Aviation Safety: FAA's New Inspection System Offers Promise, but Problems
Need to Be Addressed (Letter Report, 06/28/1999, GAO/RCED-99-183).

The aviation industry has forecast a potential 66-percent increase in
passenger travel from 1999 to 2008. The U.S. aviation accident rate,
which has remained relatively constant during the last two decades, must
be substantially lowered to avoid escalating numbers of aviation deaths
as air traffic increases. A key to reducing the aviation accident rate
is for the Federal Aviation Administration (FAA) to have an effective
process for inspecting the nation's airline operations. GAO and others
have raised concerns about the adequacy of FAA's inspection process to
meet that challenge. The report addresses the following questions: To
what extent does the Air Transportation Oversight System address past
concerns about FAA's aviation safety inspections? What factors, if any,
surfaced during the system's implementation that could impede its
success? What is FAA doing to address any factors that could impede the
system's success? GAO found that the system is largely responsive to
past concerns raised about key aspects of FAA's aviation safety
inspections and the usefulness of inspection data.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  RCED-99-183
     TITLE:  Aviation Safety: FAA's New Inspection System Offers
	     Promise, but Problems Need to Be Addressed
      DATE:  06/28/1999
   SUBJECT:  Transportation safety
	     Management information systems
	     Airline regulation
	     Safety regulation
	     Airline industry
	     Commercial aviation
	     Safety standards
	     Data bases
	     Inspection
IDENTIFIER:  FAA Air Transportation Oversight System
	     FAA Safety Performance Analysis System

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    United States General Accounting Office GAO                Report
    to the Subcommittee on Aviation, Committee on Transportation and
    Infrastructure, House of Representatives June 1999
    AVIATION SAFETY FAA's New Inspection System Offers Promise, but
    Problems Need to Be Addressed GAO/RCED-99-183 GAO      United
    States General Accounting Office Washington, D.C. 20548 Resources,
    Community, and Economic Development Division B-281502 June 28,
    1999 The Honorable John J. Duncan Chairman The Honorable William
    O. Lipinski Ranking Democratic Member Subcommittee on Aviation
    Committee on Transportation and Infrastructure House of
    Representatives The aviation industry has forecast a potential 66-
    percent increase in passenger travel from 1999 to 2008. The U.S.
    aviation accident rate, which has remained relatively constant
    over the past two decades,1 must be substantially lowered to avoid
    escalating numbers of aviation deaths as air traffic increases. A
    key to reducing the aviation accident rate is for the Federal
    Aviation Administration (FAA) to have an effective process for
    inspecting the nation's airline operations. In the past, we and
    others have expressed concerns about the adequacy of FAA's
    inspection process to meet that challenge. Concerns about the
    inspection process focused on unstructured, nonsystematic
    inspections that produced few reports of safety problems and on
    the adequacy of inspectors' technical training. These concerns
    also raised questions about the quality and consistency of the
    resulting inspection data and their usefulness for conducting
    analyses and targeting FAA's resources to the greatest safety
    risks. FAA has responded to these concerns by redesigning the
    safety inspection system that it uses to oversee the nation's
    airlines. FAA began using the revised approach, called the Air
    Transportation Oversight System (ATOS), for a limited number of
    airlines during the system's initial implementation on October 1,
    1998. Currently, the nation's 10 largest passenger airlines are
    under ATOS.2 At your request, we reviewed FAA's implementation of
    the new system. This report summarizes our work by addressing the
    following questions: * To what extent does ATOS address past
    concerns about FAA's aviation safety inspections? * What factors,
    if any, surfaced during the implementation of ATOS that could
    impede its success? 1The National Transportation Safety Board's
    statistics show an accident rate of 5 fatal accidents for each 10
    million flights on scheduled and nonscheduled service by U.S.
    airlines operating under part 121 of the Federal Aviation
    Regulations from 1982 through 1998. 2These airlines are Alaska,
    America West, American, Continental, Delta, Northwest, Southwest,
    Trans World, United, and US Airways. Page 1
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 *
    What is FAA doing to address any factors that could impede the
    success of ATOS? Results in Brief      The Air Transportation
    Oversight System is largely responsive to past concerns raised
    about key aspects of FAA's aviation safety inspections and the
    usefulness of inspection data. These concerns centered on FAA's
    unstructured inspection process, the adequacy of technical
    training for inspectors, the quality and consistency of inspection
    data, and the usefulness of those data for identifying safety
    problems and targeting the agency's resources to the greatest
    risks. Addressing these concerns involved a fundamental redesign
    of the way FAA inspects the nation's airlines. To improve
    inspection quality, the new program emphasizes a system safety
    approach that goes beyond spot-checking airlines for compliance
    with Federal Aviation Regulations. Using safety principles
    originally created for the nuclear industry, it calls for a
    systematic review of airlines' policies and procedures to ensure
    that they incorporate basic safety principles, such as clear lines
    of responsibility and written documentation. It fosters more
    consistent, structured inspections by standardizing inspection
    tasks, linking inspectors' training more closely to their assigned
    responsibilities, and using teams rather than individual
    inspectors to perform many inspections. The program also calls for
    a number of enhancements to improve the usefulness of inspection
    data for analysis and targeting. They include a standardized
    database for reporting inspection results and the addition of data
    quality assurance managers and analysts. The goal of this redesign
    is to target inspection resources to those areas that present the
    greatest safety risks. ATOS offers promise for significantly
    strengthening FAA's inspection process, but FAA must also address
    the problems identified in this report to ensure that the new
    system fulfills its promise. FAA's ability to conduct effective
    inspections remains limited by a lack of clear guidance, staff
    turnover, and continued difficulties with the adequacy of
    inspectors' technical training and experience. The anticipated
    enhancements to make inspection data more useful have not been
    achieved because of problems with reporting requirements and the
    incompatibility of the program's database with FAA's primary
    inspection analysis system. In addition, FAA planned to hire an
    analyst for each of its new inspection teams to analyze inspection
    data for safety trends and to guide inspection planning, but has
    not yet done so because of higher priorities, such as increasing
    salaries for air traffic controllers. These problems resulted
    largely from FAA's decision to implement the new inspection system
    on an overly ambitious schedule. Page 2
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    Meeting FAA's target date for implementation meant that complex,
    critical steps-such as developing guidance, training inspectors,
    creating databases, and consulting with the affected airlines-had
    to be compressed into a very short time. FAA has begun to address
    some of the problems with the program. FAA management officials
    acknowledged that ATOS faces significant challenges. They agreed
    with our conclusion that the program should not be expanded beyond
    the nation's 10 major airlines until the problems that emerged
    during the program's initial implementation are resolved. However,
    some of these problems have not yet been fully addressed.
    Consequently, we recommend several specific actions to clarify the
    program guidance and improve the usefulness of FAA's database for
    targeting inspection resources to the areas of greatest potential
    safety risk. Background      Federal law establishes that the
    safety of U.S. air passengers is a joint responsibility of the
    airlines and FAA. The airlines are responsible for operating their
    aircraft safely. FAA is responsible for, among other things,
    examining an airline's operations when the airline seeks a
    certificate to operate and for conducting periodic inspections to
    ensure continued compliance with safety regulations. Within FAA,
    the Office of Flight Standards Service develops the Federal
    Aviation Regulations that airlines must follow and prepares
    guidance on how FAA's safety inspectors should perform
    inspections. FAA has nearly 3,300 safety inspectors located in 101
    district offices throughout the United States. One of the
    inspectors' primary functions is conducting what FAA calls
    "routine surveillance"-a process of continuous periodic safety
    inspections of airlines and aviation-related activities.3 These
    inspections include having an inspector visually spot-check an
    airplane at the gate, monitor procedures on a scheduled flight, or
    observe maintenance being performed on an aircraft or its
    component parts. The inspections cover four main areas: *
    Operations inspections focus on such items as pilots'
    certification and performance, flight crews' training, and in-
    flight record keeping. * Maintenance inspections examine an
    airline's overall maintenance program, including the training of
    aviation mechanics, the development of 3Other primary functions
    include certifying airlines' operations, investigating accidents
    and incidents, and taking other steps to promote safety. Page 3
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    maintenance manuals, and procedures for repairing aircraft and
    their components. * Avionics inspections focus on electronic
    components of the aircraft. * Cabin safety inspections concentrate
    on cabin procedures, passenger safety, and carry-on baggage. In
    recent years, we and others have reported on problems with FAA's
    inspections.4 Reacting to these reports and to a series of fatal
    aviation accidents in the mid-1990s, FAA conducted a number of
    studies of its own, including the report entitled FAA 90 Day
    Safety Review, issued in September 1996.5 This review recommended
    that inspections be made more systematic and that they be targeted
    to deal with identified risks, such as airlines' financial
    instability and significant contracting out of maintenance. ATOS,
    developed by the Office of Flight Standards Service and adapted in
    part from safety principles originally created for the nuclear
    industry, resulted from these recommendations. The ATOS Concept Is
    FAA incorporated features in ATOS to address past concerns about
    Responsive to Many          inspection quality and the usefulness
    of inspection data for identifying potential safety threats and
    for targeting resources to areas that pose the Past Concerns About
    greatest risk. Before developing its new aviation safety
    inspection system, FAA's Safety                FAA analyzed past
    concerns about its inspections. The resulting ATOS inspection
    concept focuses on ensuring that an airline has operating
    Inspections                 systems in place to control the
    potential hazards and risks of flying and to prevent accidents.
