This is the accessible text file for GAO report number GAO-02-77 
entitled 'Aviation Safety: FAA and DOD Response to Similar Safety 
Concerns' which was released on December 14, 2002. 

This text file was formatted by the U.S. General Accounting Office 
(GAO) to be accessible to users with visual impairments, as part of a 
longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the 
printed version. The portable document format (PDF) file is an exact 
electronic replica of the printed version. We welcome your feedback. 
Please E-mail your comments regarding the contents or accessibility 
features of this document to Webmaster@gao.gov. 

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

United States General Accounting Office: GAO: 

Report to the Honorable Norman Y. Mineta, Secretary of Transportation, 
and the Honorable Donald H. Rumsfeld, Secretary of Defense: 

January 2002: 

Aviation Safety: 

FAA and DOD Response to Similar Safety Concerns: 

GAO-02-77: 

Contents: 

Letter: 

Results in Brief: 

Background: 

Actions of FAA and the Military Services to Address Similar: 

Aviation Safety Concerns Vary: 

Shortcomings in Existing Processes Used for Sharing Aviation: 

Safety Information: 

Conclusions and Recommendations: 

Agency Comments: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Fixed Wing Military Aircraft and Their Civil Derivatives 
Operated by DOD: 

Appendix III: Key Similarities and Differences in FAA’s and the 
Military Services’ Aviation Safety Oversight Processes: 

Appendix IV: Case Study on Aromatic Polyimide Wire Insulation: 

Appendix V: Case Study on Adoption of Cockpit Safety Equipment: 

Appendix VI Case Study on Flight Operational Quality Assurance (FOQA) 
Programs: 

FAA Continues to Encourage FOQA Programs Among Airlines: 

The U.S. Military Services Are Still in the Early Stages of Developing 
FOQA Programs: 

Appendix VII: Case Study on Communication Delays Between the Air Force 
and Civil Aviation Community: 

Appendix VIII: Case Study on Strandflex Control Cable: 

Appendix IX: Comments from the Under Secretary of Defense: 

Appendix X: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Acknowledgments: 

Tables: 

Table 1: Examples of Mechanisms for Information Exchange: 

Between FAA and the Military Services: 

Table 2: Flight Operational Quality Assurance Programs Timeline: 

Table 3: Status of Military Efforts to Implement FOQA Programs as of 
August 1, 2001: 

Figure: 

Figure 1: Examples of FAA Involvement in Certifying Air Force Aircraft 
as Airworthy: 

Abbreviations: 

AD: Airworthiness Directive: 

AMCOM: Aviation and Missile Command: 

ATSRAC: Aging Transport Systems Rulemaking Advisory Committee: 

AWIGG: Aircraft Wiring and Inert Gas Generator Working Group: 

CPDF: Central Personnel Data File: 

DOD: Department of Defense: 

DODIG: Department of Defense Office of Inspector General: 

DOJ: Department of Justice: 

DOT: Department of Transportation: 

DOTIG: Department of Transportation Office of Inspector General: 

DSB: Defense Science Board: 

EAPAS: Enhanced Airworthiness Program for Airplane Systems: 

EGPWS: Enhanced Ground Proximity Warning System: 

FAA: Federal Aviation Administration: 

FOQA: Flight Operational Quality Assurance: 

FSCAP: Flight Safety Critical Aircraft Parts: 

GAIN: Global Aviation Information Network: 

GAO: General Accounting Office: 

GIDEP: Government-Industry Data Exchange Program: 

GPWS: Ground Proximity Warning System: 

IRT: Independent Review Team: 

JSSC Joint Service Safety Chiefs: 

MOA: Memorandum of Agreement: 

NTSB: National Transportation Safety Board: 

OC-ALC: Oklahoma City Air Logistics Command: 

OPM: Office of Personnel Management: 

OSD: Office of the Secretary of Defense: 

OSHA: Occupational Health and Safety Act: 

SAE: Society of Automotive Engineers: 

SWAMP: Severe Wind And Moisture-Prone: 

TAWS: Terrain Awareness Warning System: 

TCAS: Traffic Alert and Collision Avoidance System: 

TKT: Teflon-Kapton-Teflon: 

UPN: Unapproved Parts Notification: 

[End of section] 

United States General Accounting Office: Washington, DC 20548: 

January 22, 2002: 

The Honorable Norman Y. Mineta: Secretary of Transportation: 

The Honorable Donald H. Rumsfeld: Secretary of Defense: 

Safety of aircraft is a paramount concern in both civilian and 
military aviation because safety deficiencies can cost lives and 
equipment and affect mission accomplishment. The Federal Aviation 
Administration (FAA) and the military services often face common 
safety issues as they oversee the operation of similar aircraft or 
even dissimilar aircraft that use common parts and materials. Our 
preliminary work, however, showed that in some cases FAA and the 
military services have taken different actions to address similar 
aviation safety concerns. We recognize that there could be reasonable 
explanations for FAA and the military services taking different 
approaches in addressing such concerns. 

To shed more light in this area, we used a case study approach 
supplemented by a review of FAA’s and Department of Defense’s (DOD) 
aviation safety oversight processes and related interdepartmental 
communication efforts to (1) examine different responses by FAA and 
DOD/military services to similar aviation safety concerns and (2) 
assess the processes used by FAA and DOD[Footnote 1] to communicate 
information about similar aviation safety concerns. To select case 
studies for this review, we identified aviation safety problems shared 
by FAA and the military services, selected examples in which FAA and 
DOD/military services had taken a different approach to solving a 
similar aviation safety problem or had a need to be informed about 
such a problem, and discussed potential case studies with FAA and the 
military services. 

To examine different responses by FAA and the military services, we 
used two cases in which FAA and the military services took different 
actions or similar actions at a different pace when faced with common 
aviation safety problems. These cases pertain to aircraft wiring 
insulation and cockpit equipment designed to improve safety and 
support quality assurance programs for flight operations. In addition, 
we selected two case studies to assess the exchange of aviation safety 
information between FAA and the military services. These include a 
specific brand of wire rope used in the construction of aircraft 
control cables and problems of fuel pump performance and overheating 
in fuel tanks in the E-4B, a military variant of the Boeing 747. 

We interviewed and obtained relevant documentation from federal 
officials and others familiar with FAA’s and the military services’ 
aviation safety oversight systems. We asked these officials about the 
extent to which these entities share information on aviation safety 
issues of common interest. This review focuses primarily on issues 
involving similar civilian and military aircraft equipment, parts, and 
material issues related to aviation safety, rather than issues 
concerning the operation of aircraft. It does not address aviation 
security issues, such as hijacking, sabotage, or terrorist activities. 
See appendix I for additional details on our scope and methodology. 

Results in Brief: 

For one of the two cases that we reviewed where FAA and the military 
services reacted differently to similar aviation safety concerns, the 
differences reflect the agency’s and services’ different missions and 
operational environments. In the second case, the military services 
have reacted more slowly than civil aviation due to resource tradeoffs 
between aviation safety and other mission-readiness issues. 

In the first case, when the Navy identified potential safety problems 
concerning the use of a specific type of wire insulation on aircraft 
in a moist operating environment, each of the military services and 
FAA assessed the insulation’s safety in various environments and 
responded differently. For example, FAA issued advisory notifications 
to the civil aviation community to help identify and minimize the 
potential risks associated with the use of this insulation; the Navy 
promptly removed it from areas prone to infiltration by moisture; 
while the Coast Guard lagged behind the Navy in removing this 
insulation, it later took the most extensive action by systematically 
removing it from an entire fleet of helicopters after it experienced 
in-flight fires. These different responses are largely a function of 
these entities’ respective missions and operational environments. In 
the second case, the military services have lagged as much as two 
decades behind FAA in requiring the installation of collision 
avoidance technologies aboard passenger-carrying aircraft. Despite the 
attention focused on the need to equip such aircraft with safety 
alerting systems[Footnote 2] after the 1996 crash involving the death 
of then-Secretary of Commerce Ronald Brown, timelines for equipping 
such aircraft extend out as far as 2009. The installation of these 
devices must compete with other demands to ensure mission readiness. 
Some DOD officials expressed concern that aviation safety does not 
receive adequate visibility. The office responsible for aviation 
safety currently occupies a relatively low organizational position 
within the Office of the Secretary of Defense (OSD). As a result of 
downsizing by OSD several years ago, five safety positions, which 
shared responsibility for aviation safety issues, were abolished and a 
single staff member hired. This staff member’s responsibilities 
include aviation safety and a number of other responsibilities, 
including compliance with the Occupational Safety and Health Act of 
1970 (OSHA), as amended; fire and emergency services; range and 
weapons safety; and traffic transportation. 

For the two cases where we evaluated the communication processes 
between FAA and the military services, our review showed that existing 
formal networks of communication have not always been sufficient to 
ensure the comprehensive exchange of all critical aviation safety 
information. Specifically, we found (1) a lack of a common definition 
of what constitutes an aviation safety hazard of mutual concern and 
(2) gaps in the formal communication processes, which caused delays in 
bringing critical safety information to the attention of key 
officials. In addition, the informal information exchange is currently 
sustained largely by personal rather than formal agency/service 
relationships, and is therefore vulnerable to the retirement of key 
aviation safety personnel and senior leaders. For these reasons, we 
are making a recommendation to improve the formal processes used by 
FAA and the military services to exchange aviation safety information 
of mutual interest. 

Background: 

FAA, an agency located within DOT is responsible for regulating and 
promoting the safety of civil aviation. The Coast Guard is part of 
DOT, except when operating as a service in the Navy during time of 
declared war or when the president otherwise directs;[Footnote 3] 
however, the Coast Guard follows its own rules for aviation safety 
oversight, which parallel the structure and operations followed by the 
military services rather than those of FAA. 

In contrast to FAA, DOD is both an operator and a regulator of 
aviation for the military services. Its primary mission is national 
defense, one component of which is aviation safety. OSD maintains 
oversight of the military services’ aircraft aviation safety processes 
but has delegated to the heads of the military departments the 
responsibility for aviation safety programs. For example, the secretary’
s office is responsible for issuing policies and directives pertaining 
to aviation safety that the military services must implement as they 
address their respective missions. Within OSD, aviation safety is the 
responsibility of the Office of Safety and Occupational Health, under 
the Office of the Deputy Undersecretary for Installations and 
Environment, which, among other responsibilities, includes traffic 
safety, OSHA compliance, and toxic hazards. 

There are three key similarities and three differences between the 
aviation safety oversight systems used by FAA and the military 
services. They share common internal processes for disseminating 
safety information; managing aviation safety risks (e.g., they each 
use variations of a five-step process); and certifying that aircraft 
meet civil aviation standards (FAA provides the certification services 
to the military at no cost). They differ, however, in their processes 
to certify that aircraft meet their unique safety standards and to 
investigate aircraft accidents, as well as in the timetables and 
thresholds for acting on potential and identified aviation safety 
problems. For example, the command and control structure of the 
military services allows immediate action to be ordered, such as the 
grounding of a fleet of aircraft, after weighing the impact on their 
respective missions. In contrast, although FAA can and has taken 
similar immediate action when necessary, the agency often has more to 
consider before taking equivalent action, such as consulting with 
airlines and other stakeholders, given the potential ramifications for 
the nation’s economy and the public interest. See appendix III for 
additional information on key similarities and differences between 
FAA’s and the military services’ aviation safety oversight systems. 

Flight operations for military aircraft can differ from those of civil 
aircraft in their nature and severity (e.g., turns may be made at 
steeper angles and aircraft may ascend and descend at higher speeds). 
Although standard parts may be common, the stress on the parts and 
materials in the environment in which they are used may be quite 
different. As such, the Coast Guard and the Navy frequently fly 
aircraft in close proximity to water,[Footnote 4] a condition that 
poses special maintenance concerns, while most commercial civil 
aircraft are not typically exposed to similar conditions. In addition, 
according to some military officials, military aircraft can be 
operated closer to the “edge of the envelope”—-maximum recommended 
speeds, weight, and other parameters—-than commercial civil aircraft. 
Such conditions can also accelerate wear of aircraft. 

FAA and the military services oversee the safety of some similar 
aircraft types,[Footnote 5] such as the Boeing 737 and executive jet 
aircraft. See appendix II for a more detailed listing. Even dissimilar 
civil and military aircraft often have common parts and materials such 
as bolts, fasteners, and wiring. Civil and military aircraft are 
manufactured, modified, and repaired using standard type parts, 
although their application may differ. Interdepartmental communication 
about aviation safety issues of mutual interest is important to (1) 
ensure timely correction of structural, mechanical, or material 
weaknesses on aircraft that could lead to safety problems (e.g., loss 
of lives and aircraft) and (2) make effective use of federal dollars 
by sharing lessons learned about specific problems. 

Actions of FAA and the Military Services to Address Similar Aviation 
Safety Concerns Vary: 

Similar aviation safety concerns do not necessarily lead FAA and the 
military services to take the same actions to mitigate or eliminate 
them or to act at the same pace. Different actions taken by these 
entities based on assessments of safety risk can in some cases be 
appropriate and reflect mission differences or, in other cases, may 
not seem warranted. The examples below, describing the potential 
safety concerns associated with the choice of electrical wire 
insulation and the pace of equipping aircraft with warning devices to 
alert pilots to impending collisions, illustrates this point. 

Assessments of Similar Aviation Safety Risks by FAA and the Military 
Services Can Vary: 

Given different operating environments, the same safety risk can vary 
in probability and/or severity. For example, one of the military 
services could determine that, based on its mission requirements and a 
unique and harsh operating environment, an aviation safety hazard 
poses an extremely high risk because it is likely to occur frequently 
and have a critical or catastrophic impact. Conversely, FAA might 
determine that, based on the standard operating environment for civil 
aviation, the hazard poses a low safety risk because it is unlikely to 
occur, even if its severity is deemed critical. Given the 
prohibitively high cost of eliminating all potential aviation safety 
hazards, officials responsible for aviation safety must often accept 
some level of residual risk. FAA and military service officials 
acknowledged that some of the components used in preparing such safety 
risk estimates are subjective, but said they rely to the extent 
practical on technical experts to inform the decision-making process. 

FAA and the Military Services Took Different Actions to Address 
Potential Safety Concerns Posed by a Type of Wire Insulation: 

When faced with a similar potential safety concern posed by the use of 
a specific type of wire insulation known as aromatic polyimide, FAA 
and each of the military services used common research findings, 
evidence collected from flight operations, and mission priorities to 
independently assess the safety risk of continued use of this wire 
insulation. Each arrived at different decisions about the level of 
hazard it posed and the actions warranted based largely upon mission 
differences and specific design requirements. Aviation safety 
officials involved in these risk assessments provided some 
explanations for the differing results. 

* Environment: One of the main considerations used to assess its 
safety risk was the operating environment of the aircraft. For 
example, FAA also considered that naval aircraft routinely operate in 
more harsh environments than commercial aircraft-–on aircraft carriers 
where they are constantly exposed to moisture. 

* Ballistic Testing: To explain differences between FAA’s decision and 
the Navy’s decision, some officials pointed out that the genesis of 
the Navy’s concerns grew out of ballistic testing–-a survivability 
issue that was not a concern for FAA and commercial operators. For 
example, in 1986, Navy tests found that bullets fired into an aircraft 
could sever wires, cause arc tracking events, and trip circuit 
breakers. 

* Aircraft Design Dictates Wire Installation Practices: According to 
FAA and military safety officials, another consideration that guided 
FAA to a different result from the Navy is that transport passenger 
aircraft have much more room to run wires than fighter aircraft. As a 
result, wires require much less bending that can potentially cause 
their insulation to degrade. 

