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Aviation Safety: System Safety Approach Needs Further Integration into FAA's Oversight of Airlines

GAO-05-726 Published: Sep 28, 2005. Publicly Released: Oct 26, 2005.
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Highlights

The Federal Aviation Administration (FAA) uses the Air Transportation Oversight System (ATOS), which was developed around the principles of system safety, to oversee seven "legacy airlines" and nine other airlines. In this report, we refer to airlines that are not in ATOS as non-legacy airlines. Two other processes are used to oversee 99 non-legacy passenger airlines, which represent a fast-growing segment of the commercial aviation passenger industry and carried about 200 million passengers in 2004. The National Work Program Guidelines (NPG) establishes a set of inspection activities for non-legacy airlines. The Surveillance and Evaluation Program (SEP) uses principles of system safety to identify additional risk-based inspections for those airlines. GAO's objective was to assess the processes used by FAA to ensure the safety of non-legacy passenger airlines. GAO reviewed the strengths of FAA's inspection oversight for non-legacy passenger airlines and the issues that hinder its effectiveness.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Transportation To improve the effectiveness of the agency's oversight of non-legacy airlines, the Secretary of Transportation should direct the FAA Administrator, to improve its safety oversight of airlines, to develop a continuous evaluative process for its activities under SEP and link SEP to the performance-related goals and measures developed by the agency, track performance towards agency goals, and determine appropriate program changes. The evaluation should include an analysis of inspection findings to identify trends and risks at the national level.
Closed – Not Implemented
FAA decided to transition all air carriers currently under the Surveillance and Evaluation Program (SEP) to the ATOS program by December 31, 2007. Once all air carriers have been moved to ATOS SEP will be discontinued. As a result, FAA decided not to establish an evaluation process for SEP.
Department of Transportation To improve the effectiveness of the agency's oversight of non-legacy airlines, the Secretary of Transportation should direct the FAA Administrator, in order to ensure that all regional and field offices have a complete and timely understanding of FAA's policies relating to the inspection process, to improve communication in areas such as whether and how internal risks identified by inspectors have been resolved.
Closed – Implemented
FAA revised SEP program guidance to require a separate entry in the inspection database to track each internal risk from identification to resolution and closure. FAA also revised the "National Flight Standards Work Program Guidelines" (Order 1800.56F) to provide detailed instructions to regional and field offices concerning the inspection policy and process and data entry, coding, and data quality related to documenting inspections.
Department of Transportation To improve the effectiveness of the agency's oversight of non-legacy airlines, the Secretary of Transportation should direct the FAA Administrator, To improve the effectiveness of the agency's oversight of non-legacy airlines, the Secretary of Transportation should direct the FAA Administrator, in order to ensure that all regional and field offices have a complete and timely understanding of FAA's policies relating to the inspection process, to improve training in areas such as risk management, coding items in the PTRS database, and how and under what circumstances SEP-identified activities can replace NPG-identified activities through retargeting.
Closed – Implemented
FAA revised the "National Flight Standards Work Program Guidelines (Order 1800.56F) to provide detailed instructions to regional and field offices concerning the inspection policy and process and data entry, coding, and data quality related to documenting inspections. The order also provides procedures for retargeting inspections. The SEP training course for inspectors was revised to include these program changes.
Department of Transportation To improve the effectiveness of the agency's oversight of non-legacy airlines, the Secretary of Transportation should direct the FAA Administrator, to better utilize geographic inspectors' support, to improve the geographic inspectors' understanding of the system safety approach and operations of the airlines they inspect. FAA should consider actions such as additional training, additional oversight in particular areas, having airlines' operating manuals available online for review by inspectors, and improving communication between geographic inspectors and principal inspectors on issues related to identifying safety violations.
Closed – Implemented
FAA revised the SEP program (revision 22) to require principal inspectors who originate inspection requirements to provide specific instructions to geographic inspectors who will carry out those inspections. The purpose of the instructions is to ensure correct data entry and coding. The revised order also calls for training geographic inspectors on these changes.

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Topics

AirlinesInspectionProgram evaluationSafety regulationSafety standardsTransportation safetySafetyAviationAircraftAviation safety