    FAA structured ATOS to evaluate both an airline's operating
    systems and its adherence to those systems in day-to-day
    operations. In addition, FAA incorporated specific features into
    ATOS to make inspections more consistent, structured, and thorough
    and to improve the collection and analysis of inspection data.
    ATOS Focuses on System      FAA emphasizes a system safety
    approach in ATOS that replaces routine Safety and Accident
    surveillance and goes beyond spot-checking airlines for compliance
    with Prevention                  aviation regulations. System
    safety involves the application of technical and managerial skills
    to identify, analyze, assess, and control hazards and risks. It
    covers every aspect of an airline's operations, from the design of
    4For a list of relevant reports, see the bibliography and the
    section citing related GAO products at the end of this report.
    5Challenge 2000: Recommendations for Future Aviation Safety
    Regulation, prepared for the Federal Aviation Administration by
    Booz-Allen & Hamilton Inc. (Apr. 1996); and FAA 90 Day Safety
    Review, Federal Aviation Administration (Sept. 16, 1996). Page 4
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 the
    hardware to the culture and attitudes of the airline's personnel.
    ATOS calls for a systematic review of an airline's policies and
    procedures to ensure that they incorporate such basic safety
    principles as clear lines of responsibility and written
    documentation. FAA intended ATOS to ensure that an airline has and
    follows policies and procedures that build in system safety. FAA
    implemented ATOS on October 1, 1998, to cover the nation's 10
    major passenger airlines. Under ATOS, FAA assigns a team of
    inspectors to oversee each airline. Three principal inspectors
    lead the team, one for each major area of inspections (operations,
    maintenance, and avionics). Additional team members can be based
    in one of two ways. Inspectors based at the FAA office that holds
    the airline's operating certificate work full time on the ATOS
    team. In contrast, field inspectors, who work in other locations
    to which the airline flies, work part time on the ATOS team and
    complete additional duties, such as accident investigations and
    other inspections, for the local FAA office to which they are
    assigned. About 540 inspectors are assigned to the 10 ATOS teams.
    Each ATOS team also includes one cabin safety specialist, whose
    inspections focus on such areas as flight attendants' training,
    carry-on baggage, and emergency evacuation procedures. FAA
    included two kinds of guidance in ATOS to help a team plan and
    carry out inspections of the airline it oversees. First, automated
    ATOS planning guidance is used to develop the comprehensive
    surveillance plan for each airline. The planning guidance calls
    for using existing safety data, risk indicators, and the
    inspectors' knowledge of an airline's operations to determine the
    priority and frequency of inspection activities. The resulting
    comprehensive surveillance plan includes a series of inspection
    tasks to determine whether the airline has systems in place to
    ensure safety and a second series of inspections to verify that
    the airline is actually using those systems. FAA also developed
    ATOS guidance for conducting inspections that is intended to
    describe the tasks to be performed for each type of inspection.
    For a more detailed description of the ATOS guidance and the
    development of the comprehensive surveillance plan, see appendix
    I. FAA designed ATOS to be improved on an ongoing basis. FAA has
    established an ATOS Program Office to formulate and implement
    changes to ATOS and to support FAA inspection teams through a
    hotline, help desk, and Web site. FAA has also established an
    internal audit team of aviation safety inspectors to evaluate the
    program, the System Process Audit Group. This internal audit team
    is an independent FAA organization that reports directly to the
    Director of Flight Standards. Page 5
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 ATOS
    Addresses Many    In the past, Flight Standards typically
    allocated a large portion of its Past Concerns About    inspection
    resources to thousands of unstructured inspections that Inspection
    Quality     produced few reports of problems. We reported last
    year, for example, that inspectors reported no problems for 96
    percent of the inspections they conducted in fiscal years 1990
    through 1996.6 Reviews of FAA's inspection program suggest that
    FAA detects more problems through rigorous structured inspections
    than through unstructured inspections. Our recent review of FAA's
    oversight of the facilities airlines use to repair aircraft
    confirmed that standardizing inspection tasks through the use of
    checklists promotes more comprehensive inspections.7 Past concerns
    also included problems with inspectors' training. Specifically,
    inspectors have performed inspections for which they did not have
    appropriate or current credentials, in part because of limited
    funding for training. Providing adequate technical training for
    FAA's inspector workforce has proven difficult because of the
    rapid change in aviation technology. In addition, airlines can
    meet regulatory requirements in a variety of ways, making it
    difficult for FAA's inspectors who inspect many different airlines
    to be familiar with the FAA-approved procedures of each airline.
    Both principal inspectors and airline officials we interviewed
    said that this lack of familiarity sometimes resulted in airlines'
    being unfairly cited for noncompliance. Finally, our review of
    aircraft repair facilities noted that individual inspectors
    generally identify far fewer deficiencies than teams do. The
    unstructured inspection activities and the underreporting of
    violations by inspectors resulted in inaccurate, incomplete, and
    inconsistent information that was not very useful for analyzing
    safety risks or targeting the agency's resources to the problems
    that pose the greatest risks. FAA included features in ATOS to
    move toward more consistent, structured inspections by using a
    system safety approach and by providing new, standardized
    inspection tasks. FAA developed automated ATOS planning guidance
    to ensure that inspectors use the same criteria to determine the
    annual inspection activities for each of the major airlines. An
    ATOS team uses the planning guidance to identify potential problem
    areas at each airline that should be inspected more frequently.
    Similarly, to standardize inspection activities across airlines,
    the guidance for conducting inspections lists tasks for each
    inspection. The inspection guidance is designed to ensure that
    each inspector looks at an airline's systems and 6Aviation Safety:
    Weaknesses in Inspection and Enforcement Limit FAA in Identifying
    and Responding to Risks (GAO/RCED-98-6, Feb. 27, 1998). 7Aviation
    Safety: FAA Oversight of Repair Stations Needs Improvement
    (GAO/RCED-98-21, Oct. 24, 1997). Page 6
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    elements in the same way. It is also supposed to serve as a
    checklist that inspectors can use to ensure that their inspections
    are thorough. While the old inspection system listed multiple
    tasks that could be performed, inspectors were not required to
    complete any specific tasks or to document which tasks they
    performed. Thus, the scope of the inspection work actually
    completed could not be determined. In contrast, ATOS requires
    inspectors to document whether the airline being inspected
    complied with each item on the inspection checklist. The checklist
    also serves as a template for reporting inspection results in the
    ATOS database. FAA also incorporated team inspections in the ATOS
    approach. We have reported in the past that teams have been more
    effective than individuals in identifying areas where airlines
    were not in compliance with FAA regulations. In many cases, the
    deficiencies identified by teams are systemic and long-standing.
    Under ATOS, teams will identify deficiencies and plan inspections.
    Many inspections will be performed by teams rather than by
    individual inspectors, as has been done in the past. Individual
    inspectors will continue to perform some of the inspection work
    identified in the plan. FAA also included several features in ATOS
    to address past concerns about inspectors' training by more
    effectively linking inspectors' technical training and
    qualifications to their job responsibilities. First, FAA designed
    ATOS to link inspection assignments to the technical background of
    each inspector and to identify any additional technical training
    needed to accomplish the work plan. Inspectors cannot adequately
    inspect aircraft or systems unless they have had the appropriate
    technical training. Second, inspectors assigned to an airline,
    including field inspectors, must complete training on both ATOS
    and the airline's specific policies and procedures before they can
    conduct inspection activities. The training on ATOS provides an
    overview of the system safety concept and how it differs from
    FAA's past inspection approach. The training on the airline's
    policies and procedures familiarizes inspectors with the approved
    operating procedures of the airline they oversee. Page 7
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 ATOS
    Addresses Many         FAA needs complete, accurate inspection
    data to target its limited Past Problems With the      inspection
    resources to the areas that pose the greatest potential safety
    Usefulness of Inspection    risks. We reported in 1989 and again
    in 1991 on inaccurate and incomplete Data
    data in FAA's inspection database and recommended in 1995 that FAA
    develop a comprehensive and coordinated strategy for improving its
    data.8 More recently, we reported last year that 70 percent of
    Flight Standards' inspectors did not enter all of the violations
    they found into their inspection tracking system in fiscal year
    1996.9 Some inspectors said they did not report violations when
    compliance could be achieved informally by bringing problems to
    the attention of the airlines. Others said they handled less
    serious violations informally because the paperwork involved in
    reporting violations was too burdensome. FAA is implementing a
    streamlined procedure for documenting and processing minor
    administrative violations, which should better enable the agency
    to target its limited inspection resources to the areas that pose
    the greatest risks. The streamlined procedure will reduce
    paperwork for some types of enforcement cases, but other efforts
    will be needed to ensure the complete, accurate inspection data
    needed for improved targeting of inspection resources. FAA
    included several features in ATOS to address past concerns about
    the usefulness of inspection data for analysis and targeting.