The Navy took the lead in identifying and examining potential problems 
associated with the use of this wire insulation type and in mitigating 
hazards. In the mid-1980s, when the Navy began experiencing problems 
with this wire insulation, it enlisted the support of experts from 
other military services and FAA to further characterize the problems 
and identify possible solutions. Researchers determined that prolonged 
exposure of this type of wire insulation to moisture could cause it to 
deteriorate and that it was susceptible to arc tracking. Arc tracking 
can occur when two cracks in the insulation are close enough together 
to allow the current to form a conductive path between them at 
temperatures that can cause the insulation to char and carbonize. This 
carbonization can turn the insulation into an electrical conductor, 
and, eventually, can trip a circuit breaker. When a pilot presses the 
switch to reset a tripped circuit breaker, an entire wire bundle can 
be disabled and potentially compromise the safety of an aircraft’s 
entire electrical system. 

Ultimately, the Navy and the Coast Guard took the most active measures 
to address potential problems with aromatic polyimide, which some 
experts attribute to these entities’ unique aircraft operations near 
water. In December 1985, the Navy decided that aromatic polyimide 
would no longer be its wiring insulator of choice and subsequently 
removed it selectively from parts of aircraft where it was most 
problematic (e.g., fore and aft flaps, wheel wells, and around 
unsecured seals that could leak). The Coast Guard lagged behind the 
Navy in taking action to address problems with this wire insulation; 
however, it took the most extensive action by stripping it from its 
largest fleet of helicopters as a precautionary measure after 
occurrences of in-flight fires and cockpit smoke and fumes between 
1993 and 1996. While no aircraft were destroyed, these incidents led 
to poor visibility in the cockpit and, in some cases, the loss of all 
electrically powered flight instruments. A senior Coast Guard safety 
official said that the Coast Guard completed removal of this wire 
insulation from its entire fleet of H-65 helicopters in September 
2001. In contrast, the Army did not experience similar safety 
problems. While it independently confirmed the Navy’s findings in 
1986, the Army concluded that it did not have the same problems with 
aromatic polyimide. The Army did have durability concerns, however; it 
found the degree to which aromatic polyimide chafes in Apache and 
Blackhawk helicopters is unacceptable over time and decided to remove 
it gradually as it refurbished older aircraft. 

In response to the Navy’s finding of potential hazards with the use of 
aromatic polyimide, FAA conducted independent research, tracked 
related research and operational data from industry and the military 
services, and decided that mandating the removal of this wire 
insulation from commercial aircraft was not warranted. However, FAA 
did issue three Advisory Circulars related to the use of this wire 
insulation type, in 1987, 1991, and 1998, to provide policy guidance 
to help prevent electrical problems and potential fires and to 
describe acceptable practices for aircraft inspection and repair, 
including wire installation. 

Recognizing the need for sustained attention to aircraft wiring 
issues, FAA has ongoing efforts to assess the health of wire in aging 
aircraft through its Aging Transport Systems Rulemaking Advisory 
Committee (ATSRAC). To date, working groups under ATSRAC have 
conducted visual (nonintrusive) and extensive physical (intrusive) 
inspections of wiring on aging aircraft. However, according to 
National Transportation Safety Board (NTSB) officials, it is too soon 
to determine how well the agency is doing in its assessment. These 
officials pointed out that ATSRAC has a seven-step objective of 
reviewing wiring in aging aircraft, and its recent intrusive 
inspection is only one step in the process. 

In August 2001, FAA announced a new initiative, the Enhanced 
Airworthiness Program for Airplane Systems (EAPAS), a cooperative 
effort with industry that is intended to (1) enhance the safety of 
aircraft wiring from design and installation through retirement, (2) 
increase awareness of wiring degradation, (3) implement better 
procedures for wiring maintenance and design, and (4) ensure that the 
aviation community is informed. In the same month, the Transportation 
Safety Board of Canada announced that, as a result of its 
investigation of the crash of Swissair Flight 111, it (1) concluded 
wire failure can play an active role in fire initiation and (2) 
recommended a more stringent certification test regime. FAA officials 
told us that the agency has not yet responded to the conclusions and 
recommendations of the Transportation Safety Board of Canada. See 
appendix IV for a more detailed summary of actions taken by FAA and 
the military services to address concerns about aromatic polyimide. 

The Military Services Acted More Slowly Than FAA to Require 
Installation of Cockpit Safety Equipment to Reduce Crashes Into 
Terrain, and Midair Collisions, and to Monitor Other Potential Safety 
Problems: 

The military services have lagged as much as two decades behind FAA in 
requiring the installation of cockpit technology in passenger-carrying 
aircraft to alert pilots to impending collisions. In 1974, FAA 
responded to NTSB recommendations by requiring operators of large 
commercial aircraft to equip the cockpits of these aircraft with 
Ground Proximity Warning Systems (GPWS) to provide pilots with 
warnings of potential collisions with terrain (land or water). FAA 
extended this GPWS requirement to operators of smaller airplanes and 
turbojet-powered airplanes with 10 or more passenger seats in 1978. 
However, the military services did not plan to systematically install 
GPWS in passenger- and troop-carrying aircraft until after the 1996 
crash of a military aircraft carrying then-Secretary of Commerce 
Ronald Brown and 34 others. Subsequently, a senior military safety 
official reported that the crash would almost certainly have been 
prevented had the aircraft been equipped with enhanced GPWS. The 
enhanced version of GPWS provides flight crews with earlier auditory 
and visual warnings of terrain, forward-looking capability, and more 
time to make smoother and more gradual corrective actions. 

FAA also took action in 1989—based on a 1987 congressional mandate—to 
reduce the number of midair collisions by requiring certain civil 
aircraft to be equipped with Traffic Alert and Collision Avoidance 
Systems (TCAS). These systems help pilots to avoid midair collisions 
by providing them with messages of an impending collision with another 
aircraft. According to FAA, since the advanced version of TCAS (TCAS 
II) was introduced in 1993, civil midair collisions in the United 
States have declined by 80 percent. While acknowledging the benefits 
of TCAS, the military services have equipped their passenger-carrying 
aircraft with TCAS at a slower pace. For example, in August 1996, the 
Air Force published its Navigation and Safety Equipment Master Plan 
for DOD Passenger-Carrying Aircraft, which established guidance for 
equipping passenger-and troop-carrying aircraft, including GPWS and 
TCAS in two implementation phases. Phase 1 requires installation by 
2001 of all equipment used to transport senior military leaders, and 
Phase 2 requires installation of this equipment on remaining 
passenger- and troop-carrying aircraft by 2005. As of January 2001, 
the Air Force had equipped 49 percent of its passenger-and troop-
carrying fleet with these technologies, but in some cases the 
timelines for equipping these aircraft with GPWS and TCAS extend out 
as far as 2009. As of July 2001, the Navy had equipped less than 20 
percent of its passenger-carrying fleet with GPWS[Footnote 6] and 
TCAS. According to an official from the Department of the Army, as of 
August 2001, units had equipped 38 of the Army’s 294 fixed wing 
aircraft with enhanced GPWS and 90 of these same aircraft with TCAS. 
The remaining fixed wing aircraft must be equipped with these 
technologies by fiscal year 2006. The Army has not equipped any of its 
rotary wing aircraft (i.e., helicopters) with GPWS or TCAS and 
currently has no plans to do so. In contrast, by 1998, the Coast Guard 
had installed TCAS in all of its fixed wing and rotary wing aircraft. 
In addition, according to a senior Coast Guard safety official, it has 
equipped its C-130 fleet with GPWS, and the majority of the remainder 
of its fleet is helicopters; however, due to the erratic nature of 
rotorcraft flight as compared to fixed wing aircraft flight,[Footnote 
7] making use of GPWS on helicopters is much more difficult and the 
technology development lags behind that for fixed wing aircraft. This 
official stressed that as such there is no FAA mandate that civil 
helicopters be equipped with GPWS or its enhanced version. See 
appendix V for more details on GPWS and TCAS. 

In addition, some major U.S. air carriers, in coordination with FAA, 
have generally acted sooner than the military services to install 
passenger-carrying aircraft with flight data recorders and to 
establish programs that collect and analyze aircraft data from routine 
passenger flights to detect potential safety, training, and 
maintenance problems. These programs are commonly referred to as 
Flight Operational Quality Assurance (FOQA) programs. In July 1995, as 
part of FAA’s strategy to achieve significant reductions in aviation 
accident rates, the agency initiated a 3-year, $5.5 million FOQA 
Demonstration Project to promote the voluntary implementation of FOQA 
programs by U.S. airlines. In response, several major carriers have 
initiated FOQA programs. 

In October 1999, the safety chiefs for each of the military services 
agreed that FOQA had value and endorsed projects and research by all 
services. A Memorandum of Agreement signed by the services’ safety 
chiefs in August 2000 followed this. Efforts by the military services 
to initiate FOQA programs are in the very early stages, with the Air 
Force taking the lead through a demonstration project using the C-17 
aircraft. The Air Force selected a software contractor for its FOQA 
program in June 2001 and has since begun analyzing data it has 
collected since 1994 from nearly 11,000 flights. See appendix VI for 
additional information. 

Some officials with OSD told us that because of the relatively low 
organizational position of aviation safety within DOD this issue does 
not receive the visibility that is warranted. Aviation safety is 
located within the office of the Deputy Undersecretary of Defense for 
Installations and Environment within the Office of Safety and 
Occupational Health and is one of 26 competing oversight 
responsibilities of this office, which includes OSHA compliance, 
traffic safety, and toxic hazards. Currently there is no aviation 
safety manager/officer for OSD. Several years ago, five safety 
positions were abolished as part of an OSD downsizing effort and a 
single staff member was hired to cover aviation safety and a multitude 
of other responsibilities including OSHA compliance, fire and 
emergency services, and range, weapons, traffic, and transportation 
safety. 

Shortcomings in Existing Processes Used for Sharing Aviation Safety 
Information: 

While FAA and the military services have numerous mechanisms in place 
to exchange aviation safety information, we found (1) a lack of a 
common definition of what constitutes aviation safety information of 
mutual concern and (2) gaps in the formal processes currently used to 
exchange aviation safety information. These gaps are illustrated by 
two cases where existing formal networks of communication were not 
sufficient to ensure prompt and comprehensive exchanges of aviation 
safety information and follow-up actions responding to identified 
problems. The heavy reliance by FAA and the military services on 
informal communication networks to exchange aviation safety 
information is vulnerable to an expected wave of retirements. 

Numerous Mechanisms Are Used to Exchange Aviation Safety Information: 

FAA and the military services have established numerous mechanisms for 
exchanging aviation safety information, including informal networks 
among aviation safety personnel, use of Web sites, meetings among 
senior leaders and attending each others’ meetings and conferences. 

* Informal Networks: Technical staff at FAA and the military services 
(e.g., aerospace engineers) have developed an informal network that 
has facilitated the exchange of information about similar aviation 
safety issues. These officials reported that they have set some joint 
research priorities, routinely share research findings and information 
gleaned from accident investigations, and conduct joint aircraft 
testing. According to FAA and DOD officials in the research and 
development arena, the exchange of information on aviation safety is 
excellent, routine, and reliable. This communication has provided them 
with a means of alerting colleagues in other agencies and services 
about key issues or problems. These officials cautioned that the 
effectiveness of this type of communication is attributable to its 
informal nature and that formalizing these processes would hinder 
rather than help their work. 

For example, officials from the FAA Technical Center, military 
services, and National Aeronautics and Space Administration meet at 
least semiannually to set common research priorities, share the 
research workload, and, in some cases, this has led to formal cost-
sharing for research and development on aging aircraft systems. This 
allows each of these entities to leverage the federal dollars spent on 
common aviation safety problems. While formal initiatives are in place 
regarding shared federal agency research on aviation safety and aging 
aircraft systems, these meetings and research sharing activities 
evolved from informal communication. One outgrowth of this informal 
communication has been the sharing of costs by the Navy and FAA to 
develop a new “smart” circuit breaker that can detect and interrupt 
electrical surges associated with arc tracking and minimize the damage 
to wires. This technology should help to prevent much of the damage 
that currently occurs and goes undetected. In addition, miniaturizing 
this new circuit breaker is a priority for both the military services 
and FAA, for example, for use on military aircraft that have limited 
space and aboard civil aircraft to increase the number of functions 
for which the circuit breaker can be used. Such sharing of aviation 
safety research priorities helps to ensure the timely exchange of 
lessons learned among FAA and the military services (e.g., about how a 
specific aviation safety hazard was addressed) and the effective use 
of federal funds dedicated to aviation safety oversight. 

* Use of Web Sites: Exchanges of information between FAA and the 
military services also take place when information of mutual interest 
is posted to their respective Web sites. For example, the Air Force 
currently maintains the most exhaustive database on the hazards of 
aircraft striking birds. It is used extensively by the other military 
services and FAA to identify, among other things, altitudes and 
migratory flight paths commonly used by bird species. It also serves 
as a mechanism to alert pilots and aviation safety officials to avoid 
certain flight levels and airspace, when practical. In addition, the 
Army’s Aviation and Missile Command (AMCOM) makes use of its Web site 
to post critical aviation safety messages (stripped of privileged and 
classified information) pertaining to its helicopter fleet, thus 
allowing the other military services and FAA to monitor potential 
safety hazards. Similarly, FAA’s Web site provides access to many of 
the agency’s safety databases as well as airworthiness directives, 
which are generally posted on a real-time basis. 

* Communication Among FAA and DOD Senior Leaders: Senior leaders at 
FAA and DOD reported that they generally keep informed about aviation 
safety issues common to both organizations through networking, such as 
telephone and working lunches. According to a senior DOD official, 
this networking has been a very effective way to exchange information 
with FAA, as senior leaders from both entities have become well 
acquainted and use these personal relationships to keep lines of 
communication open and active. A senior FAA safety official also 
characterized informal working relations between FAA and DOD as 
effective. 

* Other Mechanisms for Information Exchange: FAA and the military 
services use a range of other mechanisms for exchanging information 
about aviation safety. These include attending each other’s meetings 
and professional conferences, exchanging practices for assessing 
safety risks, and developing technical standards. Table 1 provides 
further examples of ways that FAA and the military services 
communicate. 

Table 1: Examples of Mechanisms for Information Exchange Between FAA 
and the Military Services: 

Communication mechanism: Commercial Aviation Safety Team; 
Information exchange activities: This team was created to identify, 
analyze, and prioritize aviation safety hazards and appropriate 
actions to mitigate these problems. 

Communication mechanism: Government-Industry Data Exchange Program 
(GIDEP); 
Information exchange activities: A cooperative activity between 
industry and government managed by the Navy through an agreement of 
the Joint Logistics Commanders. Provides a medium to exchange 
technical information about the quality and reliability of parts, 
components, equipment, and services used by the federal government. It 
is not aviation-specific. 

Communication mechanism: Aging Transport Systems Rulemaking Advisory 
Committee (ATSRAC); 
Information exchange activities: Currently, FAA, industry, DOD, and 
other stakeholders are conducting research on wiring systems in aging 
aircraft. 

Communication mechanism: Military Flight Operational Quality Assurance 
(FOQA) conferences; 
Information exchange activities: Two such conferences have been held 
to share information among the airlines and the military services on 
the FOQA concept and its implementation. 

Communication mechanism: Safety Risk Management Conferences; 
Information exchange activities: FAA and NASA sponsor an annual 
conference on Risk Analysis and Safety Performance Measurement. These 
conferences have been attended by the military services. 

Communication mechanism: Society of Automotive Engineers (SAE); 
Information exchange activities: A subset of this group is developing 
specifications for the new “smart”circuit breaker. Two engineers, one 
from the Naval Air Systems Command and the other from FAA’s Technical 
Center, are leading this effort. 

Communication mechanism: Global Aviation Information Network (GAIN); 
Information exchange activities: This network is still in the early 
stages of development. Ultimately, it will provide a means to 
voluntarily exchange information among users worldwide, including the 
military, to improve aviation safety. 

