTSB's
1990 through 1994 "Most Wanted" lists of critical safety
recommendations. These safety recommendations received specialized
attention, intensive follow-up, and heightened awareness among
industry, the Congress, and the public. In consultation with NTSB
officials, we selected seven of these recommendations for detailed
follow-up.
FAA agreed with and has taken actions to implement all seven of the
NTSB recommendations we reviewed. NTSB has classified five as closed
as a result of acceptable action by FAA and two as still open but
with acceptable actions being taken by FAA. However, we found that
for four of the five closed recommendations, not all of the actions
necessary to fully correct the problems that gave rise to the
recommendations had been completed. In some cases, the actions had
not been completed at only a few airports, but in other cases, they
had not been completed at many airports.
--------------------
\1 NTSB defines a runway incursion as "any occurrence involving an
aircraft, vehicle, person, object, or procedure that impedes the
takeoff, intended takeoff, landing, or intended landing of an
aircraft."
NTSB'S RECOMMENDATIONS
CONCERNING RUNWAY SAFETY
---------------------------------------------------------- Chapter 5:1
The complexity of today's airport operations has the potential to
create unsafe conditions, especially when aircraft, vehicles, and
even pedestrians may find themselves on active runways in direct
conflict with arriving and departing aircraft. Such runway
incursions can have tragic results and represent a breakdown in safe
operations. For example, in November 1994, a fatal accident occurred
at the St. Louis/Lambert International Airport. A jet with 132
passengers was in its takeoff run when its wing clipped a small
charter plane that should not have been on the same runway. Both the
pilot and passenger aboard the charter plane were killed, and some
passengers on the jet were slightly injured. NTSB officials told us
that since 1986, when NTSB issued a safety study on runway
incursions, FAA has made significant strides in implementing NTSB's
recommendations concerning runway safety. NTSB officials told us
that FAA has taken specific actions recommended by NTSB, such as
issuing standards for airport lights and signs.
Once specific actions are taken, NTSB then closes the
recommendations. However, NTSB officials stated they had some
concerns about the extent that corrective actions, such as installing
signs meeting FAA's new standards, were actually being carried out by
airport operators at affected airports as well as the pace at which
FAA was implementing other recommendations. As a result, we reviewed
the status of seven of NTSB's "Most Wanted" recommendations to reduce
runway incursions that involved (1) visibility from the control
tower, (2) airport signs and markings, (3) airports operating in
low-visibility conditions, (4) complex runway intersections, (5)
special highly reflective paint for surface markings, (6) runway edge
lights, and (7) radars and related systems to alert controllers of
pending runway incursions.
FAA'S ACTIONS TO IMPLEMENT
NTSB'S RECOMMENDATIONS
---------------------------------------------------------- Chapter 5:2
FAA agreed with and has taken actions to implement all seven
recommendations. The agency has resolved visibility restrictions at
control towers, taken actions to improve signs on runways and
taxiways and airport marking and lighting during low-visibility
conditions, identified problems at complex intersections at airports,
evaluated and approved the use of reflectorized paint in airport
surface markings, identified locations where edge lights should be
installed, and continues to take actions to install surface detection
radar and related equipment at airports. However, not all of the
actions necessary to correct the problems that gave rise to the
recommendations have been completed at the affected airports.
RESTRICTIONS IN VISIBILITY
FROM CONTROL TOWERS DUE TO
AIRPORT LIGHTING HAVE BEEN
RESOLVED
-------------------------------------------------------- Chapter 5:2.1
On February 1, 1991, a USAir flight collided with a Skywest flight
while the USAir flight was landing on a runway at the Los Angeles
International Airport. The Skywest flight was positioned on the same
runway, awaiting clearance for takeoff. In the collision, both
aircraft were destroyed, and all of the passengers and crew members
were killed. During the investigation of this accident, NTSB
discovered that both flight crews had received clearance from the air
traffic controller to occupy the same runway. Additionally, the
investigators agreed that three lighting fixtures produced a glare
that impeded the controller's view of the area in which the collision
occurred.
As a result of its accident investigation and subsequent findings,
NTSB recommended on December 3, 1991, that FAA conduct a one-time
examination of the airport lighting at all tower-controlled airports
in the United States to eliminate or reduce visibility restrictions
from the control tower to the runways and other traffic movement
areas. Subsequently, FAA directed all Regional Air Traffic Division
managers to examine their facilities to determine if visibility was
restricted between the control tower and the runways and other
movement areas. The Regional Air Traffic Division managers
identified restrictions at 26 airport air traffic control towers.
NTSB classified this recommendation as "closed--acceptable action" on
February 10, 1994, because FAA took actions to identify visibility
restrictions resulting from problems with lighting and the identified
airports resolved most of these problems with additional lighting,
realignments, adjustments, glare shielding, and relocations. Two
locations still require long-term construction projects--a control
tower and a passenger terminal--to eliminate restrictions with
visibility. Of the 11 airports we visited, FAA had identified 2
airports with lighting restrictions, and both of these locations have
taken corrective actions to resolve the lighting problems.
MOST AIRPORTS HAVE INSTALLED
NEW SIGN SYSTEMS
-------------------------------------------------------- Chapter 5:2.2
Two Northwest Airline DC-10s nearly collided at the Minneapolis-St.