    First, the standardization of inspections and the development of
    guidance for planning and conducting inspections are steps
    intended to improve the quality of FAA's data by making
    inspections more systematic and thorough. When inspections are
    more standardized across airlines, data quality is improved.
    Second, FAA created a new position within the ATOS team overseeing
    each airline: a data evaluation program manager, whose job will be
    to review data for validity, accuracy, and completeness before
    they are finalized in the ATOS database for analysis. ATOS also
    added a new position for an analyst on each team. The analyst is
    responsible for collecting and analyzing data to support
    inspection planning and retargeting. Finally, FAA included
    features in ATOS to improve the targeting of inspection resources.
    FAA designed ATOS to allow the targeting of inspections based on
    an airline's size, operations, past history, and known problem
    areas. The automated planning guidance can be used to indicate the
    risk factors applicable to the airline, such as whether an airline
    is a 8Aviation Safety: FAA's Inspection Management System Lacks
    Adequate Oversight (GAO/RCED-90-36, Nov. 13, 1989); Aviation
    Safety: Problems Persist in FAA's Inspection Program (GAO/RCED-92-
    14, Nov. 20, 1991); and Aviation Safety: Data Problems Threaten
    FAA Strides on Safety Analysis System (GAO/AIMD-95-27, Feb. 8,
    1995). 9GAO/RCED-98-6, Feb. 27, 1998. Page 8
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 new
    entrant or contracts with other companies for its maintenance,
    training, or ground handling services. Based on the risk factors,
    the comprehensive surveillance plan targets particular areas. FAA
    also recognized that needed inspection work must drive the
    assigned inspection resources for each airline. Finally, ATOS
    gives inspectors the flexibility to retarget resources at any
    point during the year based on inspection results. This
    flexibility allows FAA to focus on new problems as they surface,
    rather than waiting until the next year's work. Because ATOS
    currently focuses on major airlines, it does not address concerns
    about the need to provide additional oversight of new entrant
    airlines (that is, airlines in their first 5 years of operation).
    A separate FAA initiative, the Certification Standardization and
    Evaluation Team, has standardized and automated the process for
    granting operating certificates to new airlines. ATOS system
    safety concepts have been integrated into the certification
    process for new airlines. The new certification concept includes a
    national team to assist local district offices in reviewing the
    applications of new airlines and monitoring these airlines for
    their first 5 years of operation. As new airlines receive
    certification, FAA plans to oversee them using the ATOS program.
    FAA is not, however, currently providing any additional oversight
    of new entrant airlines that were already in operation prior to
    the new certification process. ATOS' Design and
    Problems that emerged during design and implementation limit the
    Implementation               potential of the ATOS concept to
    bring about needed improvements in FAA's aviation safety
    inspections. Problems with the ATOS inspection guidance, Problems
    Limit FAA's         the links between inspectors' qualifications
    and their work assignments, Efforts to Improve           and
    assembling effective teams affect the improvements envisioned for
    inspection quality and the usefulness of inspection data for
    analysis and Safety Inspections           targeting. In addition,
    FAA did not take advantage of the expertise of airline or industry
    representatives in developing ATOS. Design and
    Although ATOS calls for (1) more systematic, structured
    inspections, Implementation Problems      (2) closer links between
    inspectors' training and their assigned work Limit Improvements to
    responsibilities, and (3) greater use of team inspections to
    improve Inspection Quality           inspection quality, its
    success in the first 6 months has been limited: * Inspection
    guidance is not complete and is not sufficiently clear and
    detailed to accomplish the systematic, structured inspections
    promised by the ATOS concept. Page 9
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 *
    ATOS has not resolved the long-standing problems with matching
    inspectors' qualifications to their work assignments. * Team
    inspections are hampered by problems with assigning inspectors,
    including turnover, work locations that do not match inspection
    needs, an unwillingness of inspectors to travel, and FAA's
    inability to estimate the resources needed to complete ATOS
    inspections. ATOS Inspection Guidance           The new inspection
    guidance is not adequate to ensure the Needs Significant
    Improvement      comprehensive, standardized inspections
    envisioned by the ATOS concept. We found several problems with the
    ATOS inspection guidance as implemented. Guidance does not cover
    all applicable regulations. One basic purpose of inspections is to
    ensure that an airline complies with Federal Aviation Regulations.
    Although ATOS aims to go beyond ensuring compliance to see whether
    safety is built into an airline's operations, compliance should
    also be confirmed. Principal inspectors we interviewed expressed
    several concerns about the link between the ATOS inspection
    guidance and aviation regulations. One group of inspectors
    analyzed the ATOS inspection guidance to determine whether it
    covered all applicable Federal Aviation Regulations. They
    identified 296 specific regulatory requirements that the ATOS
    inspection guidance did not address out of approximately 2,300
    applicable requirements. While we have not verified each of the
    296 requirements said to be missing, our sampling of the
    inspectors' results confirmed that ATOS overlooked some key
    regulatory requirements. For example, the inspection guidance does
    not cover regulations requiring airline employees to be trained to
    handle hazardous materials. Because the ATOS guidance does not
    include all applicable regulatory requirements, inspections may
    not be thorough enough to ensure compliance. Some guidance is not
    applicable to ATOS airlines. In addition to the regulatory
    requirements not covered by ATOS, principal inspectors we
    interviewed identified a number of regulations referenced in ATOS
    that are not applicable to the major airlines currently under
    ATOS. For example, FAA requires that major airlines maintain an
    aircraft's weight and balance to ensure that it remains within
    approved limits. However, the ATOS inspection guidance for the
    weight and balance program is based on the FAA regulations
    governing commuter airlines.10 Because ATOS currently covers only
    the largest airlines, the inspection guidance should exclude
    10Commuter airlines are those that conduct scheduled passenger-
    carrying operations in aircraft that have 10 or fewer seats and
    operate under part 135 of the Federal Aviation Regulations. Page
    10                               GAO/RCED-99-183 FAA's New
    Aviation Inspection System B-281502 those regulations that are
    applicable to commuter airlines or other types of operators, such
    as general aviation aircraft. Principal inspectors we interviewed
    also questioned the appropriateness of some parts of the ATOS
    guidance that have no basis in regulatory requirements. For
    example, the ATOS guidance calls for reviewing the rsums of some
    airline officials, although regulations do not specify
    qualifications and experience for their positions. Principal
    inspectors also questioned the basis for some of the ATOS
    determinations that rely on very subjective judgments, such as
    whether the airline has a "safety focus." They noted that the ATOS
    guidance does not distinguish inspection tasks and findings based
    on regulations, which are legally enforceable, from those based on
    such other sources as inspector handbook guidance, which is
    advisory. Safety officials at most of the major airlines echoed
    the inspectors' concerns. Guidance is not sufficiently clear and
    detailed. The fact that ATOS provides guidance to inspectors on
    how to plan and perform their inspections represents a major step
    toward the standardization of inspection tasks. However, the
    guidance it offers is not yet thorough or detailed enough to
    achieve that goal. Principal inspectors we interviewed questioned
    its usefulness, saying that it was not clear or detailed enough.
    They reported that they found the language of the guidance for
    planning inspections difficult to use because it does not detail
    the tasks to be performed well enough. Staff at Sandia National
    Laboratories, who were asked by FAA to comment on the ATOS program
    because of their expertise in system safety in the nuclear
    industry, had pointed to similar concerns before ATOS was
    implemented. In a report on ATOS, the Sandia staff noted that the
    inspection guidance was not based on analyses of specific ATOS
    inspection tasks and the recording of the results.11 The Sandia
    report noted that a proper task analysis describes the steps to
    take and the standards for determining that the results are
    correct and complete. The inspection guidance does not provide
    this level of detail. FAA's guidance material was not thoroughly
    tested. The lack of clarity and detail in the ATOS guidance, both
    for (1) planning and (2) conducting inspections, reflects the fact
    that FAA did not thoroughly test and validate it before
    implementation. When FAA first tested the planning guidance in
    April 1998, the inspectors involved said they had trouble using it
    because the questions were too vague and broad. When FAA later
    tested a revised 11"Analysis and Data Issues for the
    Implementation of a Systems Safety Focus in Air Transportation
    Oversight," Oct. 6, 1998. Page 11
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    automated version of the planning guidance, most test participants
    were members of the ATOS work group. Work group members filled in
    the answers without actually performing the relevant analysis or
    inspection tasks. While FAA tested the planning guidance, it never
    tested the guidance for conducting inspection tasks. Flight
    standards did not allow sufficient time for ATOS' implementation.