Communication mechanism: Meetings Among Senior Leaders Senior; 
Information exchange activities: DOD and FAA leaders invite their 
counterparts to attend aviation safety meetings (e.g., FAA is a 
permanent guest of the Joint Service Safety Chiefs and a participant 
in the Joint Aeronautical Commanders Group). 

Communication mechanism: Aviation Rulemaking Advisory Committee; 
Information exchange activities: A formal FAA advisory committee 
established in 1991. It is comprised of representatives from the 
aviation community and provides the agency with industry input during 
FAA’s rulemaking activities. DOD is not a standing member, but 
participates on occasion. 

Communication mechanism: Memorandums of Understanding/Memorandums of 
Agreement; 
Information exchange activities: These memorandums are used to clarify 
how DOT/FAA and DOD work together (e.g., the sharing of civil and 
military airspace and information on air carriers’ performance). 

Communication mechanism: DOD liaisons at FAA; 
Information exchange activities: DOD liaisons working at FAA focus 
primarily on air traffic control issues; however, they relay requests 
for safety information to appropriate officials when requested. 

Communication mechanism: Risk Management Information System (RMIS); 
Information exchange activities: Software designed by the Army to 
collect and share information internally, with the other services, and 
agencies on a near real-time basis. 

Communication mechanism: Flight Safety Critical Aircraft Parts (FSCAP); 
Information exchange activities: Project A joint DOD and FAA effort to 
identify, dispose of, and control military surplus FSCAP available for 
civil purchase. 

Communication mechanism: Interagency agreement regarding information 
exchange about problem parts and materials; 
Information exchange activities: Agreement signed in 1997 by FAA, DOT 
Office of Inspector General, Federal Bureau of Investigation, U.S. 
Customs and Defense Criminal Investigative Service regarding the 
exchange of information and technical support for suspect aviation 
parts. 

Source: FAA and the military services. 

[End of table] 

FAA and the Military Services Have Not Developed a Common Definition 
of Aviation Safety Information of Mutual Concern: 

FAA and the military services have not developed a common definition 
of aviation safety information of mutual interest, and, in particular, 
what information should be considered critical. As a result, the 
information exchanged is based on individual judgment rather than on 
the systematic identification and exchange of information. Various 
definitions of critical aviation safety information have been 
established, such as that used by DOD for procuring aircraft materials 
and parts.[Footnote 8] Policies have also been established to 
facilitate the exchange of aviation safety information of common 
interest between FAA and the military services; however, the basis for 
such communication is unclear and left up to individuals’ 
interpretation. A fundamental step in developing this definition is 
establishing the universe of civil aircraft and their military 
aircraft derivatives, something senior FAA officials told us the 
agency has not been able to do.[Footnote 9] See appendix II. Such a 
definition is needed to help ensure that all aviation safety 
information of common interest, especially that deemed critical, is 
promptly identified and reported to responsible officials. 

Gaps Exist in the Processes Used By FAA and the Military Services to 
Exchange Aviation Safety Information of Mutual Concern: 

While FAA and the military services routinely exchange some aviation 
safety information of mutual concern, there are gaps in the processes 
used by both entities, including the sharing of how specific aviation 
safety concerns were addressed. For example, FAA sends its emergency 
Airworthiness Directives (AD)—-a type of critical safety information—-
to only five U.S. military addressees, as requested by the military 
services, with the same level of urgency that they are sent to owners 
and operators of civil aircraft.[Footnote 10][Footnote 11] These 
military addressees represent only a small subset of the military 
entities that could be affected.[Footnote 12] FAA officials told us 
that it has added specific military users to its list of addressees, 
but has had limited success maintaining accurate and current contact 
information. 

Despite FAA’s general practice of posting emergency ADs to its Web 
site in real time, the site contains a disclaimer that the agency 
cannot guarantee the accuracy of the information it posts—for 
instance, the information posted could be vulnerable to tampering from 
computer viruses[Footnote 13] or computer hackers. As a result, FAA 
requires that all emergency ADs be sent immediately via telegram or 
fax to owners and operators of civil aircraft and that their receipt 
be documented. While FAA is not required to send these directives to 
the military services,[Footnote 14] it appears prudent to do so when 
it involves information of mutual interest, given their common 
responsibilities for aviation safety oversight. 

Similarly, the military services provide FAA with some of their 
aviation safety information, but generally not with the same level of 
urgency with which they distribute it to the other services. For 
example, the Army’s Aviation and Missile Command strips privileged and 
classified information from its critical safety messages pertaining to 
its helicopter fleet, sends them all to the other military services 
and FAA, and posts them to its Web site. In contrast, the Navy uses 
its judgment to send some of its aviation safety messages to FAA, 
while the Air Force’s, Coast Guard’s, and Army’s Safety Centers 
generally provide aviation safety information to FAA only upon request. 

The formal processes used by FAA and the military services to exchange 
aviation safety information of mutual concern, including information 
critical to flight safety, have not always been sufficient to ensure 
the comprehensive exchange of such information. While informal 
communication networks have helped to facilitate the exchange of 
aviation safety information, these exchanges are not required and 
systematic, and do not provide assurances that such information is 
exchanged in a timely manner. The automatic exchange of critical 
safety information is important to the safe operation of both civil 
and military aviation to help ensure that entities that could be 
affected receive notification promptly to provide them with as much 
time as possible to mitigate or eliminate a given hazard and avoid 
potential loss of lives and aircraft. 

Two Cases Illustrate How FAA and the Military Services Do Not Always 
Exchange Critical Aviation Safety Information on a Systematic and 
Timely Basis: 

The importance of effective and timely information sharing between 
civil and military aviation entities on aviation safety issues was 
highlighted during the investigation of the 1996 crash of TWA Flight 
800. It was not discovered until 1999 that the Air Force had 
contracted with Boeing in the late 1970s to study problems it 
experienced with fuel pumps and overheating in the center fuel tanks 
in the E-4B aircraft—-the military variant of the Boeing 747. The Air 
Force was concerned about the E-4B engines continuing to run 
satisfactorily if a main (wing) fuel tank pump malfunctioned. There 
was also a concern over running of the air conditioning packs under 
the center wing fuel tank for extended periods of time (e.g., for 48 
hours when operated in an alert mode). In this mode, the center wing 
tank was full of fuel, and heated up slowly to a high temperature. 
Boeing found that, under certain circumstances, air conditioning wires 
running through the fuel tank could create a potential safety problem, 
but determined that the engine would continue to operate successfully 
provided certain operating restrictions were implemented. While the 
central focus of the Air Force’s concerns and Boeing’s analysis was 
fuel pump performance, not fuel vapor flammability, NTSB officials 
said that the information contained in this report would have assisted 
them with their investigations of fuel tank overheating. 

A senior NTSB official told us that it is not likely that earlier 
sharing of the report’s findings would have prevented the crash of TWA 
Flight 800. However, had NTSB received the study in 1996 following the 
crash, valuable time and resources in conducting its investigation 
could have been saved. In August 2000, NTSB released its report on the 
TWA Flight 800 accident, which included the following statement 
regarding the report Boeing prepared for the Air Force on fuel tank 
overheating in the E4-B: 

The Safety Board recognizes that the military variant of the 747 is 
not directly comparable to the civilian 747 and that the focus of that 
study was fuel pump functionality, not flammability. Nonetheless, it 
is unfortunate that potentially relevant information about 747 center 
wing [fuel] tank overheating and corrective measures were not provided 
to the FAA or to 747 operators earlier. 

In addition, according to the NTSB chairman and director of aviation 
safety, the report might have been helpful to NTSB in its 
investigation of a Boeing 737 aircraft explosion in 1990 at Manila 
Airport in the Philippines. The explosion occurred in the aircraft’s 
center fuel tank. Both the chairman and the director said that it is 
possible that if they had received this study in 1990, safety 
recommendations made as a result of the TWA Flight 800 investigation 
concerning fuel tanks might have been issued sooner. See appendix VII 
for more information about this case. 

According to DOD, the wire rope produced by Strandflex and used to 
construct aircraft control cables is critical to the safe operation of 
flight control systems, such as aircraft rudders, steering, and 
brakes, on affected aircraft, while FAA officials contend that it is 
not always critical to flight safety. According to these officials, 
this is because civil federal aviation regulations require that 
aircraft control systems incorporate redundancies, meaning that 
failure of control cables would not cause loss of the airplane. 
[Footnote 15] 

The wire rope produced by Strandflex became the subject of a Defense 
Criminal Investigative Service investigation when the military 
discovered that it was not being tested to ensure that it met military 
specifications and an independent DOD test demonstrated that it did 
not meet strength requirements. The DOD Office of Inspector General 
(DODIG) notified the military services and FAA’s Office of Civil 
Aviation Security at the same time of potential problems with 
Strandflex.[Footnote 16] The military services quickly addressed this 
situation by alerting responsible officials of the need to assess and 
address safety concerns associated with the use of this product. In 
contrast, as confirmed by a DOT Office of Inspector General’s (DOTIG) 
investigation, FAA did not issue an Unapproved Parts Notification 
(UPN) to notify civil aviation community officials of potential 
problems with the Strandflex product for a year—a problem the 
inspector general attributed to weaknesses in the agency’s overall 
processing of UPNs.[Footnote 17] FAA officials acknowledged that there 
was a delay in issuing the UPN, but said that they had assessed the 
situation and concluded that it did not require urgent action. 

Among other things, FAA did not inform the DOD Office of Inspector 
General (DODIG) that the appropriate recipient of its messages 
pertaining to suspect unapproved parts is its Suspect Unapproved Parts 
Program Office until the DOTIG initiated its investigation. While the 
DOTIG did not identify this as a key contributor to the year-long 
delay by FAA, even simple communication breakdowns such as not 
informing DOD of the appropriate addressee could lead to potential 
safety hazards being overlooked or going unreported to responsible 
officials. 

Recognizing the fundamental nature of this shortcoming, the manager of 
FAA’s Suspect Unapproved Parts Program Office cited a change in the 
FAA addressee as the first among numerous corrective actions that had 
been taken to address weaknesses identified by the DOTIG in the agency’
s processing of UPNs. Specifically, this manager advised the DOTIG 
general that the FAA copy of DOD alert messages would be sent directly 
to the Suspect Unapproved Parts Program Office rather than going 
through the Office of Civil Aviation Security. FAA and DOD officials 
told us that, while the Office of Civil Aviation Security remains the 
addressee on the official DOD notification letter to FAA, a facsimile 
copy is now sent directly to the Suspect Unapproved Parts Program 
Office. See appendix VIII for additional information on this case. 

Informal Channels of Communication Might Weaken As Key Personnel 
Retire: 

Some key individuals that have made informal communication on similar 
aviation safety issues effective between FAA and the military services 
have retired or can be expected to retire over the next several years. 
This makes succession planning an important part of aviation safety 
oversight for both departments. 

Expected retirements among senior leaders over the next several years, 
along with recent and expected retirements among aviation safety 
personnel and senior leaders, may diminish the effectiveness of 
informal networks and make formal agency-based communication 
mechanisms even more important to the exchange of safety information 
between these entities. This is especially true, given that informal 
networks are sustained primarily by personal rather than agency-based 
relationships. The anticipated departure of these employees makes 
human capital planning an issue warranting management attention at 
both departments. 

As we reported in April 2001,[Footnote 18] DOD can expect 15 percent 
(over 45,000 employees) to retire by the end of fiscal year 2006. 
Retirements have already affected some senior aviation safety 
positions during the past year. For example, the key civilian at the 
Navy Safety Center retired in April 2001 and according to Naval safety 
officials a replacement was difficult to find due to the high demands 
of the job and lack of commensurate pay.[Footnote 19] Similarly, one 
of the Army’s key civilians in charge of aviation safety—-responsible 
for the Safety of Flight Messages and routing FAA Airworthiness 
Directives to the appropriate aircraft program managers—-has also 
retired. Army officials said that the departure of this individual has 
had little or no impact on the issuance of flight safety messages. 
[Footnote 20] However, both of the retired aviation safety officials 
played a central role in the informal communication network for 
sharing aviation safety information among an extensive network of 
contacts both within and outside their respective services. 

In recent years, we have increasingly stressed the need to plan for 
retirements within the federal government to help ensure the 
availability of adequately trained personnel. As we recently 
reported,[Footnote 21] if federal employee retirements outpace the 
hiring of qualified replacement staff, the resulting loss of 
institutional knowledge and expertise could adversely affect mission 
achievement. This concern is especially great given that retirees 
often represent any agency’s most experienced and knowledgeable staff. 
DOT is among the departments with a large number of personnel that 
will become eligible to retire over the next several years. 

According to the DOT 2000-2005 Strategic Plan, the department plans to 
expand its workforce planning, including succession planning, for 
retirements in the next 10 years to ensure that DOT’s staff has the 
skills and transportation competencies to accomplish its goals. Among 
these competencies, DOT has identified the Aviation Safety Series 
[Footnote 22] job classification as a mission critical occupation 
important to succession planning. We estimate that 47 percent of the 
employees in this classification will be eligible to retire within the 
next 5 years.[Footnote 23] In April 2001, we reported that almost 37 
percent of DOT’s workforce who are eligible to retire by the end of 
fiscal year 2006 would actually retire. Applying this percent of staff 
at DOT in the Aviation Safety Series who will be eligible to retire by 
the end of fiscal year 2006, we estimate that about 17 percent will 
actually retire. DOT will thus need to do succession planning for over 
625 aviation safety positions. 

Succession planning is one mechanism that FAA, DOD, and the military 
services can use to help ensure that effective informal networks are 
sustained and/or replenished in the wake of retirements of key aviation 
safety personnel. However, succession planning can be difficult. To 
effectively deal with the expected retirements and other workforce 
challenges, an essential step for FAA and DOD is to engage in a 
planning process to identify human capital needs, assess how current 
staff and expected future staff will meet those needs, and create 
strategies to address any shortfalls or imbalances. 

Necessary near-term steps for ensuring continuity of communication 
when key aviation safety personnel and senior leaders retire is (1) 
developing a common definition of aviation safety information of 
mutual concern, especially information deemed critical; (2) 
formalizing the channels of communication by creating an explicit 
process for exchanging all critical aviation safety information of 
mutual concern, including how specific aviation safety concerns were 
addressed; and (3) requiring that such information exchanges occur. 
Such action would also close gaps created by the current practice of 
sharing only some critical safety information on a formal, systematic, 
and timely basis. 

FAA and DOD Recognize the Need to Formalize Communication, but Efforts 
to Date Have Not Addressed the Exchange of Critical Aviation Safety 
Information: 

FAA and DOD recognize the importance of formalizing communication on 
aviation issues to help ensure that communications outlast the tenure 
of specific individuals. This has been illustrated by efforts to 
develop more timely, systematic, and agency/service-based 
communication mechanisms through memorandums of 
agreement/understanding. For example, discussions are currently under 
way to determine what FAA’s future role should be in certifying that 
military variants of civil aircraft meet the agency’s aviation safety 
requirements.[Footnote 24] However, these discussions between the 
departments to formalize communication channels do not include the 
broader issue of requiring a formal exchange of aviation safety 
information, in particular, that deemed critical. 

Conclusions and Recommendations: 

Common aviation safety issues and responsibilities for safety 
oversight make the systematic and timely exchange of information a 
critical component of the aviation safety oversight systems of FAA and 
the military services. The informal and formal networks established by 
FAA and the military services to exchange critical aviation safety 
information have proven useful. However, because recent and expected 
retirements threaten to erode informal networks, additional formal 
channels of communication are needed to help ensure that safety risks 
common to both military and civil aircraft are identified and 
addressed in a formal, systematic, and timely manner. This includes 
the exchange of information on how FAA and the military services have 
addressed particular aviation safety concerns. Existing gaps in the 
formal processes used by FAA and the military services to exchange 
critical safety information—evidenced by the investigation of fuel 
tank flammability after the crash of TWA Flight 800 and the Strandflex 
case—could also allow for communication lapses and delays in getting 
critical safety information to the right parties in a timely manner, 
potentially resulting in the loss of lives and aircraft. 