Paul International Airport in Minnesota on March 31, 1985. One
aircraft was taking off from a runway after having been cleared for
takeoff by the air traffic controller. A second aircraft was taxiing
across the same runway after having been cleared to cross the active
runway by the ground controller. The captain of the first aircraft
averted a collision by lifting off below the recommended takeoff
speeds. Because of this incident and the frequency and potential
severity of similar incidents, NTSB initiated a special investigation
and study of runway incursions and accidents in July 1985.
One part of this study, issued in May 1986, concluded that the signs
on runways and taxiways are effective runway incursion prevention
tools and recommended that FAA, in cooperation with terminal air
traffic managers, airport managers, airline representatives, and
pilot groups, determine the most effective signs, markings, and
procedures, from an operational and human performance perspective, to
prevent pilot-induced runway incursions and issue an advisory
circular to disseminate this information to airport managers and
pilot organizations. On January 15, 1992, NTSB classified this
recommendation as "closed--acceptable action" on the basis of FAA's
issuance of Advisory Circular 150/5340-18C--"Standards for Airport
Sign Systems"--on July 31, 1991. This FAA action fully complied with
NTSB's recommendation. However, to determine whether the problems
that led to NTSB's recommendation had been resolved in the field, we
reviewed the status of the installation of these new sign systems.
The circular set forth standards for airports to follow when
developing plans for new sign systems, including the development of
taxiway designations, installation of holding position signs for the
intersections of taxiways and runways, and the installation of
location and directional signs. FAA initially established a January
1, 1994, deadline by regulation for certificated airports\2 to
install the new sign systems. However, by January 1, 1994, FAA
officials realized that airports were having difficulty meeting this
deadline because, among other things, they were trying to obtain
signs from the limited number of manufacturers, their funding and
budgeting cycles delayed their ability to purchase signs, their
electrical systems could not always accommodate the new signs, and
they required different signs because of their varied airport
configurations. Also, the scope of the work to install the signs was
greater than expected. Therefore, FAA extended the deadline to
January 1, 1995. As of that date, 52 of the approximately 575
certificated airports were still not in compliance. According to an
FAA official, as of August 1996, 46 of these 52 airports had come
into compliance, and 3 had decided to cease operating as certificated
airports. Of the remaining three airports, one had received an
exemption because of ongoing construction work, and two are in the
process of installing the signs.
Of the 11 airports we visited, 7 had installed their signs, and
several officials at these airports said that the new signs and
markings were an improvement because they enhanced visibility and
safety. Of the remaining four airports, FAA granted an extension to
one airport that finished installing its new signs after the
completion of our field work. The other three airports had not met
the deadline for installing signs for reasons such as contractors'
delays in providing and/or installing the new signs, the changing of
standards by FAA, and the inability of the airports' electrical
systems to accommodate the new signs.
--------------------
\2 A certificated airport is one that serves any air carrier's
scheduled or unscheduled passenger operations with an aircraft that
seats more than 30 passengers.
IMPLEMENTATION OF AIRPORTS'
PLANS FOR OPERATING IN
LOW-VISIBILITY CONDITIONS
HAS BEEN DELAYED
-------------------------------------------------------- Chapter 5:2.3
Two Northwest Airlines flights, a DC-9 and a B-727, operating under
low-visibility conditions, collided near the intersection of two
runways at the Detroit Metropolitan/Wayne County Airport on December
3, 1990. The B-727 was in its takeoff roll on the runway at the time
of the collision, and the DC-9 had taxied onto the same runway just
prior to the accident. The B-727 was substantially damaged, the DC-9
was destroyed, and eight people were killed. In its accident
investigation, NTSB determined that some rather obvious shortcomings
in the area of maintenance of signs, lights, and pavement markings on
the airport were apparent. NTSB's investigation concluded that "FAA
was aware of some of these shortcomings and could have taken actions
to correct them prior to the accident." For example, NTSB's
investigation revealed problems with the location of several signs
observed by the DC-9 crew.
On the basis of its accident investigation, NTSB recommended on July
23, 1991, that FAA improve standards for airport marking and lighting
during low-visibility conditions. Specifically, NTSB called for more
conspicuous marking and lighting, the evaluation of unidirectional
taxi lines for use on acute angle taxiways, and requirements for stop
bars or runway guard lights at all taxiways that intersect active
runways. On March 15, 1993, NTSB classified the status of this
recommendation as "closed--acceptable action" on the basis of FAA's
issuance of several advisory circulars addressing the issue of
low-visibility conditions, most notably Advisory Circular
120-57--"Surface Movement Guidance and Control System"--issued on
September 4, 1992.
The advisory circular provides guidance for the development of plans
for airports that choose to conduct landing operations under
low-visibility conditions or a runway visual range of less than 1,200
feet. According to an FAA official, 77 airports operate during
low-visibility conditions. The circular also calls for visual aids
at these airports, such as runway guard lights. FAA's deadline for
airports to develop their plans was originally January 1, 1995, but
FAA issued an update to the circular on October 5, 1994, extending
the deadline to January 1, 1996. The primary reason for the
extension was to allow airports sufficient time to plan for capital
expenditures. However, not all the airports met this deadline. The
following table illustrates the status, as of July 1996, of the 77
airports that FAA identified as being required to develop plans for
operating in low-visibility conditions.