    While FAA spent several years developing the ATOS concept, the
    target implementation date left only 7 months to take the agency's
    new inspection program from concept to reality. The target date of
    October 1, 1998, did not allow time for the adequate development,
    testing, and validation of new inspection procedures and tracking
    systems or for training and preparing the inspector workforce. The
    ATOS work group established in February 1998 faced multiple
    challenges in meeting the implementation deadline in the allotted
    7 months. These challenges included (1) implementing a completely
    reengineered process for conducting inspections, (2) developing
    new automated systems for planning ATOS inspections and tracking
    their results, and (3) preparing FAA for the cultural changes
    involved in having inspectors perform their work differently. FAA
    did not adequately train inspectors to use ATOS. The full impact
    of the shortcuts taken to meet the implementation deadline became
    apparent during the inspectors' training and, subsequently, as the
    teams of inspectors used the new ATOS planning guidance to develop
    a comprehensive surveillance plan for each major airline and to
    initiate inspections. FAA trained more than 800 inspectors,
    managers, and other FAA staff on the ATOS concept and planning
    guidance from September through November 1998. Because of the
    speed with which the ATOS guidance and tracking systems were
    developed, FAA had little time to develop training for its
    inspectors. For example, very few of the 88 ATOS lists of
    inspection tasks were available in time for the training sessions,
    and the database for reporting inspection results was not yet
    completed. Participants in the training sessions repeatedly noted
    that the implementation of ATOS had been rushed and that there
    were too many unknowns to allow for this initiative to go
    smoothly. In course evaluations and in our interviews, inspectors
    said that they were not adequately trained on (1) how to perform
    the new inspection tasks, (2) how to record the results of their
    inspections in the ATOS database, and (3) how to use the data on
    inspections to retarget resources. The ATOS internal audit team
    concluded, "The ATOS training . . . Page 12
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    dedicated an insufficient amount of time to training on the
    [inspection guidance]." Standardized inspections and reporting
    will not occur without clear, understandable guidance, detailed
    information on tasks to be completed, and training in both
    conducting inspections and reporting findings. Links Between
    Inspectors'         The ATOS model for linking inspectors'
    qualifications and training to Qualifications and Assignments
    assignments is not yet a reality. We found that some inspectors
    still lack Are Not Fully Established         experience with FAA
    or major airlines or lack the specific training needed to perform
    their jobs effectively. Lack of experience with FAA or major
    airlines. In selecting staff to fill positions on ATOS teams, FAA
    did not effectively match the qualifications of field inspectors
    to their new positions. The selection of field inspectors to fill
    ATOS assignments was not based on any nationwide criteria or
    guidance. Principal inspectors told us that they had no say in the
    selection of the field inspectors assigned to their teams. As a
    result, the qualifications of some field inspectors did not match
    the teams' needs. Several principal inspectors and managers said
    that field inspectors assigned to them included newly hired staff
    who were unfamiliar with FAA or inspectors-including experienced
    FAA staff-who lacked background with major airlines. For example,
    one manager said that some of the field inspectors assigned to his
    team had no experience in large aircraft and lacked appropriate
    qualifications. FAA principal inspectors have told us that it
    takes several years to develop familiarity with the agency's
    regulations and procedures or with an airline's procedures.
    Consequently, newly hired personnel may need several years of
    experience before they can work independently and be fully
    productive. Similarly, inspectors trained on small aircraft may
    need extensive on-the-job training to understand the workings of a
    major airline. Principal inspectors questioned whether some team
    members had the appropriate skills to oversee a major airline.
    Lack of specific training. Even inspectors who have experience
    with major airlines may not have the specific technical
    qualifications to perform the ATOS inspection tasks planned for
    the airline to which they are assigned. Principal inspectors we
    interviewed said that the technical qualifications of a number of
    the inspectors assigned to them did not match those needed to
    oversee the airline in question. For example, one operations
    inspector said that three of his field inspectors did not have the
    appropriate license required to fly the aircraft used by the
    airline or to conduct flight checks to observe its pilots.
    Similarly, a principal avionics Page 13
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    inspector said that neither he nor his assistant had the
    appropriate technical training in the Airbus aircraft that the
    airline flies. Furthermore, the rapid changes in the aviation
    industry make it difficult to provide sufficient technical
    training to keep experienced inspectors current. These
    difficulties in keeping pace with technological advances reflect
    FAA's persistent problems with providing technical training for
    inspectors and matching inspectors' qualifications to their job
    assignments. Assignment Issues Affect the    Staff turnover,
    travel requirements, and conflicting demands on inspectors'
    Quality of Team Inspections     time undermine FAA's ability to
    assemble effective ATOS teams. Many of these assignment issues
    cannot be resolved within the context of the ATOS program alone
    because they involve broader decisions about inspectors'
    responsibilities and Flight Standards' staffing. Staff turnover.
    The turnover among field inspectors assigned to the airlines
    covered by ATOS has made it difficult to plan inspection work or
    to meet the ATOS training requirements. Principal inspectors said
    that they had lost field inspectors originally assigned to their
    teams, primarily because field inspectors went elsewhere in FAA to
    accept promotions that are not available to them under Flight
    Standards' current staffing structure. For example, of the 28
    inspectors assigned to one ATOS team, 11 had been reassigned,
    leaving only 17 available. Because some replacements lacked ATOS
    training, training on the airline's policies and procedures, or
    both, they were ineligible to conduct inspections under ATOS.
    Principal inspectors were concerned about how, if turnover
    continues, to meet the requirement that inspectors be trained on
    the policies and procedures of the airline they oversee. In many
    cases, the airlines provided this training in cooperation with
    FAA. Several principal inspectors said that repeated requests for
    training would be burdensome to the airlines. Principal inspectors
    noted that the turnover of field inspectors would probably
    continue unless changes are made in Flight Standards' grade and
    pay levels to permit field inspectors to be promoted. Inspectors'
    work locations do not always match inspection needs. Because the
    work locations of some inspectors assigned to ATOS teams do not
    match inspection needs, the inspectors will have to travel to
    complete their work. This has made it difficult to assemble
    effective teams for several reasons. First, many of the principal
    inspectors we interviewed told us that field inspectors were
    assigned to locations where they are not needed, while parts of
    the country where the airlines have substantial activity have no
    field presence. For example, one principal inspector told us that
    he had a field inspector assigned to his team who was located in
    Page 14                      GAO/RCED-99-183 FAA's New Aviation
    Inspection System B-281502 Boise, Idaho, where the airline he
    oversees does not fly, but that he had no one in Kansas City,
    where he needs an inspector to oversee maintenance operations.
    Because of these problems, a number of principal inspectors
    suggested that they be given a role in identifying the needed
    qualifications and work locations for field inspectors assigned to
    the ATOS teams. Furthermore, in the past, teams overseeing an
    airline drew on field inspectors in FAA's international offices to
    inspect foreign maintenance facilities and other overseas
    operations of airlines with international routes. Because FAA has
    not trained inspectors in its international offices to perform
    ATOS inspections, ATOS team members will have to travel overseas
    to complete planned inspections, despite FAA's already limited
    travel funds. ATOS does not resolve resource constraints. FAA
    designed ATOS to address the inspection portion of its inspectors'
    workload and did not address the inspectors' other
    responsibilities. In addition to inspections, the oversight of an
    airline includes ongoing activities referred to as "demand" work.
    Demand work includes certification and approvals for initiatives
    taken by the airline, such as adding new aircraft types to the
    fleet, adding new destinations, implementing computerized record
    keeping, and restructuring by management. The ATOS internal audit
    staff confirmed that a conflict exists between demand work and
    ATOS inspection work. Inspectors based near the offices of the
    airlines they oversee are especially prone to this conflict
    because they perform both demand work and ATOS inspections. Many
    principal inspectors said that these inspectors do not have
    sufficient time to complete both their demand work and ATOS
    inspection work. Field inspectors, who are assigned only part time
    to ATOS, are subject to different pressures. ATOS field inspectors
    must also investigate accidents and perform other inspection work
    for the local offices to which they are assigned. Principal
    inspectors expressed concern that field inspectors might not be
    available for ATOS work when needed because of demands from their
    local offices. In addition, several principal inspectors and
    managers questioned whether the emphasis on ATOS has shifted
    resources away from other areas of concern, such as repair
    stations, troubled smaller carriers, and general aviation safety.