To help ensure the systematic exchange of critical safety information, 
we recommend that the Secretary of Defense and the Administrator of 
FAA, as directed by the Secretary of Transportation, develop a 
memorandum of agreement (MOA) that defines the types of safety 
information to be exchanged, the mechanisms for exchanging this 
information, and the parties responsible for this exchange. This MOA 
should also establish a mechanism for the two departments to exchange 
information on how they have responded to specific safety concerns. 

Agency Comments: 

We provided a draft of this report to the secretary of DOD and the 
secretary of DOT for their review and comment. Both departments 
generally agreed with the report and provided written technical 
comments, which we have incorporated as appropriate. The Department of 
Defense agreed with our recommendation and the Department of 
Transportation agreed to consider it. See appendix IX for DOD’s 
comments. 

Copies of this report will be made available upon request. Please call 
me at (202) 512-2834 if you or your staff have any questions. Key 
contributors to this report are acknowledged in appendix X. 

Signed by: 

Peter F. Guerrrero: 
Director, Physical Infrastructure Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

For this assignment, we used a case study approach[Footnote 25] 
supplemented by a review of the Federal Aviation Administration’s 
(FAA) and Department of Defense’s (DOD) aviation safety oversight 
processes and related interdepartmental communication efforts to (1) 
examine different responses by FAA and DOD/military services to 
similar aviation safety concerns and (2) assess the processes used by 
FAA and DOD to communicate about similar aviation safety concerns. 
[Footnote 26 This report focuses primarily on safety issues pertaining 
to aircraft structures, parts, and materials that civil and military 
aviation have in common—-not the safety of aircraft operations within 
the nation’s air traffic control system. In addition, it does not 
address aviation security issues, such as hijacking, sabotage, or 
terrorist activities. 

For the first objective, we chose case studies using two key selection 
criteria. First, we identified an aviation safety problem that was 
similar for both FAA and the military services. Second, we selected 
examples in which FAA and the DOD/military services had taken a 
different approach to solving a common aviation safety problem. After 
discussions with DOD and FAA, we selected case studies that pertain to 
aircraft wiring insulation and cockpit equipment designed to improve 
safety and support quality assurance programs for flight operations. 
The latter case study includes Ground Proximity Warning Systems, 
Traffic Alert and Collision Avoidance Systems, Flight Data Recorders, 
and Flight Operational Quality Assurance Programs. In conducting these 
case studies, we interviewed and requested documentation from 
officials with FAA, Air Force, Army, Marine Corps, Navy, Coast Guard, 
and others knowledgeable of their aviation safety oversight processes, 
including the National Transportation Safety Board, Flight Safety 
Foundation, National Aeronautics and Space Administration, Air Line 
Pilots Association, Air Transport Association, and aircraft 
manufacturers, and the DOT and DOD Offices of the Inspector General. 
In addition to our work in Washington, D.C., we also met with 
officials from each of the military services’ safety centers and 
engineering organizations responsible for maintaining the safety of 
military aircraft, as well as officials from the William J. Hughes FAA 
Technical Center. 

To answer the second objective, we interviewed the same officials 
cited under objective one. We also selected two other case studies 
that illustrate communication between FAA and the military services on 
aviation safety issues. 

These include a discussion of a brand of control cable wire rope, 
which is used in the assembly of aircraft control cables, and the 
exchange of information between Air Force and civil aviation officials 
on fuel tank overheating in the E-4B, a military variant of the 747. 

To determine the number and percent of DOT employees in the Aviation 
Safety job series who will be eligible to retire by the end of fiscal 
year 2006, we used data in the Office of Personnel Management’s 
Central Personnel Data File (CPDF). Retirement eligibility dates were 
calculated using age at hire, years of service, birth date, and 
retirement plan coverage. Although we did not independently verify the 
DOT CPDF data, we had previously found that government-wide data from 
the CPDF for the key variables in this study (agency, birth date, 
service computation date, occupation, and retirement plan) were 99 
percent or more accurate.[Footnote 27] 

We performed our work from November 2000 through January 2002 in 
accordance with generally accepted government auditing standards. 

[End of section] 

Appendix II: Fixed Wing Military Aircraft and Their Civil Derivatives 
Operated by DOD: 

Military Aircraft Type/Civilian Counterpart: E-3B/C AWACS (Boeing 707); 
Coast Guard: 0; 
Army: 0; 
Air Force: 33; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: E-4B (Boeing 747); 
Coast Guard: 0; 
Army: 0; 
Air Force: 4; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: VC-4A (Gulfstream I); 
Coast Guard: 1; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: E-6 A/B Mercury (Boeing 
707) 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 16. 

Military Aircraft Type/Civilian Counterpart: E-8A/C JSTARS (Boeing 
707); 
Coast Guard: 0; 
Army: 0; 
Air Force: 4; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: E-9A (de Havilland Dash 
8, Model 102); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-9A/C (McDonnell Douglas 
DC-9); 
Coast Guard: 0; 
Army: 0; 
Air Force: 23; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-9B (McDonnell Douglas 
DC-9); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 28. 

Military Aircraft Type/Civilian Counterpart: KC-10A (McDonnell Douglas 
DC-10-30-CF); 
Coast Guard: 0; 
Army: 0; 
Air Force: 59; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-12 (Beechcraft/Raytheon 
King Air); 
Coast Guard: 0; 
Army: 122; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-12C/D/F/J 
(Beechcraft/Raytheon King Air); 
Coast Guard: 0; 
Army: 0; 
Air Force: 39; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: RC-12 
(Beechcraft/Raytheon King Air); 
Coast Guard: 0; 
Army: 47; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: UC-12B/F/M Huron 
(Beechcraft/Raytheon King Air); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 57. 

Military Aircraft Type/Civilian Counterpart: EC-18B (Boeing 707 ARIA); 
Coast Guard: 0; 
Army: 0; 
Air Force: 3; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: TC-18E (Boeing 707); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: UV-18B (de Havilland Twin 
Otter); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-20A/B (Gulfstream III); 
Coast Guard: 1; 
Army: 0; 
Air Force: 8; 
Navy/Marines: 0. 

C-20 D/G (Gulfstream III, IV); 
Coast Guard: 0; 
Army: 3
Air Force: 0; 
Navy/Marines: 7. 

C-20H (Gulfstream IV); 
Coast Guard: 1; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-21A (Learjet 35A); 
Coast Guard: 0; 
Army: 0; 
Air Force: 78; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-22B (Boeing 727) 3 
Coast Guard: 0; 
Army: 0; 
Air Force: 3; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-23B+ Sherpa (Shorts); 
Coast Guard: 0; 
Army: 0; 
Air Force: 43; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: HU-25 Guardian (Falcon 
20); 
Coast Guard: 41; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: VC-25 (Boeing 747-200B, 
Air Force One); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-26B/UC-26C Fairchild 
(Metro III); 
Coast Guard: 0; 
Army: 11; 
Air Force: 12; 
Navy/Marines: 7. 

Military Aircraft Type/Civilian Counterpart: 7 VC-32A (Boeing 757-200); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: UC-35B/C Cessna Citation 
(560 Ultra); 
Coast Guard: 0; 
Army: 23; 0; 
Air Force: 0; 
Navy/Marines: 8. 

Military Aircraft Type/Civilian Counterpart: C-37GV/A (Gulfstream V); 
Coast Guard: 0; 
Army: 1; 
Air Force: 2; 
Navy/Marines: 4. 

Military Aircraft Type/Civilian Counterpart: C-38A (Astra SPX-Israeli); 
Coast Guard: 0; 
Army: 0; 
Air Force: 2; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-40A Clipper (Boeing 737-
700); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 29. 

Military Aircraft Type/Civilian Counterpart: CT/T-43A (Boeing 737-200); 
Coast Guard: 0; 
Army: 0; 
Air Force: 11; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-130E/H (Lockheed Martin 
L-100); 
Coast Guard: 0; 
Army: 0; 
Air Force: 525; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: C-130T (Lockheed Martin L-
100); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 20. 

Military Aircraft Type/Civilian Counterpart: HC-130 Hercules (Lockheed 
Martin L-100); 
Coast Guard: 30; 
Army: 0; 
Air Force: 34; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: KC-130 F/R/T (Lockheed 
Martin L-100); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 77. 

Military Aircraft Type/Civilian Counterpart: KC-130J (Lockheed Martin 
L-100); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 52. 

Military Aircraft Type/Civilian Counterpart: C-150 (Cessna); 
Coast Guard: 0; 
Army: 0; 
Air Force: 3; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: T-1A (Beechjet 400T 
Jayhawk); 
Coast Guard: 0; 
Army: 0; 
Air Force: 108; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: T-3A Firefly (Slingsby 
T67M260); 
Coast Guard: 0; 
Army: 0; 
Air Force: 114; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: T-34C Turbomentor 
(Beechcraft Bonanza); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 307. 

Military Aircraft Type/Civilian Counterpart: T-39 D/N/G (Rockwell 
Sabreliner); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 26. 

Military Aircraft Type/Civilian Counterpart: T-41D (Cessna Mescalero C-
172); 
Coast Guard: 0; 
Army: 0; 
Air Force: 3; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: T-44A (King Air); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 55. 

Military Aircraft Type/Civilian Counterpart: HH-65 Dolphin 
(Aerospatiale SA365N); 
Coast Guard: 95; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: HH-60J Jayhawk (Sikorsky 
S-70A); 
Coast Guard: 42; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: UH-60A Blackhawk 
(Sikorsky S-70A); 
Coast Guard: 0; 
Army: 1,523; 
Air Force: 0; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: HH/MH-60G Pavehawk 
(Sikorsky S-70A); 
Coast Guard: 0; 
Army: 0; 
Air Force: 110; 
Navy/Marines: 0. 

Military Aircraft Type/Civilian Counterpart: CH-60S Knighthawk 
(Sikorsky S-70A); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 247. 

Military Aircraft Type/Civilian Counterpart: HH-60H HCS (Sikorsky S-
70B); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 39. 

Military Aircraft Type/Civilian Counterpart: SH-60B/F Seahawk 
(Sikorsky S-70B); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 232. 

Military Aircraft Type/Civilian Counterpart: SH-60R (Sikorsky S-70B); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 248. 

Military Aircraft Type/Civilian Counterpart: TH-57 B/C Sea Ranger (Jet 
Ranger 206); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 119. 

Military Aircraft Type/Civilian Counterpart: VH-60N Whitehawk 
(Sikorsky S-70A); 
Coast Guard: 0; 
Army: 0; 
Air Force: 0; 
Navy/Marines: 8. 

Military Aircraft Type/Civilian Counterpart: UH-1N/Y Iroquois (Bell 
Model 204/205); 
Coast Guard: 0; 
Army: Unknown; 
Air Force: 64; 
Navy/Marines: 204. 

[End of section] 

Appendix III: Key Similarities and Differences in FAA’s and the 
Military Services’ Aviation Safety Oversight Processes: 

The Federal Aviation Administration (FAA) and the military services 
share certain safety oversight systems, but three primary differences 
also exist. Similarities include common processes for disseminating 
safety information, managing aviation safety risks, and certifying 
that aircraft meet civil aviation safety standards. Differences 
include processes to certify that aircraft meet their unique safety 
standards and to investigate aircraft accidents, as well as timetables 
and thresholds for making decisions about potential aviation safety 
problems. 

Internal Mechanisms to Communicate Safety-Related Information Are 
Similar: 

FAA and the military services have both created formal and informal 
internal mechanisms to implement their aviation safety oversight 
programs. 

Formal internal mechanisms are used to communicate official 
information, such as orders and directives. For example, FAA issues 
Airworthiness Directives (ADs) to provide primarily owners and 
operators of civil aircraft with formal notice of an unsafe condition. 
For large civil commercial aircraft,[Footnote 28] ADs are written by 
the agency’s Transport Airplane Directorate Aircraft Certification 
Service in Renton, Washington, and sent to FAA’s Oklahoma City office, 
which has responsibility for formal distribution to owners and 
operators of registered civil aircraft and the posting of this 
information to the FAA Web site. Similarly, the military services 
issue near-equivalents of ADs to distribute aviation safety messages 
to affected units and sister services’ aviation safety centers. In 
addition, the chiefs of the military services’ safety centers hold a 
Joint Services Safety Conference every six months. 

According to both FAA and military officials, formal communication 
mechanisms also include internal meetings among engineering and 
program staff as well as FAA senior managers or internal meetings of 
senior military officers responsible for aviation safety. Both use 
training as another means of formally sharing aviation safety 
information internally among agency/service staff. 

Both FAA and the military services also have internal informal 
networks in place among aviation safety personnel that are used to 
share information. These exchanges are typically self-initiated, occur 
on an ad hoc basis, and are based largely on personal relationships. 
It is a primary means used among the military services’ safety centers 
to keep apprised of current aviation safety issues. According to FAA 
and military aviation safety officials, personal relationships are a 
cornerstone of informal communication within both FAA and the military 
services and have resulted in extensive networking that allows for an 
active exchange of aviation safety information. 

FAA and the Military Services Use a Similar Process for Managing 
Aviation Safety Risks: 

FAA and the military services all use variations of a five-step 
process for managing aviation safety risks.[Footnote 29] 

(1) Identifying potential aviation safety risks. FAA and the military 
services employ similar proactive and reactive methods for identifying 
potential aviation safety risks. For example, they monitor pilots’ 
reports of aircraft performance problems, manufacturers’ 
recommendations, foreign civil and military aviation authorities’ 
reports, mechanics’ reports of aircraft structural, part, or material 
weaknesses, inspectors’ reports of aircraft conditions and maintenance 
records, and information exchanges between stakeholders (e.g., 
airlines, pilots, and engineers) in the aviation community. Reactive 
methods include actions taken as the result of findings and 
recommendations from aircraft mishaps and accident investigations. 

(2) Assessing safety risks to determine if corrective action is 
warranted. Both FAA and the military services assess the safety risks 
of a potential aviation safety problem to determine if action is 
warranted. This includes weighing the costs and benefits that taking 
action might have in mitigating or eliminating a safety risk and 
fulfilling their responsibilities. For example, this process assists 
military decision-makers in choosing if and how much to fund a project 
and in comparing its urgency to other projects competing for resources. 

DOD requires the military services to use risk management and accident 
investigations as decision-making tools for identifying potential 
safety problems, assessing safety risks, and implementing and 
monitoring corrective actions.[Footnote 30] FAA requires the use of 
safety risk management by all offices, consistent with their role 
within the agency.[Footnote 31] 

FAA and the military services commonly use a risk assessment matrix to 
estimate the level of risk associated with a potential or identified 
aviation safety risk. The safety risk is estimated in terms of its 
probability and severity. For example, FAA and the Air Force use a 
risk matrix to classify identified or potential safety problems into 
one of four categories of risk— extremely high, high, medium, and low. 
FAA and military service officials acknowledge that some of the 
components used to prepare this type of safety risk estimate are 
subjective but, to the extent practical, they rely on technical 
experts to inform the decision-making process. 

An assessment of safety risk may lead decision-makers to conclude that 
no action is warranted or that the implementation of measures to 
mitigate a problem will achieve an acceptable level of safety risk. 
For example, according to Air Force safety officials, if a major 
command concludes that a risk to life, health, property or environment 
posed by the operation of an aircraft system or subsystem falls within 
acceptable limits—-without mitigation or upon completion of mitigation 
efforts-—a formal decision will likely be made to accept the residual 
risk. 