Table 5.1
Status of Low-Visibility Operating
Plans, as of July 1996
Status of plan Airports
-------------------------------------------------- ------------------
Plan approved by FAA 19
Plan submitted to FAA's regional office for 14
approval
Working group formed and developing plan 21
No working group formed 23
======================================================================
Total airports needing plans 77
----------------------------------------------------------------------
Source: Based on information from FAA.
Of the 11 airports we visited, 9 were to develop plans for
low-visibility operations. Of those nine airports, two had
implemented plans, two had their plans approved and were in the
process of implementing them, three had submitted plans to FAA for
approval, and two were still drafting their plans. Officials at some
of these airports said that FAA's delays in issuing its new lighting
specifications have caused problems. For example, an official at one
airport stated that the implementation of their plan for
low-visibility operations had been delayed because FAA's lighting
specifications had not been completed. An FAA official stated that
the new specifications for lighting equipment had not been completed
as of July 1996.
Thus, 5 years after NTSB made its recommendation, and almost 4 years
after NTSB classified the recommendation as "closed-acceptable
action" on the basis of FAA's issuance of several advisory circulars
addressing this recommendation, the intent of the recommendation is
far from being achieved by all affected airports.
COMPLEX INTERSECTIONS HAVE
BEEN IDENTIFIED, BUT MANY
CORRECTIVE ACTIONS HAVE NOT
BEEN COMPLETED
-------------------------------------------------------- Chapter 5:2.4
As a result of the accident in Detroit in December 1990 mentioned
earlier, NTSB was also concerned that "the problem of complex
intersections, which can confuse pilots, exists at other airports and
presents a situation that would require additional lighting and
signage." Subsequently, NTSB recommended on July 23, 1991, that FAA
identify complex intersections where a potential for pilot confusion
exists at the nation's approximately 575 certificated airports.
NTSB's recommendation also stated that where needed, FAA should
require additional lighting and signs at these complex intersections.
Beginning in October 1991, FAA established Runway Incursion Action
Teams (RIATs) in each regional office. These teams comprised airport
owners, FAA airports' personnel, air traffic controllers, flight
standards personnel, pilots, airline representatives, and other
interested parties. The teams' mission was to identify complex
intersections as well as other conditions or procedures that could
cause runway incursions. In fiscal years 1991 through 1994, the
teams completed reviews at 51 airports that FAA identified as having
complex intersections and issued recommendations aimed at reducing
runway incursions at these airports. According to FAA officials, the
recommendations resulted in improvements in the guidance for
intersections at certificated airports. However, because of resource
constraints in both FAA and the industry, FAA discontinued RIAT
meetings after the initial 51 reviews.
On the basis of FAA's completion of the RIAT reviews and the
development of new standards for signs, NTSB classified this
recommendation as "closed--acceptable action" on August 31, 1994.
However, according to FAA and airport officials, actual
implementation of the recommendations resulting from the RIAT reviews
had not been completed by airport operators at all the airports. In
fact, only 27 of the 51 airports had implemented all of the reviews'
recommendations.\3 The remaining airports had not implemented the
recommendations because, among other things, they (1) found that
implementing the recommendation requires the completion of other
future airport projects, (2) lacked funds to take action immediately,
(3) had other high priority needs, or (4) they were awaiting new or
revised FAA standards. Thus, 2 years after NTSB closed the
recommendation on the basis of FAA's actions, many airports have not
completed the actions recommended as a result of the RIAT reviews.
An FAA official pointed out that FAA cannot require airports to
implement the RIAT recommendations because the recommendations were
advisory in nature.
FAA had conducted RIAT reviews at 7 of the 11 airports we visited.
Of those seven airports, five had implemented all the recommendations
resulting from the reviews, and two had not. At one of these two,
the installation of the new sign system at the airport had delayed
the implementation of one of the RIAT recommendations. Officials at
the other airport did not implement all the RIAT recommendations
because they believe that the existing controls provide an adequate
assurance of safety to satisfy one recommendation and that another
recommendation involves future projects that the airport has not yet
begun.
--------------------
\3 FAA was only able to provide us with information about the RIAT
recommendations for 49 of the 51 airports because the officials who
maintained such data in one of the FAA regions had retired or were
unavailable for other reasons.
USE OF REFLECTORIZED PAINT
FOR SURFACE MARKINGS IS AT
THE DISCRETION OF AIRPORT
OFFICIALS
-------------------------------------------------------- Chapter 5:2.5
NTSB's investigation of the Detroit accident also revealed several
areas of faded or nearly invisible taxi lines on the airfield,
especially near the area where the DC-9 was taxiing. The
investigation found that these deficiencies may have been factors in
the DC-9 flight crew's incorrect decision to turn left onto the
taxiway. In 1991, NTSB recommended that FAA require certificated
airports to use reflectorized paint for airport surface markings.
Glass beads are dropped onto paint during its application to make the
paint reflect more light.
To implement this recommendation, FAA established a research program
to evaluate materials and techniques to improve the durability and
conspicuity of pavement markings, including testing such materials
and techniques at several airports. On the basis of its research
results, FAA issued a September 20, 1994, "Signs and Marking
Supplement to Advisory Circular 150/5340-1G" stating that glass beads
meeting the federal specification requirements may be used in the
paint to make runway markings more conspicuous.