    Managers contended that such conflicts between demand work and
    inspection activities will persist as long as ATOS focuses solely
    on inspections, rather than having a broader view of the work that
    inspectors perform. These conflicting demands on inspectors' time
    and on resources such as travel funds are exacerbated because
    managers do not know what resources will be needed to perform ATOS
    inspections. The ATOS guidance Page 15
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 does
    not include estimates of how long various inspection tasks should
    take. Without such information, it is difficult to estimate how
    many inspectors will be needed to perform the tasks or what travel
    funds they may need to accomplish the planned work. Both
    inspectors and their managers told us that they are unable to
    estimate how much time many of the ATOS inspection tasks will
    require. Two principal inspectors told us that managers of some
    local offices will not approve ATOS work plans for field
    inspectors unless they know how much time will be needed to
    complete the work. Testing and validation of the ATOS guidance
    would have provided preliminary estimates for the time needed to
    complete various ATOS inspection tasks. The ATOS Data Collection
    Although ATOS includes initiatives to address past problems with
    the Process Limits the               usefulness of FAA's
    inspection data for analysis and targeting of resources Usefulness
    of Data for           to the greatest safety risks, this goal may
    not be fully realized for several Analysis and Targeting
    reasons. First, because of the problems with the ATOS guidance
    that we have already discussed, the data collected from ATOS
    inspections are not likely to be reliable enough to support
    meaningful analyses. Furthermore, in translating ATOS from concept
    to design and eventual implementation, FAA did not adequately
    determine its data analysis needs. The volume of inspection data
    available for analysis has also dropped dramatically under ATOS
    because few inspections have been completed. Finally, principal
    inspectors responsible for overseeing airlines did not have timely
    access even to the limited data available until FAA granted them
    access in May 1999. FAA Did Not Adequately           While ATOS
    calls for structured inspections intended to result in more
    Determine Data Analysis Needs    thorough and consistent data, the
    way ATOS collects data limits the potential of its database as a
    tool for analysis and targeting. The data limitations reflect the
    fact that FAA did not sufficiently analyze its data needs before
    developing ATOS inspection guidance and its automated database.
    The development of an effective automated system begins with a
    thorough analysis of the data required to meet the needs of those
    using the database. In the case of ATOS, a thorough analysis would
    describe in detail the questions that need to be asked to improve
    aviation safety, determine precisely what data are needed to
    answer those questions, and plan the appropriate analyses to be
    conducted on those data to answer the questions. After the
    preliminary analysis of the users' data needs is completed, the
    prototype system must be tested, validated, and revised in an
    iterative process between data users and automation developers.
    Staff from Sandia National Laboratories reviewed ATOS and
    concluded that its Page 16                       GAO/RCED-99-183
    FAA's New Aviation Inspection System B-281502 developers did not
    go beyond abstract, high-level statements about users' needs to
    the level of detail essential to ensure data quality. They added
    that without more detailed information it will be difficult to
    identify the data and information needed to answer questions about
    aviation safety and impossible to support the detailed automated
    analysis of an airline. Because FAA did not sufficiently analyze
    or list the data needed by inspectors to make determinations about
    aviation safety and did not adequately test or validate ATOS,
    features that would maximize the usefulness of data for analysis
    and targeting were not built into the system. We found four
    specific limitations with the ATOS database. Key information is
    not required. ATOS does not currently require inspectors to record
    inspection data that are essential for effective analyses. To
    perform effective analyses of safety data, basic information is
    needed, such as the airline's name; the make, model, and series of
    the aircraft; the aircraft and pilot identification numbers; and
    where the inspection was performed. However, an ATOS inspection
    record can be closed without any of this basic information having
    been entered because the system requires only that inspectors
    indicate whether an airline is in compliance and explain any
    violations. For example, our review of completed ATOS inspections
    found 18 completed inspection activities related to de-icing
    operations for which the location had been entered, not in the
    appropriate field, but in a comment field. Data contained in
    comment fields cannot be used for automated analyses to determine,
    for example, which airports are experiencing problems with de-
    icing. In addition, the ATOS inspection guidance does not provide
    inspectors with an index or clear instructions on where in the
    ATOS database to report findings. If an inspector cannot easily
    figure out where to report a finding, it may go unreported. For
    example, an inspector who found incorrect safety placards on an
    aircraft said he had to search ATOS for nearly 4 hours to record
    this violation. Inspectors' underreporting of violations that they
    observed has jeopardized the completeness and quality of
    inspection data in the past. ATOS does not resolve the problems
    that contributed to underreporting, and the difficulty in finding
    where to report violations in ATOS may exacerbate this problem.
    Response options preclude meaningful analyses. Many ATOS
    inspection activities are to be summed up in a report with a
    single "yes" or "no" response to the items on the inspection
    checklist for a given area. If an inspector finds problems during
    a single inspection activity, it results in a Page 17
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 "no"
    for the entire question. Regardless of whether an inspector finds
    one problem in 10 inspections or one in 100, a "no" results.
    Without knowing the proportion of "no" responses for a given item,
    FAA cannot use the inspection results to conduct quantitative
    analyses on ATOS data, for example, a trend analysis to determine
    whether the airline's compliance in a given area has improved.
    Minimum number of inspection activities needed is not specified.
    ATOS currently does not specify the minimum number of activities
    needed to complete each inspection. Instead, individual inspectors
    decide independently how many times inspection observations should
    be performed to determine whether the airline follows its
    procedures and complies with regulations. This determination is
    subjective. In our review of the ATOS data available as of March
    31, 1999, we found that four inspectors conducted anywhere from 2
    to 12 observations to complete the record for the same type of
    inspection. Because these reports result in "yes" or "no" answers
    on the completed inspection report, rather than in a quantifiable
    report of the proportion of "no" answers, the data submitted by
    these inspectors cannot be compared or analyzed. Because
    inspectors will never have enough time to observe every safety-
    related component of an airline's system, it is important to
    define the minimum number of inspections to be conducted and to
    report accurately the proportion of instances of noncompliance.
    ATOS does not link to Flight Standards' existing data analysis
    system. The information in the ATOS database cannot be analyzed by
    Flight Standards' existing aviation risk analysis system, the
    Safety Performance Analysis System (SPAS). FAA has spent $95
    million developing SPAS to analyze key aviation safety data,
    identify trends and potential safety concerns, and target
    inspection resources accordingly. In January 1998, the ATOS
    development team noted that ATOS inspection data could not be
    analyzed by SPAS. The development team recommended that ATOS not
    be implemented until FAA could develop appropriate links between
    ATOS and SPAS. However, FAA, in its efforts to meet the October 1,
    1998, implementation date, went forward without addressing this
    recommendation. SPAS program officials told us that significant
    work remains to link the two systems. An ongoing FAA work group
    studying ways to incorporate system safety into Flight Standards'
    programs has been given responsibility for linking ATOS and SPAS.
    This work group has not yet established a timetable for how or
    when the link will be completed. Page 18
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    Availability of ATOS Data    The usefulness of ATOS data for
    analysis and targeting has been limited by Limits Analysis
    the overall lack of information in the ATOS database as well as by
    initial problems with accessing what information is available. FAA
    devoted much of the early part of fiscal year 1999 to planning
    ATOS inspections and training inspectors in the new system. As a
    result, very few data on the performance of the airlines covered
    by ATOS have been available for analysis. By the end of the second
    quarter, fewer than 60 of approximately 5,400 planned inspections
    had been completed, entered into the ATOS database, and made
    available to principal inspectors. These completed inspections
    comprised fewer than 1,200 individual inspection activities,
    substantially fewer than those recorded in previous years.12 The
    flow of inspection activity results into the ATOS database has
    since accelerated, with an additional 267 inspections and 1,808
    individual inspection activities recorded over the first 6 weeks
    of the third quarter. Nevertheless, only 326 inspections,
    consisting of 3,079 inspection activities, had been completed by
    May 11, 1999, and for one airline no inspections had been
    completed. In contrast, during the first two quarters of fiscal
    year 1998, over 37,000 inspection activities had been recorded in
    the Program Reporting and Tracking System for the 10 airlines now
    covered by ATOS.13 We also found that access to the information
    available in the ATOS database was limited until inspections were
    completed. FAA designed ATOS so that neither principal inspectors
    nor analysts could access data until inspectors completed all
    inspection activities and the team's data evaluation program
    manager reviewed and approved the data. The lack of access to key
    safety data created problems for principal inspectors, who are
    responsible for overseeing operations, maintenance, and avionics
    inspections at each airline. They could not view inspection
    results until the data evaluation program manager reviewed the
    data for clarity and consistency. Several principal inspectors
    expressed concern about not having timely access to key safety
    data, which they use as an early warning of potential safety
    risks. In February 1999, we briefed FAA on the concerns expressed
    about delayed access to inspection results in the ATOS database.
    In March 1999, FAA directed its automation contractor to take the
    steps necessary to grant principal inspectors immediate read-only
    access to inspection findings. Until this access was granted,
    principal inspectors remained dependent on 12Under ATOS, each
    inspection recorded in the database summarizes the results of
    multiple observations called inspection activities. 13While the
    3,079 ATOS inspection activities may not be directly comparable to
    the 37,000 inspections conducted under the previous inspection
    system, a substantial drop-off in the inspection information
    available to managers and analysts has clearly occurred over the
    first half of fiscal year 1999. Page 19
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502 such
    informal means as e-mail and telephone calls to learn of any
    problems or violations found during inspections. Principal
    inspectors now have access to all final inspection activity
    reports related to their specialty for the airline that they
    oversee. This change made data on 2,724 ATOS inspection activities
    available to principal inspectors as of May 11, 1999. ATOS'
    Targeting                The previously mentioned inadequacies in
    the ATOS guidance and problems Capabilities Are Limited by    with
    the usefulness of the resulting data for analysis limit FAA's
    ability to Inadequate Inspection          use ATOS for targeting
    inspection resources to the problems that pose the Guidance and
    Problems          greatest safety risks. Prior to the
    implementation of ATOS, the primary With the Usefulness of
    purpose of inspections was to identify individual safety problems
    and ensure their correction. Under ATOS, the primary objective is
    to provide Data                           reliable data to enable
    FAA to identify the highest-priority safety concerns and target
    the agency's resources to reduce these concerns or risks as well
    as to ensure that individual safety problems are corrected. As
    implemented, ATOS falls short of this goal. Significant revisions
    will be needed to the ATOS guidance and database before the
    potential of this new inspection system can be realized. FAA Did
    Not Take               Although FAA has many ongoing initiatives
    with the aviation industry, Advantage of Industry
    coordination with industry was lacking in the design of ATOS.