Assessments of risks associated with aircraft safety can vary among 
FAA and the military services, even when they share a similar safety 
hazard. According to FAA and military officials, this variability can 
be attributed, in part, to differences in missions, operating 
environments, and aircraft operational practices. 

(3) Determining a corrective course of action to be taken. According 
to FAA and military officials, when determining the appropriate course 
of action to address a potential or identified aviation safety hazard, 
their organizations consult with technical experts, including 
engineers, manufacturers’ representatives, pilots, and maintenance 
personnel. These experts identify a range of potential remedies, weigh 
the costs and benefits of each remedy, and select the most appropriate 
course of action to minimize danger to air crews and damage to 
aircraft by eliminating a safety risk or achieving an acceptable level 
of residual risk. For example, following the crash of Alaska Air 
Flight 261 on January 31, 2000, FAA determined that an emergency AD 
was warranted to inspect several McDonnell Douglas aircraft for 
excessive wear of their jackscrew assemblies on the horizontal 
stabilizer. Such wear could severely limit the ability of aircrews to 
control an airplane and posed an unacceptable level of risk to flight 
safety. 

The military services follow a similar process. For example, according 
to a senior Army safety official, once Army engineers from the 
Aviation and Missile Command (AMCOM) have determined an appropriate 
course of action for a given aviation safety hazard, they prepare a 
narrative describing to field personnel the precise remedy that they 
are ordered to implement. This narrative also indicates whether the 
action is an interim or final approach for reducing the hazard. AMCOM 
engineers may require the replacement of a defective part immediately; 
the operation of aircraft at or below a prescribed speed; more 
frequent inspections of aircraft; or that the aircraft be grounded 
immediately. The Army took the last action in June 2001, when 
investigators in Israel discovered damage to an Apache helicopter’s 
tail rotor after a low number of flight hours. In response, AMCOM 
engineers decided that the potential risk to flight safety warranted 
grounding the majority of the Army’s fleet of Apache helicopters to 
allow tail rotors that had been in service for greater than 1000 hours 
to be x-rayed immediately. 

(4) Implementing corrective actions. According to FAA and military 
officials, their organizations also have similar methods to implement 
corrective actions to address a potential or identified aviation 
safety problem. Corrective actions can be taken to restore the safety 
of approved products to the level of safety required by airworthiness 
standards (e.g., through the issuance of an AD by FAA) or to upgrade 
airworthiness standards through the issuance of new rules that will 
apply to aircraft at some future date. For example, FAA issues an AD 
to notify primarily civil aircraft owners and operators of an unsafe 
condition and to mandate a specific corrective action.[Footnote 32] 
The military services issue their respective equivalents. Both 
identify required actions and time frames for implementing those 
actions. 

Depending on the perceived level of safety risk to flight operations, 
a directive may require corrective action once a certain number of 
flight hours has been reached. Physical inspections might determine if 
a problem exists on a given aircraft, if a certain part must be 
repaired or replaced, or if the installation of equipment is required. 
Alternatively, a directive may place restrictions on certain flight 
maneuvers, while continuing to permit an unlimited number of flight 
operations. Finally, a directive may not be deemed necessary and an 
advisory message issued instead. Such advisories are designed to alert 
flight crews and maintenance personnel to potential equipment defects 
or limitations. 

When FAA determines that action is warranted, it may develop a 
regulation through the federal rulemaking process. As we recently 
reported,[Footnote 33] in doing so, it must balance the potential 
consequences for the aviation community and the nation with the 
consequences of inaction on public safety. On the one hand, the 
process of developing regulations, or rulemaking, is complex and time-
consuming. Because rules can have a significant impact on individuals, 
industries, the economy, and the environment, proposed rules must be 
carefully considered before being finalized. On the other hand, 
threats to public safety and the rapid pace of technological 
development in the aviation industry demand timely action. A need for 
rulemaking can be identified internally, by one of FAA’s offices, or 
externally, by an outside source such as Congress through a statutory 
mandate or the National Transportation Safety Board (NTSB) through a 
recommended rulemaking. When the Congress mandates a rulemaking, FAA 
is required to initiate the process. When NTSB issues a 
recommendation, FAA studies the situation and decides whether to 
initiate the rulemaking process. 

Both FAA and the military services maintain emergency procedures to 
compel immediate action. If FAA determines, for example, that a 
serious threat of an unsafe condition exists, the agency may decide to 
issue an emergency AD. This process allows FAA to issue an emergency 
directive first and submit it for stakeholders’ comments and potential 
revision at a later date. Issuance of an emergency AD can require that 
aircraft operators comply before making their next flight. 

Each branch of the military maintains a similar emergency process. For 
example, the Army may issue an Emergency Safety of Flight Message that 
immediately grounds all affected aircraft. The Air Force and Coast 
Guard, likewise, signal an emergency situation by publishing a Time 
Compliance Technical Order. The Navy issues a message called a 
Bulletin Technical Directive (Immediate Compliance). 

(5) Monitoring to ensure that corrective actions have been taken. Both 
FAA and the military services monitor compliance with required 
corrective actions largely through inspections and audits. For 
example, federal law establishes that the airlines are responsible for 
providing service with the highest possible degree of safety in the 
public interest and FAA is responsible for, among other things, 
overseeing airlines’ compliance with the statute and regulations. This 
includes, for example, examining airlines’ operations when they seek a 
certificate to operate and for conducting periodic inspections to 
oversee airlines’ continued compliance with safety regulations. FAA 
also tracks various reports from flight crews to monitor airline 
compliance with FAA requirements. 

Similarly, the military services also rely upon inspections and audits 
to ensure that corrective actions have been implemented. Compliance 
measures include recording in aircraft logbooks or other official 
documents that corrective actions have been taken and, in some cases, 
reporting compliance directly to the responsible oversight 
organization by unique aircraft identification numbers. 

The Military Services Adhere to FAA’s Regulations to Establish and 
Maintain the Airworthiness of Some Military Aircraft That Are Civil 
Variants: 

The military services use FAA’s civil aircraft certification services 
to establish the airworthiness of some similar aircraft types (e.g., 
the civil variant of the Air Force’s T-43 is the Boeing 737 commercial 
aircraft) and can retain this certification by maintaining the 
aircraft in accordance with the civil federal aviation regulations. 
FAA has responsibility for certifying that civil aircraft meet federal 
airworthiness requirements. To document that aircraft comply with 
these requirements, the agency issues type (aircraft design), 
production, and airworthiness certificates for aircraft produced by 
civil aircraft manufacturers in the United States. In some cases, FAA 
may issue aircraft type, production, and airworthiness certificates 
for a military variant of a civil aircraft as well as supplemental 
type certificates when modifications to an aircraft are made, but 
still meet civil airworthiness standards.[Footnote 34] See figure 1. 
Discussions among senior FAA and DOD officials are under way to 
determine FAA’s future role in certifying that military aircraft that 
are variants of civil aircraft comply with FAA’s minimum safety 
requirements. Some consideration is being given to the military 
reimbursing FAA for its certification services. 

Figure 1: Examples of FAA Involvement in Certifying Air Force Aircraft 
as Airworthy: 

[Refer to PDF for image: 3 photographs and associated data] 

Listed from Heavy FAA Involvement to No FAA Involvement: 

KC-10, C-32, C-20, C-27: 
* FAA certified Type Design (basic airplane) maintained throughout 
service life; 
* Provided airworthiness, test engineering and production staff to 
certify aircraft design; 
* Air Force responsible for mission suitability and effect. 

Joint-Stars, Airborn Laser Aircraft: 
* Basic airplane FAA certified; 
* Modifications more extensive than FAA is willing to certify; 
* Air Force responsible for mission airworthiness and quality of all 
modifications. 

F-117, F-15, F-16, B-1, B-2, many others: 
* No FAA certification involved; 
* Air Force operators/acquirers determine and contract for requirement. 

Source: U.S. Air Force. 

[End of figure] 

Different Methods Are Used to Certify the Airworthiness of Military 
Aircraft That Do Not Meet Civil Standards: 

Different certification methods are used when military aircraft 
derived from civil variants are modified for mission-readiness 
purposes to the extent that they no longer meet civil standards for 
airworthiness and when an aircraft is operated exclusively by the 
military (e.g., fighter aircraft).[Footnote 35] In such cases, DOD 
engineers must use their own standards to certify that an aircraft 
meets requirements for the minimum level of safety. For example, if 
the military modifies a C-130 (a variant of the civil L-100) to 
convert it from a passenger-carrying aircraft to one used for air-to-
air aircraft refueling, the modifications would not meet civil 
airworthiness standards. Consequently, DOD engineers would assume 
responsibility for certifying the airworthiness of this aircraft and 
it would no longer maintain its safety certification for civil use. In 
contrast to FAA’s aircraft certification procedures, the military 
services serve as both the approving officials and the ultimate users 
of military aircraft. In addition, the approval process must consider 
not only the safety and airworthiness of an aircraft, but also its 
suitability and effectiveness to meet mission readiness requirements. 
Furthermore, the military services do not issue certificates 
documenting that military aircraft meet military standards for 
aircraft type (design), aircraft production, and airworthiness. 

Civil and Military Accident Investigation Processes Differ: 

A second key difference is the accident investigation process: the 
military services conduct their own accident investigations while 
civil aviation accident investigations are conducted primarily by an 
independent agency, NTSB.[Footnote 36] Following an aircraft accident, 
the military conducts a “safety investigation” to determine the cause 
of an accident, followed by a separate “legal accident investigation” 
to obtain and preserve evidence for the chain of command and for use 
in litigation, claims, disciplinary action or adverse administrative 
actions against flight crews.[Footnote 37] In contrast, the NTSB, 
which has the authority to conduct all civil accident investigations, 
performs a single investigation following an aircraft accident. FAA 
conducts the on-site investigations in most (80 percent) of general 
aviation accidents and submits a factual report to NTSB. During 
accident investigations, FAA looks into the potential roles of the air 
traffic control system, navigational aids, pilots’ flight and medical 
qualifications, as well as the adequacy of the agency’s rules and 
whether or not those rules were followed. 

The reports of military “safety investigations” contain two types of 
information-—nonprivileged and privileged. Nonprivileged data, such as 
engineering analyses, may be released to the public. Privileged 
data,[Footnote 38] such as confidential witness statements[Footnote 
39] made by flight crew members, reluctant witnesses, and some 
contractors, are not made accessible to the public or used in 
litigation, claims, disciplinary actions or other adverse 
administrative actions.[Footnote 40] The intent of this discretion is 
to quickly identify root causes by encouraging candor among flight 
crews and witnesses to prevent similar accidents in the future and to 
help ensure military readiness. In contrast, during the civil version 
of the “safety investigation” by the NTSB, the only protection against 
potential criminal action available to civil commercial pilots is 
refusing to be interviewed or testify. 

Pace of Decisionmaking and Thresholds for Safety Actions Differ for 
Military and Civil Aviation: 

The pace with which FAA and the military services make decisions about 
potential and identified aviation safety concerns differs, as do the 
thresholds used to determine that action is warranted. For example, 
the command and control structure of the military services allows 
immediate action, such as the grounding of a fleet of aircraft, after 
considering the impact on their respective missions, but without 
consulting outside entities or considering economic impact. In 
contrast, while FAA can and has taken similar immediate action, the 
agency must also weigh the potential ramifications for the nation’s 
economy. Arriving at such a decision may involve consultation with 
manufacturers, operators, and other aviation stakeholders. Such 
consultation and coordination can take place at a very rapid pace when 
dictated by an unsafe condition. 

FAA and DOD operate under different formal requirements for issuing 
aviation safety regulations. For example, when DOD issues an order to 
address an aviation safety hazard, the military services are required 
to issue instructions implementing the order, which are effective upon 
signature by the approving official. In contrast, FAA, as a regulator 
of civil aircraft, must often follow a complex rulemaking process 
(except in emergency situations). This includes providing a full and 
open notice and comment period for stakeholders to help ensure that 
all aspects of any regulatory change are fully analyzed before the 
change goes into effect. As we recently reported, from fiscal year 
1995 through fiscal year 2000, FAA took about 2-1/2 years on average 
to proceed from formal initiation of the rulemaking process through 
publication of the final rule—-a process it completed for 29 
significant rules. However, for 6 of these rules it took 10 years or 
more to complete this process.[Footnote 41] Furthermore, the 
thresholds used by FAA and the military services to determine when and 
if a potential or identified aviation safety problem should be 
addressed also vary due primarily to mission differences. FAA’s 
primary mission is safety, while the military services must weigh 
multiple mission-readiness requirements against taking action to 
maximize aviation safety. 

[End of section] 

Appendix IV: Case Study on Aromatic Polyimide Wire Insulation: 

In the mid-1980s, the Navy began experiencing problems with aromatic 
polyimide, a general purpose wire insulator (commonly known as 
Kapton)[Footnote 42], that it did not fully understand. In response, 
the Navy enlisted the assistance of experts from other military 
services and the Federal Aviation Administration (FAA) to better 
characterize the problems and develop possible solutions. Ultimately, 
FAA and each of the military services responded differently to the 
problems of aromatic polyimide. 

Aromatic polyimide is the most commonly used wire insulation on many 
older Boeing and McDonnell Douglas airplanes that were built beginning 
in the late 1960s.[Footnote 43] It is lightweight, resistant to 
abrasion and cuts, is able to withstand high temperatures, and is 
flame and environmentally resistant. However, two weaknesses have also 
been documented. First, water alters the chemical composition of this 
insulation and diminishes its integrity. A second weakness occurs when 
two cracks in the insulation occur close together, enabling the 
current to arc between the cracks (arcing events) at high 
temperatures.[Footnote 44] Exposure to this heat causes the insulation 
to “carbonize” and actually become a conductor rather than an 
insulator. 

United States Navy: 

The Navy started using aromatic polyimide in the mid-1970s, began 
noticing cracks and breaks in the top coats of this insulation in 1980 
and 1981, and undertook research to identify potential problems with 
its use. In 1984, researchers at the Naval Research Laboratory 
reported that moisture caused aromatic polyimide to break down when it 
was exposed to high humidity, moisture, or water for long periods of 
time. It also found that carbon deposits can form and build up between 
two cracks in this insulation after several arcing events, a process 
that ultimately trips a circuit breaker. When a pilot presses a 
tripped circuit breaker to reset it, an entire wire bundle can be 
disabled, potentially causing catastrophic results. 

In December 1985, the Navy decided that aromatic polyimide would no 
longer be its wiring insulator of choice. Subsequently, the Navy 
selectively removed this wire insulation from parts of aircraft where 
it was most problematic, such as fore and aft flaps, wheel wells, and 
around unsecured seals that could leak. However, because the Navy 
still had a large supply of aromatic polyimide on hand, it continued 
its use on aircraft in areas that were not vulnerable to water 
infiltration. The Navy also took delivery of some McDonnell Douglas 
aircraft in 1988 that were built with aromatic polyimide wiring 
insulation that had been purchased before problems with this wire 
insulation were recognized. 

United States Coast Guard: 

In 1993, the Coast Guard also developed problems with aromatic 
polyimide on its fleet of H-65 Dolphin helicopters. These helicopters 
are exposed to a significant amount of water during normal operations, 
such as from swimmers undergoing rescue training and individuals 
rescued. In addition, many of these helicopters often spend as long as 
6 months patrolling at sea where they are constantly exposed to salt 
spray and salt water. 

Between 1993 and 1996, some serious events of in-flight fires 
resulting in cockpit smoke and fumes occurred in the Coast Guard’s H-
65 helicopters. Some of these mishaps led to loss of all electrically 
powered flight instruments. One incident (at low altitude, over water, 
in fog, and at dusk) nearly resulted in the loss of helicopter and 
crew. While no helicopters were destroyed as a result of cockpit 
fires, the Coast Guard decided to take precautionary measures to 
reduce the likelihood of future fires in these helicopters by 
systematically removing aromatic polyimide. In 1994, they began 
replacing this type of wire insulation during the H-65’s regularly 
scheduled forty-eight month maintenance cycle and according to a 
senior Coast Guard safety official, completed this removal in 
September 2001. 