The use of reflectorized paint for airport surface markings is not a
requirement but, rather, an option that airport officials may choose.
However, according to FAA, a new paint specification is in the final
approval stage that would require glass beads in paint when federal
funds are involved. NTSB classifies this recommendation as
"open--acceptable response," pending completion of FAA's research and
implementation of the results. FAA officials were unable to provide
us with information on which airports were using the reflectorized
paint and which ones were not because they do not have a centralized
system containing such data. Of the locations we visited, some were
using reflectorized paint and others were not. Officials in one
region that we visited stated that all the airports in the area are
using the reflectorized paint.
MANY AIRPORTS HAVE NOT
COMPLETED INSTALLATION OF
RUNWAY EDGE LIGHTS
-------------------------------------------------------- Chapter 5:2.6
NTSB's investigation of the Detroit airport accident also revealed
that the absence of runway edge lights, particularly in the area
where runways and taxiways intersect, probably contributed to the
DC-9 flight crew's actions. NTSB investigators determined that if
runway edge lights had been embedded in the pavement at intervals of
200 feet as recommended by the existing Advisory Circular
150/5340-24, "Runway and Taxiway Edge Lighting System," the DC-9
pilots would probably have noticed them before the runway incursion
and stopped taxiing. Subsequently, NTSB recommended in 1991 that FAA
require certificated airports to install semiflush runway edge
lights\4 in accordance with Advisory Circular 150/5340-24.
On November 23, 1992, FAA issued a notice to its airport
certification inspectors to request that during their inspections,
they focus their attention on the absence of lights at runway and
taxiway intersections to determine if safety has been compromised.
Subsequently, during their fiscal year 1993 inspections of airports,
FAA inspectors identified 424 spots where a semiflush light should be
installed on a runway surface at 72 airports. However, for the
majority of these airports, FAA, after assessing the individual
safety situation at each airport, informed airport officials that
these lights did not have to be installed immediately but rather when
airport officials had other electrical work planned for the runways
or during runway reconstruction work.
On February 16, 1995, NTSB classified this recommendation as
"closed--acceptable action" on the basis of these actions by FAA.
During our current review, FAA could not locate the original list of
the 424 needed lights. Consequently, as of October 1995, FAA could
account for only 405 of the original 424 needed lights at the 72
airports. Of the 405 lights, FAA determined after additional
analysis, that 32 were not needed. Of the remaining 373, 175 lights
had not been installed at 26 airports as of October 1995--up to 3
years after FAA identified the need for installing semiflush lights,
and over 8 months after NTSB closed this recommendation on the basis
of FAA's actions. Figure 5.1 shows the installation status of the
373 lights.
Figure 5.1: Status of
Installation of Runway Edge
Lights, as of October 1995
(See figure in printed
edition.)
Of the 11 airports we visited, none had been identified as having
these lighting deficiencies.
--------------------
\4 These lights are referred to as semiflush lights because they are
embedded in the edge of the runway and are nearly flush with the
ground.
DELAYS HAVE OCCURRED IN
INSTALLING SURFACE DETECTION
RADAR AND RELATED EQUIPMENT
-------------------------------------------------------- Chapter 5:2.7
On January 18, 1990, at the Atlanta Hartsfield International Airport,
an Eastern Airlines B-727 collided with an Epps Air Service
Beechcraft King Air A100. The B-727 was landing on the same runway
that the King Air A100 was preparing to turn off from after landing
ahead of the B-727. As a result of the collision, the King Air A100
was destroyed and the B-727 incurred substantial damage. The pilot
of the King Air was killed, and the copilot was seriously injured.
To augment visual observations of aircraft and/or vehicular movements
on runways and taxiways or other movement areas and to help identify
and preclude runway incursions such as the one described above, FAA
has developed a special ground-mapping radar known as the Airport
Surface Detection Equipment (ASDE). This radar provides tower
controllers with surveillance of an airport's runways and taxiways
and of any stationary or moving aircraft or vehicles on these
surfaces under all weather conditions. FAA began developing an
ASDE-3 system in the late 1970s to replace an earlier system. The
new system was to be installed at 29 airports. FAA estimated that
the first of these systems would be implemented in the field by March
1988 and the last of these systems would be implemented by April
1990. However, FAA has been slow in deploying and commissioning
these systems.\5
As a result of its investigation of the Atlanta accident in 1991,
NTSB recommended on June 12, 1991, that FAA expedite funding the
development and implementation of an operational system to alert
controllers of impending runway incursions at all terminal facilities
that are scheduled to receive the ASDE-3. The system that NTSB
referred to in this recommendation is the Airport Movement Area
Safety System (AMASS), which is designed to provide controllers using
the ASDE-3 radar with audio and visual alerts. AMASS, a software
enhancement to ASDE-3, cannot operate as a stand-alone system. AMASS
cannot be installed at a location until ASDE-3 is operational. NTSB
classifies this recommendation as "open--acceptable response,"
meaning that although the recommendation has not been fully
implemented, FAA is taking action to do so.
FAA's initial estimates of the number of ASDE-3 systems to be
installed at airports has increased to 38.\6 As of June 1996, 28
systems had been installed at airports, and 23 of these had been
commissioned. Table 5.2 shows the status of the installation and
commissioning of these systems.