    Although Expertise in Developing        several aspects of ATOS
    involve areas in which industry safety experts have ATOS
    experience and similar goals, the design process did not include
    airline or industry representatives, who were briefed on ATOS
    after the concept was developed. The industry's input is missing,
    for instance, in the risk weights ATOS uses in its planning
    guidance to help determine the number of inspections a team is to
    conduct, thus directing resources to areas that require additional
    oversight. For example, the weight ATOS gives to an airline's
    screening, boarding, and briefing procedures for passengers is
    greater than that assigned to cockpit procedures. FAA neither
    validated these weights nor discussed them with airline safety
    officials. FAA Has Initiated              We briefed FAA in
    December 1998 and again in February 1999 on the Improvements to
    problems we had found with the implementation of ATOS. Because of
    the magnitude and seriousness of the problems associated with the
    current ATOS                           ATOS guidance and database,
    we suggested that FAA not expand ATOS to additional airlines,
    repair stations, or other aviation operations until these problems
    are resolved. Acknowledging that there were significant Page 20
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    challenges to further implementing the program, FAA agreed that
    expansion of the program needs to be delayed.14 In March 1999, the
    Director of Flight Standards and key ATOS program officials met
    with the principal inspectors who lead the 10 ATOS teams to brief
    them on our findings and to obtain their views on the system's
    implementation. This meeting resulted in a list of immediate and
    future actions to be undertaken to address the concerns raised.
    First, FAA has taken steps to provide principal inspectors with
    immediate access to completed inspection reports. FAA also
    provided partial funding for planned overseas inspections, which
    will allow inspectors to complete some of the more critical
    overseas inspections. Finally, FAA will incorporate additional
    information on the inspection guidance task lists and database
    tracking system into ATOS training beginning in July. These
    initiatives will help alleviate several of the more immediate
    problems with ATOS by (1) making key safety information available
    to principal inspectors as soon as inspections are completed, (2)
    allowing at least some of the planned overseas inspections to take
    place, and (3) providing better training for inspectors on how to
    conduct inspections and record their results. In addition, both
    the ATOS Program Office and the ATOS internal audit group will
    continue to monitor the implementation closely to ensure that
    these problems and others that may arise are addressed. Funding
    has not yet been allocated to support the needed improvements to
    ATOS or to link ATOS with FAA's existing data targeting and
    analysis system, SPAS. Conclusions    The ATOS concept offers
    significant promise for helping FAA overcome deficiencies in its
    past approach to aviation safety inspections. However, its
    potential will not be fully realized until FAA resolves the
    problems resulting from the ambitious schedule it followed in
    implementing ATOS. These problems limit both FAA's ability to
    conduct more systematic, structured inspections and analyze the
    resulting data to identify safety trends and its ability to target
    its resources to the greatest risks. The ATOS guidance is not
    clear and detailed enough to ensure more systematic, structured
    inspections that will result in more usable data. In addition, FAA
    has not adequately analyzed the data needs of ATOS users to ensure
    that the system collects the information that will enable the
    agency to perform critical trend and safety analyses. Such
    analyses are also limited because ATOS does not link to FAA's
    other major database for safety analyses (SPAS). FAA has
    recognized the need for significant improvements before ATOS will
    14FAA already had plans to bring two additional airlines into ATOS
    in the near future. These airlines have recently completed
    certification activities and will begin ATOS inspections upon
    completion of a transition phase. Page 21
    GAO/RCED-99-183 FAA's New Aviation Inspection System B-281502
    achieve its full potential as a system for overseeing commercial
    airline safety, and the agency has taken actions to correct some
    of the problems we found. Because of the challenges involved in
    making the needed improvements to ATOS, FAA officials have
    postponed plans to expand ATOS to other airlines until these
    problems are corrected. In addition, FAA is aware that the
    resolution of some problems with the implementation of ATOS
    involve broader issues that concern staffing decisions and
    workload issues that can affect all of Flight Standards'
    inspectors. Recommendations      To strengthen the efforts to
    improve FAA's aviation safety inspections and the usefulness of
    the data that result from these inspections for analysis and for
    targeting the agency's resources to the greatest potential safety
    threats, we recommend that the Secretary of Transportation direct
    the FAA Administrator to take the following actions: * Develop a
    structured process and timeline for working with inspectors to
    revise the Air Transportation Oversight System's planning and
    inspection guidance. The process should involve the inspectors now
    using this guidance to (1) identify problems with the clarity of
    the guidance, (2) revise the inspection guidance to include tasks
    related to all applicable Federal Aviation Regulations, and (3)
    define the tasks to be completed during inspections. * Revise the
    inspection guidance to (1) include guidelines on the minimum
    number of times to perform various inspection tasks and (2)
    distinguish between tasks based on regulatory requirements and
    those based on handbook or other guidance. * Develop a plan that
    involves both inspectors and experts in risk assessment and
    database development in revising and refining the analysis of the
    data needs of users of the new inspection program. The
    requirements analysis should describe in detail the questions that
    need to be asked to improve safety, determine precisely what data
    are needed to answer those questions, and plan the appropriate
    analyses to be conducted on those data to answer the questions. *
    Restructure the inspection database to (1) require that essential
    data fields be completed before inspection reports can be closed
    out and (2) clearly indicate the proportion of inspection
    observations in which an airline complies with regulations. Page
    22                       GAO/RCED-99-183 FAA's New Aviation
    Inspection System B-281502 * Determine what revisions will be
    needed to the Air Transportation Oversight System database and the
    agency's existing Safety Performance Analysis System database to
    maximize the potential of these two systems by coordinating their
    trend analyses to identify potential safety risks. * Test and
    validate the revised guidance and database for the new inspection
    program. Agency Comments         We provided FAA with a draft of
    this report for review and comment. We and Our Evaluation      met
    with the Deputy Associate Administrator for Regulation and
    Certification, the Director of the Office of Flight Standards
    Service, the Acting Manager of the Air Transportation Oversight
    System Program Office, the Manager of the System Process Audit
    Group, and other FAA officials. The agency agreed with the
    substance of the report but commented that the tone was
    unnecessarily negative and could leave the impression that we
    believe that the program should be abandoned. Agency officials
    also said that they made a conscious decision to implement the new
    system aggressively, rather than in stages, and recognized that
    this approach would result in some implementation problems.
    However, they believe that ultimately the new system will be fully
    operational sooner than if they followed a more conservative
    implementation approach. The agency also commented that our review
    of the program was premature and suggested that an evaluation of
    the program in another year would find that most of the problems
    we reported had been resolved. We do not believe the program
    should be abandoned. We believe that our report clearly supports
    the Air Transportation Oversight System and acknowledges its
    potential for significantly strengthening FAA's inspection
    process. However, we continue to believe that serious challenges
    need to be overcome before this program can achieve its potential.