United States Air Force: 

According to an Air Force wiring expert, the Air Force also 
experienced failures associated with aromatic polyimide and took steps 
to mitigate them. It was also aware of the concerns raised by the Navy 
and sponsored a research program that led to the development of a 
composite wiring construction (Teflon-Kapton-Teflon) that mitigated 
many of the problems exhibited by aromatic polyimide. In October 1988, 
the Air Force chief of staff issued a policy statement on aromatic 
polyimide that no perfect wire exists and such requirements as 
operational performance, maintenance, logistics needs, resistance to 
combat damage, and safety and environmental aspects must be considered 
when choosing a wire. Aromatic polyimide would no longer be considered 
the wire of first choice for new systems, modifications, or rewiring 
applications, and not be used in severe wind and moisture-prone 
(SWAMP) areas or in locations with frequent flexing. However, 
wholesale removal of aromatic polyimide was not planned. This policy 
remains in force. 

United States Army: 

In response to potential hazards identified by the Navy with the use 
of aromatic polyimide, the Army conducted further testing in 1986 and 
confirmed the Navy’s findings. In 1988, the Army concluded that it did 
not have the same problems with aromatic polyimide that the Navy did 
and determined that no action was necessary. The Army attributed the 
Navy’s problems with this insulation to its operating environment, in 
particular the long-term exposure of its aircraft to salt water. 

The Army’s Aviation Missile Command (AMCOM) officials decided that the 
use of aromatic polyimide in Army helicopters was not a primary safety 
issue. While the Army had experienced some wiring-related problems, 
there was no evidence linking them to aromatic polyimide. The Army did 
have durability concerns; however, it found the degree to which 
aromatic polyimide chafes in Apache and Blackhawk helicopters is 
unacceptable over the long-term. The Army did not order the immediate 
removal of this wire insulation, but has decided to strip it from 
aircraft when they are refurbished. As of June 2001, aromatic 
polyimide had been removed from 1,389 of the 1,523 Blackhawk 
helicopters in the Army’s fleet. According to an AMCOM official, 
current funding is sufficient to remove this wire insulation from only 
4 of the 134 remaining Blackhawks. 

AMCOM also conducted a system safety risk assessment on aromatic 
polyimide for its Blackhawk helicopters, issued in July 2001. The 
assessment concluded the most appropriate action is to replace Kapton 
(aromatic polyimide) wiring with non-Kapton wiring during scheduled 
upgrades or any time the aircraft is sent into a depot to be rebuilt, 
overhauled, or refurbished. This approach would allow all aircraft 
that are currently wired with Kapton to be upgraded to non-Kapton 
wiring by 2008. 

Federal Aviation Administration: 

FAA wiring experts reported that they were aware of only one incident 
on a commercial aircraft linked to aromatic polyimide wire insulation. 
In 1985, a Boeing 757, operated by Monarch Airlines in the United 
Kingdom, experienced an arc-tracking event in aromatic polyimide wire 
insulation after circuits were tripped, and smoke appeared in flight. 
Investigators suspect that the wire bundle was damaged when it was 
marked with a hot stamping tool and subsequently came into contact 
with fluid leaking from a lavatory. 

FAA has not mandated the removal of aromatic polyimide from commercial 
aircraft. The agency, however, has issued three advisory circulars 
(AC) on wiring practices: (1) in March 1987, FAA issued AC 25-10 to 
provide guidance on the installation of miscellaneous, nonrequired 
electrical equipment; (2) in April 1991, the agency issued AC 25-16 on 
electrical fault and fire prevention and protection, including the 
need to keep aromatic polyimide away from moisture-prone areas; and 
(3) in September 1998, FAA issued AC 43.13-1B to describe acceptable 
methods, techniques, and practices for aircraft inspection and repair, 
including wires insulated with aromatic polyimide. 

In addition, FAA’s Technical Center conducted studies on arc tracking 
under wet conditions in August 1988 and found, among other things, 
that certain polyimide (including aromatic polyimide) wire insulation 
constructions can be modified to resist wet-wire arc tracking by 
applying thin protective coatings. It conducted an additional study on 
arcing events under dry conditions in July 1989 and found that severe 
dry arc tracking occurred for all aromatic polyimide samples, with 
extensive damage to all wires in the bundles. This was followed by a 
study of electrical short circuit[Footnote 45] and current overload 
tests on aircraft wiring in March 1995. This study found that circuit 
breakers provide reliable protection against excessive or dangerous 
rises in temperature in the conductor or its insulation caused by 
direct short circuits. 

A senior FAA official stressed that improved safety margins can be 
achieved by measures other than wire replacement: use of enhanced 
circuit protection, increased separation of wires, removal of 
flammable materials, or protection of wires from moisture. These 
methods may be more effective than wholesale modification or re-
manufacture. 

The same official told us that the rules that admitted aromatic 
polyimide 20 years ago would prohibit it today because of the failure 
modes that have been identified. Much more is known now about the 
limitations of this type of wire insulation, specifically that it has 
the potential to arc track and can contribute to a single event or 
combination of events that could be a hazard to aircraft. According to 
this official, given current knowledge, it would be difficult for FAA 
to support the use of aromatic polyimide insulation, in its original 
form, in new aircraft designs. However, this same official noted that 
while new wire insulation types introduced on the market are likely to 
have improved performance characteristics, they are also likely to 
have shortcomings not anticipated at their introduction into service. 

Boeing Commercial Group: 

In response to the Navy’s problems with aromatic polyimide, Boeing 
conducted laboratory experiments in 1985 and 1986 and found that they 
could simulate arc tracking in Boeing commercial aircraft. Boeing 
officials told us that they immediately notified Dupont Chemical 
Corporation, the manufacturer of Kapton (aromatic polyimide). Boeing 
officials also told us that the company wanted to anticipate any 
potential FAA rulemaking on aromatic polyimide and began using a new 
wire insulator known as BMS-60, or Teflon-Kapton-Teflon (TKT), in 
1993. This wire retained aromatic polyimide’s favorable mechanical 
qualities while embedding the aromatic polyimide between layers of 
Teflon to strengthen it. Boeing still uses aromatic polyimide for 
wiring to power feeders that run from a set of engines into a power 
panel. These runs are long and do not require that the wire be bent; 
Boeing reported that it has not found any instances of cracks or arc 
tracking in these areas. 

Joint Military/FAA/Industry Efforts: 

In February 1997, the White House Commission on Aviation Safety and 
Security issued a report to President Clinton identifying aging wiring 
as a safety issue in aviation. The Commission recommended that three 
federal agencies—FAA, Department of Defense, and National Aeronautics 
and Space Administration—expand their aging aircraft program to 
include the issue of aging wire systems in commercial aircraft. These 
agencies have established research initiatives and partnerships with 
industry to address wiring issues in aging aircraft as a part of 
ongoing informal coordination and in response to this recommendation. 

In October of 1998, the director of Navy Safety and System 
Survivability established a government and industry forum, known as 
the Aircraft Wiring and Inert Gas Generator Working Group (AWIGG), to 
(1) ensure that information on aircraft wiring and fire suppression is 
shared and understood by all interested parties and (2) combine the 
resources of interested participants to accelerate the development of 
aviation safety technologies. AWIGG membership now totals more than 
350 individuals, representing military services, airlines, aircraft 
and wire manufacturers, pilots and mechanics unions, researchers, FAA, 
National Transportation Safety Board, NASA, and others. 

In October 1998, FAA established the Aging Transport System Rulemaking 
Advisory Committee (ATSRAC)[Footnote 46] to serve the public interest 
by providing a forum for interaction among FAA, the military, NASA, 
the airlines, airline pilots, manufacturers, and their representatives 
on aging aircraft. FAA believed that the level of expertise and 
balanced viewpoint of this committee would enable early identification 
of potential problem areas and accelerate development of cost-
effective corrective actions. Under ATSRAC two separate working groups 
were created—one to conduct visual (nonintrusive) inspections and 
another to conduct comprehensive physical (intrusive) inspections of 
aging aircraft wiring. 

One ATSRAC working group conducted visual (nonintrusive) inspections 
of eighty-one in-service aircraft that were over twenty years old. The 
working group was comprised of lead airline representatives from each 
of the fleet types, the airframe manufacturers, and FAA. The purpose 
of these inspections was to assess the condition of the U.S. transport 
fleet with respect to wiring, identify areas of concern, and make 
recommendations, if necessary. The results were released August 1, 
2000, and found that the majority of discrepancies with wire were in 
areas of frequent maintenance activity where wiring was unprotected 
from debris and fluid contamination. 

To complement and extend the results of the nonintrusive inspections, 
ATSRAC requested a joint working group effort to conduct extensive 
physical (intrusive) inspections of aging aircraft wiring systems. FAA 
conducted this work in conjunction with ATA and with the support of 
the Navy and Air Force. Intrusive inspections were performed on six 
recently decommissioned airplanes to assess the conditions of the 
electrical wiring on aged airplanes.[Footnote 47], [Footnote 48] The 
results were released December 29, 2000. The working group report 
identified two items that FAA should pursue aggressively to develop 
options to eliminate or mitigate electrical hazards: arc-fault circuit 
breakers and nondestructive test equipment for aircraft wiring. An arc-
fault circuit breaker is being developed by a number of government and 
industry organizations, including the Navy and FAA. This type of 
circuit breaker can detect and react to an electrical arc much faster 
than those currently used in aircraft today. When an arc is detected, 
this type of circuit breaker can disable the circuit and provide a 
warning that a fault exists. The report did not recommend systematic 
removal of aromatic polyimide from aging aircraft. 

The report also included a dissenting opinion from one of the working 
group members. Among other things, this member contended that (1) the 
data collection and analysis was seriously flawed, that the group 
inappropriately reinterpreted data and that they had little or no 
opportunity to review and validate the original data; (2) there was a 
lack of rigor in the process as demonstrated by informal, changing, or 
imprecise definition of terms; (3) the testing protocols were not 
executed rigorously; and (4) certain findings were not classified 
appropriately. The working group disagreed with these and other 
criticisms raised by this member, responded formally to them in the 
report, and invited other interested parties to read both the report 
and the dissenting opinion to ascertain the merits of each. 

[End of section] 

Appendix V: Case Study on Adoption of Cockpit Safety Equipment: 

Beginning in the early 1970s, a number of studies looked into the 
occurrence of accidents where a properly functioning aircraft under 
the control of a fully qualified and certified crew flew into terrain 
with no awareness by the crew. According to the Flight Safety 
Foundation, this type of accident represents the single largest safety 
risk to aircraft. In the mid-1980s, the high number of aircraft 
accidents caused by midair collisions also became a central concern 
for aviation safety. To address these safety issues, the Federal 
Aviation Administration (FAA) required the installation of Ground 
Proximity Warning Systems (GPWS) on most passenger-carrying aircraft 
to alert pilots to potential collisions with terrain and Traffic Alert 
and Collision Avoidance Systems (TCAS) to warn pilots of potential 
airborne collisions with other aircraft and provide them with 
information to take evasive action.[Footnote 49] The military services 
have moved more slowly to install similar safety equipment in their 
passenger-and troop-carrying aircraft due to resource tradeoffs 
between aviation safety and other mission-readiness issues. 

FAA Has Required GPWS Aboard Passenger-Carrying Aircraft Since the 
1970s: 

In 1974, as a result of studies and recommendations from the National 
Transportation Safety Board, FAA required all operators of large 
turbine-powered airplanes and some operators of large turbojet 
airplanes to install approved GPWS equipment. In 1978, the FAA 
extended the GPWS requirement to operators of smaller airplanes and 
turbojet-powered airplanes with ten or more passenger seats. In 1992, 
in response to studies by the NTSB, FAA required GPWS equipment on all 
turbine-powered airplanes with 10 or more passenger seats. 

Advances in terrain mapping technology led to the development of a new 
type of ground proximity warning system that provides greater 
awareness for flight crews. FAA ultimately approved the advanced 
equipment known as the enhanced ground proximity warning system 
(EGPWS).[Footnote 50] EGPWS equipment standards have been improved to 
provide flight crews with earlier auditory and visual warnings of 
terrain, forward-looking capability, and additional time to take 
corrective actions in a more smooth and gradual manner. 

In 1996, a FAA study concluded that existing GPWS would have prevented 
75 percent of 44 accidents that occurred on smaller capacity aircraft 
between 1985 and 1994, while EGPWS would have prevented 95 percent of 
those accidents. A second study, focusing on the merits of 
retrofitting large-capacity scheduled and unscheduled airline fleets 
with EGPWS, showed that four of nine accidents, or 44 percent, should 
have been prevented by the basic GPWS if it had been functioning or 
utilized properly. The study concluded that the EGPWS technology would 
have prevented all nine of those accidents. 

In 1998, FAA issued a draft rule proposing that all turbine-powered 
U.S. airplanes registered with FAA that have six or more passenger 
seats be equipped with a FAA approved EGPWS. On March 29, 2000, the 
agency issued the final rule mandating the installation of EGPWS 
equipment on all such aircraft.[Footnote 51] The new regulation 
applies immediately to those aircraft built after March 29, 2002. 
Aircraft manufactured on or before March 29, 2002, will be required to 
comply by March 29, 2005. 

FAA Has Required TCAS Installation Since the Late 1980s: 

For the past 13 years, FAA has taken active steps to require 
installation of TCAS on commercial passenger aircraft. Following a 
1986 midair collision between two commercial aircraft in California, 
Congress passed a law in 1987 requiring FAA to mandate the use of 
TCAS. In January 1989, the agency published a rule requiring 
installation and use of TCAS II (enhanced version) in commercial 
passenger-carrying aircraft and TCAS I in commuter aircraft with 10 to 
30 passenger seats. By 1993, all air carrier aircraft with more than 
30 passenger seats were equipped with TCAS II. 

Furthermore, FAA has recently proposed a new regulation to require 
certain cargo airlines to install TCAS to minimize the possibility of 
midair collisions. The proposed regulation would require affected 
aircraft to be equipped with TCAS II or another FAA-approved traffic 
alert and collision avoidance system no later than October 31, 2003. 

The Military Services Have Recently Begun Installation of GPWS and 
TCAS: 

The military services were aware of FAA’s requirements for installing 
GPWS and TCAS on civil aircraft and have requested technical 
information from the agency on these technologies. While the military 
has lagged behind FAA in issuing similar mandates for its passenger-
and troop-carrying aircraft, the Department of Defense (DOD) recently 
required each branch of the military to devise a plan for installing 
TCAS on its fleet of passenger-and troop-carrying aircraft. Soon after 
then-Secretary of Commerce Ronald Brown and 34 others were killed in 
April 1996 in an Air Force passenger-carrying aircraft that was 
equipped with GPWS, but not the enhanced version, the secretary of 
defense mandated a program to improve navigation and safety 
capabilities for passenger-and troop-carrying aircraft. 

In August 1996, the Air Force published its Navigation and Safety 
Equipment Master Plan for DOD Passenger-Carrying Aircraft, which 
established guidance for equipping passenger-and troop-carrying 
aircraft, including GPWS and TCAS. The plan calls for two phases of 
implementation. Phase 1 requires installation by 2001 on all equipment 
used to transport senior military leaders, and Phase 2 requires 
installation by 2005 of all equipment components, including GPWS and 
TCAS, on remaining passenger-and troop-carrying aircraft. 