Table 5.2
Status of Installation and Commissioning
of ASDE-3 Systems, as of June 1996
Status Number
-------------------------------------------------- ------------------
Systems commissioned 23
Systems installed but not commissioned 5
Systems awaiting delivery to airports 10
======================================================================
Total 38
----------------------------------------------------------------------
Source: Based on information from FAA.
In a February 1995, letter to FAA, the NTSB Chairman stated that the
1994 accident in St. Louis, discussed in the beginning of this
chapter, may have been prevented had AMASS been in use at that
airport and suggested that FAA accelerate the commissioning of the
ASDE-3 systems. NTSB stated that within 60 days of receipt of the
letter, FAA should provide NTSB with a firm schedule for
commissioning those systems that had been installed and adhere to
that schedule.
In an April 14, 1995, response, FAA stated that it would adhere to
its schedule for fiscal year 1995 to commission all 23 systems that
had been delivered as of that date. At the time of its response, FAA
had commissioned 12 of the 23 systems; dates were set for
commissioning the remaining 11. However, FAA did not meet its
schedule; by the end of fiscal year 1995, three systems had been
commissioned as scheduled, two had been commissioned but later than
their scheduled date, and six remained to be commissioned. As of
April 1996, FAA had also fallen behind schedule for installing 6 of
the 10 systems that remained to be installed. The last site
installation is not expected until 1999.
Since AMASS cannot be installed until ASDE-3 is in place, delays with
ASDE-3 will also delay AMASS. In addition, AMASS has experienced its
own delays. For example, FAA's original estimated installation date
for the last site has slipped from October 1999 to August 2000.
Ten of the airports we visited are scheduled to install ASDE-3, and 7
of them had commissioned systems in place. The controllers at these
airports generally believed that the ASDE-3 is a vast improvement
over the previous version. At two of the airports we visited, a
prototype AMASS unit had been used, but air traffic officials did not
yet have enough experience with AMASS to allow us to measure their
satisfaction with the system.
--------------------
\5 Commissioning occurs when the system has demonstrated, for a
period of 30 consecutive days, operational availability at least 99.5
percent of the time.
\6 Two additional systems have been installed at FAA's Aeronautical
and Technical Centers. These systems will not be commissioned
because they will not be used for air traffic control.
CONCLUSIONS
---------------------------------------------------------- Chapter 5:3
While FAA has taken actions to address the seven NTSB recommendations
on runway safety that we examined, FAA's actions alone have not
necessarily resolved the problems that led to the recommendations.
Until the affected airports have fully completed the corrective
actions, the problems may remain.
NTSB closes recommendations when FAA takes what NTSB considers as
"acceptable action" on its recommendations. Acceptable actions may
include, among other things, FAA's issuing of instructions or
requirements to airports or its own field offices. If these
requirements are not carried out in the field, they will not correct
the problems that gave rise to the recommendations in the first
place. While we found that for five of the seven NTSB
recommendations that were classified as "closed--acceptable action,"
all actions needed to address the problems that gave rise to the
recommendations were not yet completed. This situation is not unique
to NTSB's recommendations. As discussed in chapter 1, DOT's
Inspector General is currently performing an audit of the
implementation of several of its recommendations that were closed as
fully implemented because of concerns about actual in-the-field
implementation. If corrective actions in the field are not
periodically monitored, there is no assurance that actual corrective
actions have been completed.
RECOMMENDATION
---------------------------------------------------------- Chapter 5:4
We recommend that the Secretary of Transportation instruct the
Administrator of FAA to periodically monitor the implementation of
critical safety recommendations and the actions needed to fully
resolve the problems that gave rise to the recommendations at the
field level and report the status to the Congress and the agency that
made the recommendations.
AGENCY COMMENTS AND OUR
EVALUATION
---------------------------------------------------------- Chapter 5:5
We discussed a draft of this report with DOT officials, including the
managers of the National Runway Incursion Program, the Airport Safety
and Operations Division, and the Recommendation Branch. DOT raised
concerns about following up on all recommendations until in-the-field
actions necessary to address the intent of the recommendations are
complete. These officials said that they have insufficient resources
to perform detailed follow-up on the implementation of all
recommendations at all certificated airports and other field
locations. In a draft of this report, our proposed recommendation
did not make a distinction about which recommendations warranted
intensive follow-up. We recognize that FAA does face resource
limitations that can limit its follow-up activities, and we have
modified our recommendation, which now calls for FAA to periodically
monitor in-the-field follow-up for those recommendations that are
particularly critical to safety and to report the results of these
efforts to the Congress and the agency that issued the
recommendations.
Additionally, DOT disagreed with our discussion of actions on one
NTSB recommendation dealing with airport sign systems. Specifically,
DOT stated that our draft report went beyond NTSB's recommendation,
which called for FAA to determine the most effective markings, signs,
and procedures and issue an advisory circular to disseminate the
information. DOT said that the inclusion of the status of the
installation of the new sign systems in the draft report led the
reader to believe that NTSB recommended that the signs be installed.