    Because our review coincided with the program's implementation, we
    were able to identify serious problems early and to promote
    constructive action by FAA to begin resolving them. As we
    reported, FAA has begun to address some of these problems. In
    commenting on this report, FAA also provided some updated
    information on its inspection activities and suggested wording
    revisions that we incorporated as appropriate. We conducted our
    work from September 1998 through June 1999 in accordance with
    generally accepted government auditing standards. Appendix II
    contains details of the scope and methodology of our review. Page
    23                      GAO/RCED-99-183 FAA's New Aviation
    Inspection System B-281502 As you requested, unless you publicly
    announce its contents earlier, we plan no further distribution of
    this report until 10 days from the date of this letter. We will
    then send copies to the appropriate congressional committees;
    Rodney E. Slater, the Secretary of Transportation; Jane F. Garvey,
    the Administrator, FAA; Jacob J. Lew, the Director, Office of
    Management and Budget; and other interested parties. We will also
    make copies available to others upon request. If you have any
    questions about this report or need additional information, please
    call me at (202) 512-2834. Major contributors to this report are
    listed in appendix III. John H. Anderson, Jr. Director,
    Transportation Issues Page 24                      GAO/RCED-99-183
    FAA's New Aviation Inspection System Page 25      GAO/RCED-99-183
    FAA's New Aviation Inspection System Contents Letter
    1 Appendix I
    28 ATOS Guidance and       The System Safety Assessment Tool
    30 The Air Carrier Assessment Tool
    32 the Comprehensive       The Comprehensive Surveillance Plan
    33 Surveillance Plan       Safety Attribute Inspections
    33 Element Performance Inspections
    34 Appendix II
    35 Objectives, Scope, and Methodology Appendix III
    37 GAO Contacts and Staff Acknowledgments Bibliography
    38 Related GAO Products
    39 Tables                  Table I.1: The Seven Airline Systems
    Defined in ATOS                             30 Table I.2:
    Categories of System Safety Used With SSAT
    31 Table I.3: ACAT Risk Indicators
    32 Figure                  Figure I.1: How FAA Designs
    Comprehensive Surveillance Plans                     29 Through
    ATOS Abbreviations ACAT         air carrier assessment tool ATOS
    Air Transportation Oversight System EPI          element
    performance inspection FAA          Federal Aviation
    Administration GAO          General Accounting Office SAI
    safety attribute inspection SPAS         Safety Performance
    Analysis System SSAT         system safety analysis tool Page 26
    GAO/RCED-99-183 FAA's New Aviation Inspection System Page 27
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan The Air
    Transportation Oversight System (ATOS) is a process designed to
    improve the Federal Aviation Administration's (FAA) oversight of
    airlines. FAA's Office of Flight Standards Service developed ATOS
    with the support of Sandia National Laboratories. ATOS uses system
    safety principles created for the nuclear industry and risk
    management to ensure that airlines have safety built into their
    operating systems. A systems safety approach means that FAA's
    inspection efforts will cover all aspects of an airline's
    performance that can affect safety and will focus on preventing
    accidents. A certificate management team oversees each of the 10
    airlines under ATOS. Each team is led by three principal
    inspectors, one for each major area of inspections (operations,
    maintenance, and avionics). Additional team members include those
    based at the FAA office that holds the airline's operating
    certificate and field inspectors in other FAA offices at locations
    to which the airline flies. The team uses automated planning
    guidance to develop a comprehensive surveillance plan for the
    airline. The planning guidance consists of two automated tools-the
    system safety analysis tool (SSAT) and the air carrier assessment
    tool (ACAT). The principal inspectors complete the SSAT and ACAT
    prior to an annual planning meeting. During the meeting, team
    members discuss the SSAT and ACAT, and their feedback is included
    in the final version. The results of the ACAT help define
    inspection activities that the team will include in the airline's
    comprehensive surveillance plan. The SSAT, ACAT, and comprehensive
    surveillance plan are described in more detail below. Figure I.1
    shows how these ATOS components relate to one another. Page 28
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan Figure I.1:
    How FAA Designs Comprehensive Surveillance Plans Through ATOS
    Source: Federal Aviation Administration. Page 29
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan Using the
    automated planning guidance, the team analyzes the airline's
    operations, which are divided into seven systems (see table I.1).
    These systems are made up of 14 subsystems and of 79 elements. For
    example, the flight operations system is made up of two
    subsystems, which encompass elements such as aircraft dispatch and
    flight deck procedures. FAA designed the SSAT to help the team
    assess the systems in place at an airline to ensure safe
    operations. The ACAT applies a set of risk indicators to the
    airline's subsystems and elements to generate a comprehensive
    surveillance plan. These risk indicators for the ACAT are based on
    safety and performance information that reflects areas of
    potential risk for an airline's operations. Hence, the
    comprehensive surveillance plan will target those areas most
    likely to have safety problems. Table I.1: The Seven Airline
    Systems Defined in ATOS                         System
    System's purpose Aircraft configuration and control
    Maintains the physical condition of the aircraft and associated
    components. Manuals
    Controls the information and instructions that define and govern
    an airline's activities. Flight operations
    Governs aircraft movement. Personnel training and qualifications
    Ensures that an airline's personnel are trained and qualified.
    Route structures                                 Maintains an
    airline's facilities on approved routes. Airman/crew member
    flight, rest, and duty        Prescribes time limitations for
    airline time
    employees. Technical administration
    Addresses all other aspects of an airline's certification and
    operations. Source: FAA Order 8400.10, Air Transportation
    Operations Inspector's Handbook, appendix 6. The System Safety
    The SSAT is a computerized tool designed to focus the inspection
    team's Assessment Tool                         attention on the
    systems that an airline has in place. It poses questions to the
    team covering six categories: safety attributes, safety culture,
    communications, accountability, training programs, and potential
    problem areas. (See table I.2.) The principal inspectors complete
    the SSAT prior to a yearly meeting to plan inspections to oversee
    the airline's operations. To complete the SSAT, the principal
    inspectors rely on their knowledge of the airline and on the data
    available through FAA's Safety Performance Analysis System (SPAS),
    the Flight Standards Automated System, or other sources. Before
    the annual meeting, the team members review the SSAT Page 30
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan completed by
    the principal inspectors and provide feedback. The SSAT is
    finalized at the annual meeting but may be revised during the year
    to retarget inspection resources. Table I.2: Categories of System
    Safety Used With SSAT                            Category
    Definition Safety attributes                                ATOS
    identifies six safety attributes: Responsibility: The unit or
    person in the airline that determines the course of action for a
    process. Authority: The unit or person in the airline that has the
    authority to establish or modify a process. Procedures: A
    documented method of accomplishing a process. Controls: A check or
    restraint that is designed into a process to ensure a desired
    result. Process measurements: The unit or person in the airline
    that measures and assesses information to identify, detect,
    analyze, and document problems or potential problems. Interfaces:
    Points at which independent processes interact. Safety culture
    The priority given to safety by the airline's systems, including
    the airline's identification and response to safety risks, and the
    effectiveness of internal evaluation systems. Communications
    The communication and feedback channels within the airline to
    report and respond to safety risks as well as open and timely
    communication with FAA and equipment manufacturers. Accountability
    The extent to which the airline holds its management and employees
    accountable for their assigned responsibility and authority.
    Training programs                                The priority an
    airline places on training as well as the effectiveness of initial
    and recurrent training programs. Potential problem areas
    The existence of concerns based on previous accidents or
    incidents, hotline complaints, or trends revealed in safety data.
    Source: FAA Order 8400.10, Air Transportation Operations
    Inspector's Handbook, appendix 6. Page 31
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan By
    completing the SSAT, the ATOS inspection team assesses how well an
    airline addresses system safety issues. Using this information,
    the team determines whether to inspect any of the systems more or
    less frequently than suggested by the ATOS guidance and
    incorporates the inspections in the comprehensive surveillance
    plan for the airline. The Air Carrier                    In
    completing the ACAT, principal inspectors use the results of the
    SSAT, Assessment Tool                    their knowledge of the
    airline their team oversees, and any other available data to
    indicate concerns about any real or potential problem that could
    contribute to the failure of one of the airline's elements,
    subsystems, or systems. The ACAT applies risk indicators to each
    of the airline's systems. Table I.3 shows the types of risk
    indicators that are assessed when inspectors complete an ACAT.
    Table I.3: ACAT Risk Indicators    Type of risk indicator
    Definition and examples Operational stability
    Those aspects of an airline's organization and environment over
    which it has no direct control and that, when managed effectively,
    could enhance system safety and stability (e.g., turnover in
    personnel, or a merger or takeover). Airline dynamics
    Aspects of an airline's environment that it directly controls and
    that could be used to enhance system safety and stability (e.g.,
    an internal evaluation program, and risk management). Performance
    history                              The results of an airline's
    operations over time (e.g., enforcement actions, self-disclosure
    reports to FAA). Environmental criticality
    Those aspects of an airline's surroundings that could lead to or
    trigger a failure of one of its systems, subsystems, or elements
    and potentially create an unsafe condition (e.g., age of the
    fleet, outsourcing of maintenance). Source: FAA Order 8400.10, Air
    Transportation Operations Inspector's Handbook, appendix 6. The
    principal inspectors complete the ACAT prior to the annual
    planning meeting. During the annual planning meeting, the team
    members provide feedback on the ACAT that is included in the final
    version. Page 32                             GAO/RCED-99-183 FAA's
    New Aviation Inspection System Appendix I ATOS Guidance and the
    Comprehensive Surveillance Plan The Comprehensive    The
    comprehensive surveillance plan is automatically generated based
    on Surveillance Plan    the information the team enters into ACAT.
    This provides a baseline surveillance plan that is tailored to the
    airline, reflecting concerns indicated by the principal
    inspectors. Each comprehensive surveillance plan incorporates two
    types of inspections, safety attribute inspections (SAI) and
    element performance inspections (EPI). SAIs appraise the quality
    of an airline's safety attributes (see table I.2) for each system,
    its subsystems, and its elements. A team of inspectors conducts
    these system inspections. EPIs determine whether an airline
    adheres to its written procedures and controls for each system
    element and whether the established performance measures for each
    element are met. Individual inspectors conduct these inspections.
    ATOS allows the principal inspector to increase or, in some cases,
    decrease the level of inspection generated by the surveillance
    plan. This allows principal inspectors to use their expertise and
    personal knowledge of the airline to target resources toward the
    greatest safety risks. Although the comprehensive surveillance
    plan is automatically generated based on the results of the SSAT
    and ACAT, the plan is not finalized until the annual inspection
    planning meeting, which is attended by all members of the team.
    This allows the principal inspectors to discuss the completed SSAT
    and ACAT and to make changes based on other inspectors' feedback.