In 1997, the DOD Defense Science Board Task Force on Aviation Safety 
found GPWS and TCAS to be effective in significantly reducing the 
risks of a major accident (e.g., fatal accidents or total loss of 
aircraft). The task force membership included a cross section of 
representation from the aviation community—the airlines, universities, 
military services, and FAA consultants. According to the board, GPWS 
and TCAS provide both safety and flight efficiency benefits and 
significant opportunities exist to leverage NASA, FAA, and commercial 
airline research and development initiatives pertaining to aviation 
safety. 

In April 1998, the Office of the Secretary of Defense issued a 
memorandum to the secretaries of the Army, Navy, and Air Force to 
accelerate their installation of TCAS. The military services are now 
moving forward to implement this memorandum’s requirements on the 
following schedules. 

Army: No Army-specific policy directing field units to install GPWS or 
TCAS in aircraft exists. Rather, the Army relies on the April 1998 DOD 
memorandum as its prevailing guidance for TCAS. According to officials 
from the Department of the Army, as of August 2001, units had equipped 
38 of the Army’s 294 fixed wing aircraft with EGPWS and 90 of these 
same aircraft with TCAS. The remaining fixed wing aircraft must be 
equipped with these technologies by fiscal year 2006. The Army has not 
equipped any of its rotary wing aircraft (i.e., helicopters) with GPWS 
or TCAS and currently has no plans to do so. According to an Army 
safety official, the Army’s helicopters are typically operated at very 
low altitudes and pilots are generally able to make effective visual 
contact with any hilly or mountainous terrain and take action to avoid 
contact with the terrain without the assistance of GPWS. As such, the 
Army would rather dedicate its limited resources to improving its 
visual guidance systems for these aircraft. Furthermore, according to 
Army officials, Army helicopters are equipped with “radar altimeter” 
in lieu of GPWS, with the exception of some legacy aircraft that are 
being phased out of the fleet. 

Navy: In December 1996, the Navy Air Board agreed that installing 
safety technology (e.g., TCAS) into new and existing aircraft would 
improve safety. In June 1998, the Navy implemented a new policy 
requiring installation of TCAS and other safety equipment in newly 
produced and “re-manufactured” aircraft.[Footnote 52] In addition, it 
required passenger-and troop-carrying aircraft to be equipped or 
retrofitted with additional commercial safety systems that are already 
standard equipment in comparable civilian aircraft. 

Air Force: In 1996, the Air Force began installing TCAS in its 
passenger-carrying aircraft and is moving forward to implement the DOD 
guidance cited above. 

Coast Guard: In 1998, the Coast Guard completed installation of TCAS 
in its entire inventory of fixed wing and rotary-wing aircraft. In 
addition, they have equipped their fleet of C-130 aircraft with GPWS. 
However, the majority of the Coast Guard fleet is comprised of 
helicopters for which GPWS technology is relatively new. According to 
a senior Coast Guard safety official, due to the dynamic nature of 
rotorcraft flight as compared to fixed wing aircraft flight,[Footnote 
53] making use of GPWS on helicopters is much more difficult and has 
led technology development to lag behind that for fixed wing aircraft. 
This official also said that the Coast Guard spends the majority of 
its time flying over water and uses “radar altimeter” equipment to 
monitor the clearance under the aircraft along with a horn set by the 
pilot to alert flight crews when a helicopter descends below an 
established minimum altitude. In addition, this official noted that 
FAA has not mandated the use of GPWS or its enhanced version in civil 
helicopters, but that a certified enhanced GPWS became available last 
year and the Coast Guard is monitoring the results of its use. 

[End of section] 

Appendix VI: Case Study on Flight Operational Quality Assurance (FOQA) 
Programs: 

Flight Operational Quality Assurance (FOQA) programs allow routine 
flight data to be collected and analyzed to detect and resolve 
potential safety, training, and maintenance issues. The experience of 
domestic and foreign airlines with these programs attests to their 
potential to enhance aviation safety. Given the potential of FOQA 
programs to improve both civil and military aviation safety, this case 
study was selected to determine the current status and pace of efforts 
by the Federal Aviation Administration (FAA), the aviation industry, 
and the military services to put them in place. 

History of FOQA: 

In its 1992 study for FAA, the Flight Safety Foundation coined the 
term “Flight Operational Quality Assurance Program” and defined it as 
“a program for obtaining and analyzing data recorded in flight to 
improve flight crew performance, air carrier training programs and 
operating procedures, air traffic control procedures, airport 
maintenance and design, and aircraft operations and design.”[Footnote 
54] The objective of a FOQA program is to use flight data to detect 
technical flaws, unsafe practices, or conditions outside of desired 
operating procedures early enough to allow timely intervention to 
avert accidents or incidents. For example, FOQA data can be used to 
improve aviation safety by identifying hazardous approaches into a 
particular airport and helping to justify to FAA the need for a new 
approach pattern that is less likely to lead to an accident under 
adverse conditions, or to improve pilot training. These data can also 
yield operational efficiencies, such as identifying and mitigating 
flight practices that place unnecessary strain on aircraft engines and 
other parts. 

Modern commercial aircraft contain sophisticated electronic systems 
that gather, process, and manage digital data on many aspects of 
flight. These data originate from various systems and sensors 
throughout the aircraft. Some of these data are continuously recorded 
by the aircraft’s digital flight data recorder to help investigators 
understand what happened if the aircraft is involved in an accident or 
a serious incident.[Footnote 55] Designed to survive crashes, flight 
data recorders generally retain the data recorded during the last 25 
hours of flight. Airlines with FOQA programs typically use a device 
called a quick access recorder to capture flight data onto a removable 
optical disk that facilitates the data’s frequent removal from the 
aircraft.[Footnote 56] 

British Airways has had a FOQA-type program in place since the late 
1960s. This program has served as the model for similar programs in 
the United States and around the world. In July 1995, as part of FAA’s 
strategy to achieve significant reductions in aviation accident rates—
despite the rapid increase in air travel anticipated over the next 
decade—the agency initiated a three-year, $5.5 million FOQA 
Demonstration Project to promote the voluntary implementation of FOQA 
programs by U.S. airlines. The project was designed to facilitate the 
start-up of voluntary airline FOQA programs and to assess the costs, 
benefits, and safety enhancements associated with such programs. FAA 
provided hardware and software to United, US Airways, and Continental 
and each has implemented FOQA programs according to the demonstration 
project requirements. Since that time, others including Delta Airlines 
and American Airlines, have also initiated FOQA programs. The rules 
under the project required airlines to provide FAA with access to “
aggregate” FOQA data on the airlines’ premises and did not require 
them to submit these data to FAA. See table 2 for a timeline of key 
events pertaining to the implementation of FOQA programs. 

Table 2: Flight Operational Quality Assurance Programs Timeline 

Date: Late 1960s; 
Agency, industry, or military branch: British Airways; 
Action: Inaugurates first airline FOQA program. 

Date: 1992; 
Agency, industry, or military branch: Flight Safety Foundation; 
Action: Publishes study recognizing that acceptance of FOQA programs 
by the aviation industry hinges on adequate protection of data 
collected. 

Date: March 1993; 
Agency, industry, or military branch: FAA; 
Action: Begins rulemaking effort. However, progress quickly stalled by 
airline concerns about FAA’s intended use of FOQA data. 

Date: July 1995; 
Agency, industry, or military branch: FAA; 
Action: Begins a FOQA demonstration project— “Demoproj”— and issues 
statement indicating commitment to using FOQA data for safety analysis 
purposes only. 

Date: 1997; 
Agency, industry, or military branch: Department of Justice (DOJ); 
Action: Cautioned FAA that a federal regulator may not be able to 
exempt regulated parties from enforcement actions, even if information 
is submitted voluntarily. 1997 – 2000 FAA and DOJ Work together to 
develop a proposed FOQA rule that would be acceptable to all 
stakeholders (e.g., industry, FAA, and DOJ). 

Date: November 1997; 
Agency, industry, or military branch: Defense Science Board; 
Action: Publishes report finding that inconsistencies exist between 
civil aviation’s commitment to use FOQA programs for safety purposes 
and the military services’ own such commitment. Issues two related 
recommendations to military. 

Date: 1998; 
Agency, industry, or military branch: FAA; 
Action: Publishes a policy statement indicating an intent to use FOQA 
data for enforcement purposes, but only when rule violations are “
egregious” (i.e., criminal or negligent). 

Date: October 1999; 
Agency, industry, or military branch: Joint service safety chiefs 
(heads of the military services’ safety centers); 
Action: Agree informally that FOQA has value and endorse projects and 
research by all military services. 

Date: July 2000; 
Agency, industry, or military branch: FAA; 
Action: Formally publishes a Notice of Proposed Rulemaking on 
voluntary implementation of FOQA programs by U.S. airlines. 

Date: August 2000; 
Agency, industry, or military branch: Joint service safety chiefs; 
Action: Formally endorse military FOQA programs—-“MFOQA”—-and 
recommend full funding for their implementation. 

Date: July 2001; 
Agency, industry, or military branch: FAA; 
Action: Rule issued protecting voluntarily submitted aviation safety 
and security data are protected from release (e.g., under Freedom of 
Information Act). 

Date: October 2001; 
Agency, industry, or military branch: FAA and DOT; 
Action: Publication of final FOQA rule. 

Source: FAA, airlines, and the military services. 

[End of table] 

FAA Continues to Encourage FOQA Programs Among ?Airlines; 

FAA efforts to encourage the implementation of FOQA programs have 
been under way for nearly a decade. In addition to the FOQA 
demonstration project mentioned earlier, FAA has issued separate rules 
on FOQA and issued a rule to protect those submitting voluntary 
aviation safety information. 

FAA Has Taken Steps to Alleviate Aviation Industry Concerns About Data 
Use: 

Key aviation industry stakeholders, including airline executives, 
pilots and other crewmembers, are enthusiastic about FOQA’s continuing 
potential for saving lives, but they are nevertheless concerned about 
the possible consequences of a FAA rule about FOQA. These stakeholders 
considered the draft rule to be overly intrusive because of the agency’
s insistence that these data be removed from airlines’ property and 
concerns about how these data will be used (e.g., to take enforcement 
actions against pilots or airlines). However, as requested by 
industry, the final rule limits the use of FOQA data by FAA to 
enforcement actions for criminal and deliberate acts. 

The 1992 Flight Safety Foundation study recognized that the acceptance 
of FOQA programs by the aviation industry hinges on adequate 
protection of the data collected. In particular, the study noted that 
airlines were concerned about increased accident liability and 
possible punitive actions by FAA, for rule infractions that could be 
revealed by FOQA. Airlines are also concerned about the release of 
these data to the media and the potential for unfair criticism of 
their commitment to safety if data are not interpreted in the proper 
context. Pilots’ concerns focused on possible punitive actions by 
airline management and FAA. We have also reported that resolution of 
data protection issues was the primary impediment to the 
implementation of FOQA programs among the major domestic carriers. 
[Footnote 57] 

FAA began its FOQA rulemaking effort in January 1993. However, 
progress on this rulemaking stalled due to unresolved concerns among 
the airline industry about whether or not FAA would use the data 
submitted voluntarily by the airlines under FOQA to take enforcement 
action. Before initiating the FOQA Demonstration Project in 1995, FAA 
issued a statement that it was committed to not using FOQA data for 
enforcement purposes. FAA reiterated this position in 1998. 

According to FAA officials, when the agency reestablished the FOQA 
rulemaking effort in 1997, it encountered some resistance from DOJ. 
Specifically, DOJ raised concerns that a government regulatory agency 
such as FAA may not be able to exempt those who are regulated from 
enforcement actions based on information received from them, voluntary 
or not. Between December 1997 and June 2000, rulemaking officials, in 
conjunction with the DOJ, worked to develop a rule that was acceptable 
to the industry and the administrator. However, in response to 
continued industry concerns about the use of FOQA data for 
enforcement, the FAA administrator published in 1998 a policy 
statement that the agency would only use FOQA data for enforcement 
purposes in egregious cases (e.g., if the violation were deliberate, 
involved a criminal offense, or the violator had committed a similar 
violation within the previous five years). The statement further 
asserted that, in order to qualify for protection from punitive action 
based on analysis of FOQA data, an airline must submit to FAA for 
approval a FOQA implementation and operation plan describing its 
procedures for taking remedial action on any identified deficiencies 
that become apparent as the result of FOQA data analysis. 

FAA Has Finalized FOQA Rule: 

In October 2001, FAA published a final rule on FOQA encouraging 
voluntary implementation of FOQA programs by airlines. The final rule 
provided that information obtained from airlines’ voluntary FOQA 
programs could be used in enforcement actions against air carriers, 
commercial operators, or airmen (e.g., pilots), only for criminal or 
deliberate acts. The final rule requires air carriers participating in 
FOQA programs to submit aggregate data to FAA for use in monitoring 
safety trends. FAA could also use these aggregated data as a basis for 
initiating safety rulemakings.[Footnote 58] 

However, there are outstanding concerns within the aviation industry 
about the rule’s possible ramifications. For example, the final rule 
says that FAA will maintain the discretion to take enforcement action 
and that this action will not be affected by the final rule. Concerns 
also persist about the removal of FOQA data from airlines’ premises 
because this makes the airlines vulnerable to other federal agencies’ 
reviews of the data. FAA’s definition of “aggregate data” is also 
unclear; if it refers to a single airline’s aggregate data, this is 
not acceptable to the airline industry, while aggregate data reported 
industrywide would be acceptable. 

FAA Issues Rule Intended to Protect Safety Data That Are Voluntarily 
Submitted From Release to the Public: 

In June 2001, FAA issued a rule[Footnote 59] that protects voluntarily 
submitted aviation safety and security data from release, for example, 
under the Freedom of Information Act. With this type of protection in 
place, the agency is confident that it will be able to obtain more 
voluntarily submitted safety and security data than it does currently. 
However, some aviation industry stakeholders told us that they are 
still reluctant to submit such data—-fearing that the media and/or the 
public will misinterpret it. 

Another rule offering limited protection for voluntarily submitted 
FOQA data is pending. 

The U.S. Military Services Are Still in the Early Stages of Developing 
FOQA Programs: 

The U.S. military services readily acknowledge the potential benefits 
of implementing FOQA programs despite varied mission requirements that 
could make implementing such programs more difficult for them than it 
has been for commercial aviation.[Footnote 60] To date, the military 
services have taken various levels of action-—from high-level 
discussions about how to proceed with FOQA to initiating demonstration 
projects for specific aircraft types. 

In February 1997, a Defense Science Board (DSB) report “Task Force 
Report on Aviation Safety,” conducted at the request of the Congress, 
found that “inconsistencies exist between aircraft used for passenger 
and troop transport and civil aircraft leased for similar purposes” 
and made two recommendations specifically related to FOQA. First, it 
recommended that a policy be developed for military transport aircraft 
that requires the same safety equipment (flight data recorders) as 
that required for commercial airlines—with waivers to be approved only 
at the service chief level.[Footnote 61] It also recommended that the 
military services “fully exploit the new opportunities afforded by 
flight data recorders to collect performance and hardware maintenance 
data,” and noted the value of flight data to monitoring aircraft 
conditions, crew performance and communication, and aircraft 
maintenance. 

In October 1999, the Joint Service Safety Chiefs (JSSC) agreed that 
FOQA had value and endorsed projects and research by all services. A 
Memorandum of Agreement signed by the JSSC on August 28, 2000, 
formally endorsed military FOQA and recommended full funding of 
required resources. In response to the safety chiefs’ endorsement of 
FOQA and in an effort to increase cross-service communication on the 
subject, the military has held two FOQA conferences and plans to hold 
such meetings annually for the combined services. The first 
conference, held in October 2000, introduced the services to FOQA; the 
second conference (held in March 2001) emphasized economics, policy, 
technology, and analysis associated with FOQA. Aside from the safety 
chiefs’ formal endorsement of FOQA and the two related conferences, 
the military branches have taken only initial steps in implementing 
formalized FOQA programs, due in part to budget tradeoffs between 
aircraft safety and other mission-readiness needs. See table 3 for the 
status of the military services’ efforts to implement FOQA programs. 