Our draft report clearly pointed out that FAA fully implemented
NTSB's recommendation with the issuance of the called-for advisory
circular in 1991. We also explained in our draft report that we
performed detailed field work to determine whether actions necessary
to fully correct the problems that gave rise to NTSB's
recommendations had been completed at airports. In this case, we
determined whether airports were implementing the advisory circular
by installing the new sign systems. Our draft report pointed out
that almost all of the new sign systems had been installed as of
August 1996, but this was more than 4 years after the recommendation
had been closed by NTSB as a "closed--acceptable action." To address
DOT's concerns, we have added a specific statement to the section in
question clarifying why we included the status of the installation of
the new sign systems. We believe our follow-up work on this 1986
NTSB recommendation illustrates the importance of our recommendation
calling for FAA's periodic monitoring of critical safety
recommendations or the actions needed to fully resolve the problems
that gave rise to the recommendations, at the field level, and for
reporting the results to the Congress and the agency that made the
recommendations.
OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I
At the request of Representative Collin C. Peterson, we examined the
Federal Aviation Administration's (FAA) responsiveness to
recommendations to improve aviation safety from GAO, the Department
of Transportation's (DOT) Inspector General, and the National
Transportation Safety Board (NTSB). We focused our review on two
questions.
-- What has been FAA's overall record in responding to, agreeing
with, and implementing significant recommendations concerning
aviation safety made by GAO and DOT's Inspector General from
1990 through 1994 as well as recommendations made by or added to
NTSB's "Most Wanted" list of safety recommendations from 1990
through 1994?
-- To what extent have GAO's specific recommendations made on
aircraft certification, airline inspections and oversight of
foreign carriers, and NTSB's recommendations concerning safety
on runways been fully implemented?
To address these questions, we first established a universe of
significant GAO, NTSB, and DOT Inspector General reports and
recommendations from which we gathered statistical data and then
selected a limited number of recommendations on which to perform
detailed follow-up audit work on the actual implementation status of
these recommendations at FAA locations and airports.
To determine which reports and recommendations to include in our
review, we consulted with NTSB, DOT's Inspector General, and our own
officials responsible for aviation work and reviewed documents in
which significant reports or recommendations were indicated.\1 This
enabled us to narrow down our initial listings of aviation safety
reports and recommendations over the 5-year period from 1990 through
1994 to a more workable list of significant recommendations, which
became our universe. Subsequently, we used the same method to select
a limited number of recommendations, which we used to conduct
follow-up audit work in the field.
--------------------
\1 This initial information included 57 GAO reports and testimonies,
30 DOT Inspector General reports, and 714 NTSB recommendations issued
to FAA from 1990 through 1994.
SELECTION OF UNIVERSE OF
RECOMMENDATIONS
--------------------------------------------------------- Appendix I:1
To identify GAO's significant reports and recommendations, we relied
on (1) our annual "Status of Open Recommendations" reports to the
Congress, which list key open recommendations; (2) FAA's annual
reports, which cite significant GAO reports; (3) the DOT Inspector
General's reports to the Secretary of Transportation in 1993 and
1994, which cited GAO (and Inspector General) reports as the basis
for the DOT Inspector General's recommendation that FAA's oversight
and inspection activities be included as a high-risk area in the
annual Federal Managers' Financial Integrity Act report to the
President and the Congress; and (4) our testimony on aviation safety
before the Senate Committee on Commerce, Science, and Transportation
on January 12, 1995, which discussed significant GAO reports and
recommendations. For NTSB's significant recommendations, NTSB
officials of the Office of Safety Recommendations and Office of
Aviation Safety suggested that we obtain NTSB's "Most Wanted"
recommendations lists for 1990 through 1994 and consider any aviation
safety recommendations made to FAA on these lists to be significant
and thus eligible to be included in our universe.
To identify significant reports and recommendations by DOT's
Inspector General, we reviewed (1) the Inspector General's semiannual
reports to the Congress, which list reports and recommendations
selected as significant; (2) FAA's annual reports, which refer to
significant reports and recommendations by the DOT Inspector General;
and (3) the DOT Inspector General's reports to the Secretary of
Transportation in 1993 and 1994, as noted above.
This review resulted in a universe of 256 significant recommendations
on aviation safety. The universe included 34 GAO reports and
testimonies with 113 recommendations, 16 DOT Inspector General
reports with 114 recommendations, and all 29 of NTSB's "Most Wanted"
recommendations to FAA on lists from 1990 through 1994. These lists
included 10 recommendations that dated from 1986. We then obtained
data from NTSB's, the DOT Inspector General's, and our tracking
systems on the status of each recommendation. We did not verify the
accuracy of the overall data in the tracking systems. We also
discussed and obtained data on the status of these recommendations
from the FAA headquarters liaison offices responsible for tracking
these recommendations. We reviewed NTSB's, DOT's, FAA's, the Office
of Management and Budget's, and our own policies and procedures for
responding to and tracking recommendations.
SELECTION OF RECOMMENDATIONS
FOR DETAILED FOLLOW-UP WORK
--------------------------------------------------------- Appendix I:2
From our universe, we initially selected 11 GAO, 7 NTSB, and 5 DOT
Inspector General recommendations for detailed follow-up audit work
to determine their actual implementation status, including the status
of actions necessary to fully correct the problems that gave rise to
the recommendations at selected FAA field locations and airports.