    In addition, work assignments are discussed and made for each of
    the SAIs and EPIs that are planned. Principal inspectors complete
    and approve the final plan. Safety Attribute     The ACAT provides
    information directly to the SAI planning system in ATOS,
    Inspections          which indicates an inspection priority for
    each of the airline's subsystems. Considering the SAI priority, a
    principal inspector enters the number of SAIs to be completed for
    each of the airline's elements during the year. Automation of the
    SAI also allows a principal inspector to assign teams for each of
    the SAI activities. The principal inspector can also provide
    specific instructions to the team regarding the inspections. An
    SAI is an in-depth look at an airline's policies and procedures
    for a system element. This inspection is structured to look at the
    safety attributes shown in table I.2. An SAI is completed by a
    team of inspectors, led by a team coordinator. This team assesses
    the accuracy and completeness of written policies and procedures
    governing each safety attribute associated with one of the airline
    system elements. For example, Page 33
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix I
    ATOS Guidance and the Comprehensive Surveillance Plan one element
    of the route structure system is the line stations for servicing
    and maintaining the airline's aircraft at each city it serves.
    Teams performing line station SAIs determine if there are
    qualified persons accountable for the line stations and if those
    persons have the authority to change the processes governing those
    facilities. The teams also review the procedures governing line
    stations to determine if proper controls are in place-such as
    standards for the maintenance conducted at the line station or for
    the training of line station employees. Finally, the teams
    determine if processes are in place to identify and correct
    problems as well as to ensure that other processes, such as de-
    icing and refueling, are coordinated. Element Performance    FAA
    established a baseline for how frequently each of the 79 ATOS
    elements Inspections            should be inspected. This
    frequency baseline identifies whether a system element should be
    inspected on an annual, semiannual, or quarterly basis within the
    planning cycle. The ACAT calculates an assessment value that, when
    applied to the frequency baseline, increases or decreases the
    number of inspections based on the concerns the principal
    inspectors have identified. Elements must be inspected at least
    once a year. Once the principal inspectors have determined the
    number of EPIs that will be conducted, the work is assigned to
    other inspectors on the team using the automated system. An EPI
    shows whether the airline follows the airline's procedures and
    controls. Individual inspectors conduct EPIs, which most resemble
    the routine inspections FAA conducted in the past. For example,
    the line station EPI requires an inspector to visit a line station
    to determine if procedures and controls in place are being
    followed at that location. A line station inspection under ATOS
    may include multiple visits to one location or to a variety of
    other locations as well. All of these visits may be included in a
    single EPI report. Page 34                       GAO/RCED-99-183
    FAA's New Aviation Inspection System Appendix II Objectives,
    Scope, and Methodology In September 1998, the Chairman and Ranking
    Democratic Member of the Subcommittee on Aviation, House Committee
    on Transportation and Infrastructure, asked us to address
    questions related to FAA's new Air Transportation Oversight
    System: * To what extent does ATOS address past concerns about
    FAA's aviation safety inspections? * What factors, if any,
    surfaced during the implementation of ATOS that could impede its
    success? * What is FAA doing to address any factors that could
    impede the success of ATOS? To determine to what extent ATOS
    addresses problems identified in the past with FAA's inspection
    program, we reviewed previous reports by GAO, the Department of
    Transportation's Inspector General, and internal FAA reports, such
    as FAA 90 Day Safety Review. In addition, we attended ATOS
    training provided to FAA inspectors and the annual inspection
    planning meeting held by 1 of FAA's 10 certificate management
    teams. We interviewed members of the ATOS work group and program
    office to discuss how the new program was developed and the
    agency's intentions for its implementation. In total, we
    interviewed 68 FAA employees assigned to the airlines ATOS covers,
    including 64 of 540 ATOS inspectors and 4 of the 10 unit
    supervisors. The 64 inspectors included 28 of the 30 principal
    inspectors who oversee ATOS airlines. In the two cases, we
    interviewed the assistant principal inspectors because the
    principal inspectors were not available. We discussed the ATOS
    concept, training, and implementation with each inspector. In
    addition to the 68 FAA employees assigned to oversee airlines
    under ATOS, we interviewed five Flight Standards district office
    managers and supervisors who oversee ATOS field inspectors to gain
    a broader perspective on inspector workload issues beyond those
    involving ATOS inspections. We also reviewed all 10 comprehensive
    surveillance plans developed for the 10 airlines covered by ATOS,
    as well as inspection findings reported through May 11, 1999. To
    determine what factors, if any, surfaced during the implementation
    of ATOS that could impede its success, we interviewed FAA's
    principal inspectors for all 10 airlines covered by ATOS and also
    inspectors (including field inspectors) assigned to the
    certificate management teams. We interviewed staff from Sandia
    National Laboratories who served as consultants on the ATOS
    project and reviewed Sandia's reports on the Page 35
    GAO/RCED-99-183 FAA's New Aviation Inspection System Appendix II
    Objectives, Scope, and Methodology system's implementation. At FAA
    headquarters, we interviewed data management and system officials
    as well as staff assigned to the System Process Audit Group. We
    also reviewed reports prepared by these FAA units on the
    implementation of ATOS. In addition, we discussed ATOS specifics
    with key safety officials at the 10 airlines covered by the
    system. To determine what FAA is doing to address any factors that
    could impede the success of ATOS, we reviewed internal reports on
    ATOS and associated recommendations. We discussed these
    recommendations and what impact FAA's budget shortfall will have
    on ATOS inspection efforts with principal inspectors on the ATOS
    teams and with Flight Standards headquarters officials. We
    conducted our work from September 1998 through June 1999 in
    accordance with generally accepted government auditing standards.
    Page 36                          GAO/RCED-99-183 FAA's New
    Aviation Inspection System Appendix III GAO Contacts and Staff
    Acknowledgments GAO Contacts       John H. Anderson, Jr., (202)
    512-2834 Robert White, (202) 512-5463 Acknowledgments    In
    addition to those named above, Leslie Albin, Bonnie A. Beckett,
    David K. Hooper, Christopher M. Jones, Fran Featherston, Debra
    Prescott, and Stan Stenerson made key contributions to this
    report. Page 37                     GAO/RCED-99-183 FAA's New
    Aviation Inspection System Bibliography Booz-Allen & Hamilton Inc.
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    Transportation. Washington, D.C.: May 21, 1997. White House
    Commission on Aviation Safety and Security. Final Report of the
    White House Commission on Aviation Safety and Security. Feb. 12,
    1997. Page 38                       GAO/RCED-99-183 FAA's New
    Aviation Inspection System Related GAO Products Aviation Safety:
    Weaknesses in Inspection and Enforcement Limit FAA in Identifying
    and Responding to Risks (GAO/RCED-98-6, Feb. 27, 1998). Aviation
    Safety: FAA Oversight of Repair Stations Needs Improvement
    (GAO/RCED-98-21, Oct. 24, 1997). Aviation Safety and Security:
    Challenges to Implementing the Recommendations of the White House
    Commission on Aviation Safety and Security (GAO/T-RCED-97-90, Mar.
    5, 1997). Aviation Safety: New Airlines Illustrate Long-Standing
    Problems in FAA's Inspection Program (GAO/RCED-97-2, Oct. 17,
    1996). Aviation Safety: Targeting and Training of FAA's Safety
    Inspector Workforce (GAO/T-RCED-96-26, Apr. 30, 1996). Aviation
    Safety: Data Problems Threaten FAA Strides on Safety Analysis
    System (GAO/AIMD-95-27, Feb. 8, 1995). FAA Technical Training
    (GAO/RCED-94-296R, Sept. 26, 1994). Aviation Safety: FAA and the
    State Department Can Better Manage Foreign Enforcement Cases
    (GAO/RCED-94-87, Mar. 17, 1994). Aviation Safety: Progress on FAA
    Safety Indicators Program Slow and Challenges Remain (GAO/IMTEC-
    92-57, Aug. 31, 1992). Aviation Safety: FAA Needs to More
    Aggressively Manage Its Inspection Program (GAO/T-RCED-92-25, Feb.
    6, 1992). Aviation Safety: Problems Persist in FAA's Inspection
    Program (GAO/RCED-92-14, Nov. 20, 1991). Aviation Safety:
    Emergency Revocation Orders of Air Carrier Certificates (GAO/RCED-
    92-10, Oct. 17, 1991). Aviation Safety: FAA's Safety Inspection
    Management System Lacks Adequate Oversight (GAO/RCED-90-36, Nov.
    13, 1989). Aviation Training: FAA Aviation Safety Inspectors Are
    Not Receiving Needed Training (GAO/RCED-89-168, Sept. 14, 1989).
    Page 39                       GAO/RCED-99-183 FAA's New Aviation
    Inspection System Related GAO Products Aviation Safety: Needed
    Improvements in FAA's Airline Inspection Program Are Underway
    (GAO/RCED-87-62, May 19, 1987). (348129)    Page 40
    GAO/RCED-99-183 FAA's New Aviation Inspection System Ordering
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