These recommendations were chosen by consulting with NTSB, DOT's
Inspector General, and our own officials and by using the indicators
of significance discussed earlier. The GAO recommendations chosen
were in the areas of aircraft certification, safety inspections, and
oversight of foreign carriers. The NTSB recommendations relate to
actions to reduce runway incursions at airports. The NTSB safety
issue arising from runway incursions represents over half of NTSB's
"Most Wanted" recommendations to FAA for the 5-year period covered by
this report. The five recommendations by DOT's Inspector General
involved FAA's inspection activities that were covered in an
important 1992 audit by the Inspector General and classified as
"closed and fully implemented." However, the Deputy Assistant
Inspector General for Audits told us that because his office was also
concerned about whether the recommendations on inspections in that
report were being effectively implemented by FAA, the office was
conducting a follow-up review involving the same recommendations we
had identified as significant candidates for our follow-up work. To
avoid duplication, we agreed with the DOT Inspector General's office
not to conduct any follow-up work on these recommendations.
We chose our field locations to obtain geographical diversity and to
allow us to follow up on a number of recommendations at each
location. Appendix II shows the locations we visited by safety
issue. However, not all the recommendations applied to all of the
locations visited. The information developed at these locations
cannot be generalized to our larger universe. The locations we
visited included FAA headquarters, 3 FAA regional offices, 11 FAA
flight standards district offices, 2 FAA international field offices,
2 FAA aircraft certification offices, and 2 FAA certificate
management offices. We also visited 11 airports and met with FAA's
air traffic control staff and the airports' operating staff. The
following sections describe our detailed follow-up work.
RECOMMENDATIONS CONCERNING
AIRCRAFT CERTIFICATION
------------------------------------------------------- Appendix I:2.1
Our objectives were to determine if FAA had implemented our
recommendations to ensure that its staff are effectively involved in
the certifications process and have the necessary technical
assistance and training. We discussed the recommendations with
officials from FAA headquarters, including the Director and Deputy
Director of the Aircraft Certification Service, and two aircraft
certification offices to determine the progress made by FAA in
implementing the report's recommendations. We also reviewed relevant
FAA documents and data.
To determine if FAA ensures that its staff are effectively involved
in the certification process, we reviewed and discussed FAA's
guidance with headquarters officials and interviewed 2 managers and
17 other officials in the aircraft certification offices to obtain
their views on the agency's involvement in the process since 1993.
To determine if FAA provides its engineers with the technical
assistance and training needed to evaluate the latest technologies,
we interviewed FAA headquarters officials from the Aircraft
Engineering Division on their implementation of the National Resource
Specialist Program and discussed with the 2 managers and 17 staff of
the certification offices the extent to which they involve the
national resource specialists in the certification process. To
evaluate FAA's training program for certification staff, we
interviewed the same certification officials, three headquarters
officials from the Program Planning and Analysis Branch, and the
Director of the Aircraft Certification Service. We also reviewed
pertinent training plans and documents to determine the progress made
by FAA in its initiatives to improve staff members' technical
competence.
RECOMMENDATIONS ON THE
AIRLINE INSPECTION PROGRAM
------------------------------------------------------- Appendix I:2.2
Our objectives were to determine if FAA has implemented our
recommendations to improve its inspection reporting system by (1)
completing its efforts to provide inspectors with clear and
distinctive definitions of the comment codes used to classify the
airlines' problems into broad categories, (2) requiring inspectors to
record corrective actions taken for identified problems, and (3)
developing a risk-assessment system to make more effective use of its
limited inspection resources.
We reviewed FAA's guidance for inspectors for reporting inspection
results, including the use of comment codes and the recording of
corrective actions taken by air carriers and discussed this guidance
with FAA headquarters officials. In addition, we interviewed 68 FAA
inspectors about their use of FAA's system for reporting inspection
results and the way they record corrective actions taken in response
to identified deficiencies. In addition, we discussed with officials
at FAA headquarters the plans and status of FAA's efforts to develop
its risk-assessment system. We performed work at FAA headquarters in
Washington, D.C., and at three FAA regional offices. We also
interviewed inspectors and reviewed documents at 11 FAA Flight
Standards District Offices.
RECOMMENDATIONS ON OVERSIGHT
OF FOREIGN CARRIERS
------------------------------------------------------- Appendix I:2.3
Our objectives were to determine if FAA had implemented our
recommendations to (1) give priority to assessing the oversight
capabilities of countries with serious safety problems, (2) require
its field offices to perform comprehensive inspections of foreign air
carriers that fly into the United States, and (3) promptly notify
field offices of serious safety concerns about foreign carriers.
We discussed FAA's efforts to assess the oversight capabilities of
foreign civil aviation authorities with FAA headquarters officials.
We reviewed pertinent documents and obtained the results of
assessments performed thus far by FAA. We discussed inspections of
foreign carriers with officials at FAA headquarters and two
international field offices and reviewed related documentation to
determine what changes had been made relating to the issues raised in
our recommendations. We also interviewed 22 field inspectors who
perform inspections of foreign carriers to determine the (1) extent
and comprehensiveness of these inspections and (2) actions that FAA
headquarters takes to notify the field inspectors when it becomes
aware of safety concerns about foreign carriers. Also, to determine
if field offices were performing comprehensive inspections, we
analyzed FAA's inspection records for 20 of 73 foreign carriers that
have appeared on FAA's quarterly "special emphasis" inspection list
for an 18-month period (Apr. 1, 1994, through Sept. 30, 1995).
RECOMMENDATIONS ON RUNWAY
INCURSIONS
------------------------------------------------------- Appendix I:2.4
Our objectives were to determine if FAA had implemented NTSB's
recommendations aimed at reducing runway incursions and to determine
the status of the corrective actions taken at the airports where such
actions were needed. NTSB's recommendations involved (1) visibility
from the control tower, (2) airport signs and marking standards, (3)
airports' operations in low-visibility conditions, (4) complex runway
intersections, (5) special highly reflective paint for surface
markings, (6) runway edge lights, and (7) radars and related systems
to alert controllers of pending runway incursions. We performed our
work at NTSB and FAA headquarters. At NTSB headquarters, we reviewed
the studies and reports leading to the recommendations and data on
the status of FAA's actions on these recommendations. At FAA
headquarters, we reviewed documents relating to the overall status of
the recommendations and the status of the actions relating to the
recommendations at affected airports. At the 11 airports we visited,
we reviewed documents and actions to implement the applicable
recommendations with 24 airport management officials, 18 officials
from the FAA airport tower managers' offices, 33 FAA air traffic
controllers, 7 FAA supervisory air traffic controllers, 9
representatives of the National Air Traffic Controllers Association,
8 FAA airport safety certification inspectors, and 4 FAA radar
technicians. We also accompanied an airport certification inspector
on an inspection of one airport's lights and signs.
LOCATIONS VISITED FOR DETAILED
FOLLOW-UP WORK
========================================================== Appendix II
AIRCRAFT CERTIFICATION
------------------------------------------------------ Appendix II:0.1
Aircraft Certification Service, FAA, Washington, D.C.
Aircraft Certification Office, FAA, Renton, Wash.
Aircraft Certification Office, FAA, Lakewood, Calif.
AIR CARRIER INSPECTION
------------------------------------------------------ Appendix II:0.2
Flight Standards Service, FAA, Washington, D.C.
Flight Standards District Office, FAA, Atlanta, Ga.
Flight Standards District Office, FAA, Baltimore, Md.
Flight Standards District Office, FAA, Chantilly, Va.
Flight Standards District Office, FAA, Charlotte, N.C.
Flight Standards District Office, FAA, Denver, Colo.
Flight Standards District Office, FAA, Fort Lauderdale, Fla.
Flight Standards District Office, FAA, Los Angeles, Calif.
Flight Standards District Office, FAA, Miami, Fla.
Flight Standards District Office, FAA, Portland, Oreg.
Flight Standards District Office, FAA, Seattle, Wash.
Flight Standards District Office, FAA, Van Nuys, Calif.
Certificate Management Office, FAA, Atlanta, Ga.
Certificate Management Office, FAA, San Francisco, Calif.
OVERSIGHT OF FOREIGN AIR
CARRIERS
------------------------------------------------------ Appendix II:0.3
Flight Standards Service, FAA, Washington, D.C.
Flight Standards District Office, FAA, Atlanta, Ga.
Flight Standards District Office, FAA, Baltimore, Md.
Flight Standards District Office, FAA, Chantilly, Va.
Flight Standards District Office, FAA, Charlotte, N.C.
Flight Standards District Office, FAA, Denver, Colo.
Flight Standards District Office, FAA, Fort Lauderdale, Fla.
Flight Standards District Office, FAA, Los Angeles, Calif.
Flight Standards District Office, FAA, Miami, Fla.
Flight Standards District Office, FAA, Seattle, Wash.
International Field Office, FAA, Miami, Fla.
International Field Office, FAA, San Francisco, Calif.
RUNWAY INCURSIONS
------------------------------------------------------ Appendix II:0.4
National Transportation Safety Board, Washington, D.C.
Various FAA offices, Washington, D.C.
FAA Northwest Mountain Region, Airports Division,
Renton, Wash.
FAA Southern Region, Airports Division, Atlanta, Ga.
FAA Western-Pacific Region, Airports Division,
Los Angeles, Calif.
Hartsfield-Atlanta International Airport, Atlanta, Ga.
Baltimore-Washington International Airport, Baltimore, Md.
Charlotte-Douglas International Airport, Charlotte, N.C.
Denver International Airport, Denver, Colo.
Dulles International Airport, Chantilly, Va.
Fort Lauderdale-Hollywood International Airport,
Fort Lauderdale, Fla.
Los Angeles International Airport, Los Angeles, Calif.
Miami International Airport, Miami, Fla.
Portland International Airport, Portland, Oreg.
San Francisco International Airport, San Francisco, Calif.
Seattle-Tacoma International Airport, Seattle, Wash.
MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III
RESOURCES, COMMUNITY, AND ECONOMIC
DEVELOPMENT DIVISION
Charles Barchok, Jr.
Nancy A. Boardman
Gerald L. Dillingham
Barry R. Kime
Jean A. Wright
ATLANTA FIELD OFFICE
Johnny W. Clark
Jyoti Gupta
Joanna M. Stamatiades
SAN FRANCISCO/SEATTLE FIELD OFFICE
Steven N. Calvo
Christopher M. Jones
*** End of document. ***