Table 3: Status of Military Efforts to Implement FOQA Programs as of 
August 1, 2001: 

Authority: Air Force; 
Key actions: 
* Policy established the Aircraft Information Program with a main goal 
of enabling FOQA (February 2001). 
* Selected a software contractor to support a one-year FOQA 
demonstration project (June 2001). 
* Has collected data since 1994 on nearly 11,000 flights. The software 
support obtained in June 2001 has allowed them to start processing 
these data. They will use a maximum of 30 C-17 aircraft at McChord Air 
Force Base in Washington state to operate this demonstration. 

Authority: Marine Corps; 
Key actions: 
* The Executive Safety Board set a goal to “initiate the FOQA process 
with the MV-22,” the Marine’s newest airplane (August 2000). It also 
set a secondary goal to “expand the FOQA process to other aircraft 
with digital electronic systems, as soon as possible.” 

Authority: Navy; 
Key actions: 
* Has “proven” the value of the FOQA concept using the C-2 aircraft. 
* Is still debating whether FOQA should be used as a training tool to 
improve aviation safety or as an enforcement tool to protect taxpayer 
investments in naval aircraft. 
* According to a senior Navy Safety Center official, the Navy could 
improve its mission effectiveness by implementing a military FOQA 
program to improve pilot training, make better use of limited flight 
hours, and ultimately train better pilots. However, implementing FOQA 
in the Navy would be a “tough sell” given the basic needs competing 
for resources, such as funding to repair aircraft engines. 

Authority: Coast Guard; 
Key actions: 
* Currently examining how best to establish a FOQA program. 
* All helicopters are equipped with Flight Data Recorders (FDR). A 
proposal to equip Falcon and C-130 fixed wing aircraft has been 
submitted within the Coast Guard; however, the Falcon aircraft are 
old, expensive to equip, and may be nearing the end of their service 
lives. 

Authority: Army; 
Key actions: 
* Is drafting and staffing a military FOQA usage policy that mirrors 
FAA’s protection of FOQA data. In addition, some aircraft are already 
equipped with the hardware necessary for collecting FOQA data. 
Furthermore, some aircraft have been/are continuing to be equipped 
with FDRs or new digital technology to capture flight data. 

Source: Military services. 

[End of table] 

[End of section] 

Appendix VII: Case Study on Communication Delays Between the Air Force 
and Civil Aviation Community: 

During the National Transportation Safety Board (NTSB) accident 
investigation into the July 1996 crash of TWA Flight 800, it was 
discovered that the Air Force had experienced problems with 
overheating in the center wing fuel tank of the E4-B aircraft (a 
military variant of the 747). In response, the Air Force contracted 
with Boeing’s Military Group to study the problem between 1979 and 
1980; the group issued a report to the Air Force in 1980. However, the 
report was not shared with the civil aviation officials until 1999. 
[Footnote 62] This case study illustrates the importance of effective 
and timely communication between the military and civilian aviation 
communities on similar aviation safety problems. 

The Air Force was concerned about the E-4B engines continuing to run 
satisfactorily if a main (wing) tank fuel pump malfunctioned. In 
addition, there was concern over the running of the air conditioning 
packs under the center wing tank for extended periods of time when the 
airplane was on alert, idling on the ground with engines running for 
48 hours. In this mode, the center wing tank was full of fuel, and 
heated up slowly to a high temperature. The 1980 Air Force report 
prepared by Boeing’s Military Group found that, under certain 
circumstances, air conditioning wires running through the fuel tank 
could create a potential safety problem, but determined that the 
engine would continue to operate successfully provided certain 
operating restrictions were implemented. 

The central focus of the Air Force’s concerns and Boeing’s analysis 
was fuel pump performance, not fuel tank flammability. Federal 
Aviation Administration (FAA) officials said that this test was not 
envisioned as one of flammability of the vapor in the fuel tank, but 
merely to assess the effectiveness of fuel being fed to the engine. 
They added that it was always assumed that fuel vapor might be 
flammable under certain conditions.[Footnote 63] However, NTSB 
officials maintain that the information contained in this report would 
have assisted them with their accident investigations related to fuel 
tank flammability. While the report’s authors did not recommend 
structural changes to the E-4B aircraft, they did recommended taking 
mitigating actions, such as flying the aircraft with the center fuel 
tank empty. 

In July 1996, NTSB began its investigation into the crash of TWA 
Flight 800. As part of the investigation, Boeing was requested to 
search its database for any information concerning heating problems 
with the 747’s center (wing) fuel tanks. According to both NTSB and 
Boeing officials, the Boeing Commercial Airplane Group told NTSB that 
it had no such data. However, in December 1997, the Air Force report 
came to the attention of the Boeing Military Group when it was found 
during a “housecleaning effort.” It was determined that the report was 
the property of the Air Force and subsequently sent to the Air Force 
Oklahoma City Air Logistics Command (OC-ALC). 

Boeing officials told us that the report should have been located and 
turned over to NTSB in 1996, even though the Boeing Military Group 
prepared it for the Air Force. They stated that human error had caused 
an incomplete search to be made of the Boeing records system for 
information on heat studies involving center (wing) fuel tanks. A 
senior Boeing safety official told us that the company has modified 
its electronic library to allow key word searches across all of the 
company’s reports. Its accident investigation processes have also been 
revised to include electronic searches for technical documents. 

In 1998, the Air Force OC-ALC initiated an Independent Review Team 
(IRT) to discuss center (wing) fuel tank issues connected with the E-
4B aircraft in light of recommendations issued by the NTSB following 
its investigation of the TWA Flight 800 accident. The Air Force OC-ALC 
held an IRT meeting in March 1999 to continue to review safety issues 
concerning the center (wing) fuel tank of the E-4B aircraft. As part 
of that meeting, the Air Force included the report on the meeting 
agenda. Air Force officials told us that the report was put on the 
agenda to show that the E-4B aircraft was equipped somewhat 
differently and was capable of operating under more difficult 
conditions than the commercial 747, not for safety reasons. 
Participants in this meeting included officials from Boeing’s 
Commercial Airplane Group and Military Group and NTSB. Officials of 
both Boeing’s Commercial Airplane Group and NTSB told us that this was 
the first time they had heard about the report. 

Air Force OC-ALC officials told us that when Boeing brought the report 
to their attention, it was placed on the IRT agenda for discussion. 
These officials said that they did not intentionally withhold the 
report from the NTSB because both military and civilian personnel in 
their organization considered it to be an operational or readiness 
study, not a safety study. The NTSB director told us that, after the 
March 1999 IRT meeting, NTSB requested a copy of the entire study from 
the Air Force, but instead received a summary. In June, after 
intervention by a U.S. Senate committee,[Footnote 64] the Air Force 
provided the entire study to NTSB. 

A senior NTSB official told us that it is not likely that earlier 
sharing of the report’s findings would have prevented the crash of TWA 
Flight 800. However, had NTSB received the study in 1996 following the 
crash of TWA Flight 800, it would have saved valuable time and 
resources in conducting its investigation. Both the NTSB’s chairman 
and director of aviation noted that the study might have been very 
helpful to the NTSB in its 1990 investigation of a Boeing 737 aircraft 
explosion at Manila Airport in the Philippines—the explosion occurred 
in the aircraft’s center fuel tank. According to both officials, it is 
possible that, if they had received the Boeing study by 1990, safety 
recommendations made as a result of the TWA Flight 800 crash could 
have been issued sooner. 

In August 2000, NTSB released its report on the TWA Flight 800 
accident, which included the following statement regarding the report 
Boeing prepared for the Air Force on fuel tank overheating in the E4-B: 

The Safety Board recognizes that the military variant of the 747 is 
not directly comparable to the civilian 747 and that the focus of that 
study was fuel pump functionality, not flammability. Nonetheless, it 
is unfortunate that potentially relevant information about 747 center 
wing [fuel] tank overheating and corrective measures were not provided 
to the FAA or to 747 operators earlier. 

[End of section] 

Appendix VIII: Case Study on Strandflex Control Cable: 

In January 1999, a former employee of the Strandflex Company alleged 
in federal court that the corporation was not conducting quality 
assurance tests to ensure that its wire rope used in the assembly of 
aircraft control cables met military specifications. According to the 
Department of Defense (DOD), this wire rope is critical to the safe 
operation of flight control systems (e.g., aircraft rudders, wing 
flaps, brakes, and steering) on affected aircraft. However, Federal 
Aviation Administration (FAA) officials contend that this wire rope is 
not always critical to flight safety because civil federal aviation 
regulations require that aircraft control systems incorporate 
redundancies, meaning that failure of control cables would not cause 
loss of the airplane.[Footnote 65] 

In response to the allegation against the Strandflex Company, the 
Defense Criminal Investigative Service initiated an investigation and 
an independent test by DOD demonstrated the wire rope did not 
consistently meet strength requirements. The Department of Defense 
Office of Inspector General (DODIG) alerted the military services and 
FAA concurrently in May 1999. The military services took prompt action 
to notify responsible officials to assess the extent of safety hazards 
and correct them. FAA took just over a year to notify the civil 
aviation community. FAA officials acknowledged that there was a delay, 
but said that they had assessed the situation and concluded that it 
did not require urgent action. However, the agency’s inaction resulted 
in a Department of Transportation Office of Inspector General (DOTIG) 
investigation into the delay and FAA’s overall process for issuing 
notifications of unapproved parts. On May 30, 2001, the Strandflex 
Company admitted to making false claims to the United States and 
falsely certifying that its aircraft control cable wire rope met U.S. 
military specifications and was ordered by a U.S. District Court judge 
to pay a criminal fine and restitution. 

DOTIG Has Reported That FAA Delayed Action on Strandflex Concerns: 

Concerned about FAA’s delay in notifying air carriers of possible 
problems with Strandflex cables, a June 2000 Congressional request 
called for the DOTIG to investigate, among other things, the 
timeliness and effectiveness of FAA’s response to information about 
possible flaws in the Strandflex control cable. 

In March 2001, the DOTIG reported that FAA did not act in a timely 
manner in response to the information it received about Strandflex, 
confirming that just over a year had passed between the time that the 
DODIG notified FAA about possible problems with Strandflex and the 
date that FAA published an Unapproved Parts Notification (UPN) on 
Strandflex. A UPN disseminates information about unapproved parts to 
the civil aviation community.[Footnote 66] 

Furthermore, the DOTIG identified three primary factors that accounted 
for FAA’s untimely response: FAA (1) misfiled the initial 
notification, resulting in an initial delay of approximately 3 months; 
(2) spent an additional month forwarding a Suspect Unapproved Parts 
investigative request to the New England Regional office for further 
investigation; (3) delayed an additional 4 months because a legal 
challenge made it reluctant to issue advisory field notifications 
about suspect unapproved parts.[Footnote 67] 

FAA Has Taken Action to Improve Communication with DOD in Response to 
the DOTIG Investigation of Strandflex: 

FAA notified the DODIG in August 2000 of the need for DOD to send 
alert messages pertaining to suspect unapproved parts directly to 
FAA’s Suspect Unapproved Parts Program Office. This action was taken 
in response to the DOTIG’s investigation of FAA’s delay in alerting 
the civil aviation community about potential quality assurance 
problems with Strandflex wire rope. Specifically, DOD alerts about 
suspect unapproved parts were being sent to FAA’s Civil Aviation 
Security Office[Footnote 68] rather than FAA’s Suspect Unapproved 
Parts Program Office. While the DOTIG did not identify this as a key 
contributor to the year-long delay by FAA, such simple communication 
breakdowns as not sending safety notifications to all responsible 
officials could lead to delays in addressing potential hazards. In its 
response to the DOTIG finding of weaknesses in FAA’s overall 
processing of UPNs, the FAA manager for the Suspect Unapproved Parts 
Program Office advised the DOTIG that corrective action had been taken 
to ensure that all DOD alert messages were now sent directly to FAA’s 
Suspect Unapproved Part Program Office. According to FAA and DOD 
officials, while FAA’s Office of Civil Aviation Security remains the 
addressee in the official letter from DOD alerting FAA to potential 
problems with suspect unapproved parts, the FAA Unapproved Parts 
Program Office is included on DOD’s list of facsimile recipients and 
receives notifications immediately after signature. 

[End of section] 

Appendix IX: Comments from the Under Secretary of Defense: 

Office of The Under Secretary of Defense: 
Acquisition, Technology	and Logistics: 
3000 Defense Pentagon: 
Washington, DC 20301-3000: 

January 14, 2002: 
	
Mr. Peter Guerrero: 
Director, Physical Infrastructure Issues: 
U.S. General Accounting Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Mr. Guerrero: 

This is the Department of Defense (DoD) response to the GAO draft 
report, "Aviation Safety: FAA and DoD Communication and Response to 
Similar Safety Concerns," dated November 30, 2001 (GAO Code 395001/GAO-
02-77). 

DoD agrees with the report and has the attached comments. 

Thank you for the opportunity to review the final draft report. Like 
the Federal Aviation Administration, we are most concerned about 
aviation safety and look forward to a closer working relationship. 

My action officer is Mr. Craig Schilder, who can be reached at (703) 
604-1612 or craig.schilder@osd.mil if you have any questions. 

Sincerely, 

Signed by: 

Raymond F. DuBois, Jr. 
Deputy Under Secretary of Defense (Installations and Environment): 

Attachments: As stated: 

GAO Draft Report — Dated November 30, 2001: 
GAO Code 395001/GAO-02-77: 
"Aviation Safety: FAA and DOD Communication And Response To Similar 
Safety Concerns" 

Department Of Defense Technical Comments: 

1. Page 3, paragraph 1, line 9 and page 11, paragraph 1. Replace: 
"...five aviation safety positions were abolished" with "...five 
safety positions were abolished." Reason: OSD did not have 5 safety 
positions that were dedicated to only aviation safety. In fact the 
aviation safety responsibilities were shared by all. 

2. Page 36: Paragraph 2, line 2, Replace "factual and privileged" with 
(safety investigation reports) contain two types of information 
"nonprivileged" and "privileged". Reason: Proper identification of the 
report data. 

3. Page 40, Replace the first two sentences under the heading of 
United States Air Force. Delete: According to an Air Force wiring 
expert, the Air Force did not experience any problems with aromatic 
polyimide but were aware of the concerns raised by the Navy and Coast 
Guard. It sponsored the development of new wire insulation, the TKT 
Composite (Telfon-Kapton-Teflon) manufactured by DuPont, that 
eliminated problems exhibited by aromatic polyimide alone. 

Page 40, Insert: According to an Air Force wiring expert, the Air 
Force also experienced failures associated with aromatic polyimide 
wiring and took steps to mitigate failures. It was also aware of the 
concerns raised by the Navy and sponsored a research program that led 
to the development of a composite wiring construction 
(Teflon/Kapton/Teflon) that mitigated many of the problems exhibited 
by aromatic polyimide. 

Reason: Air Force requested clarification. 

Department Of Defense Comments To The Recommendation: 

Recommendation: The GAO recommended that the Secretary of Defense 
develop a memorandum of agreement (MOA) with the Administrator of the 
Federal Aviation Administration. The MOA would ensure the systematic 
exchange of critical safety information. The MOA should define the 
types of safety information to be exchanged, the mechanisms for 
exchanging this information, and the parties responsible for this 
exchange. The MOA should also establish a mechanism for the two 
departments to exchange information on how they have responded to 
specific safety concerns. (Page 23/GAO Draft Report) 

DOD Response: 

We agree that a memorandum of agreement with the Federal Aviation 
Administration (FAA) would enhance the exchange of critical 
information, even though several Navy and Air Force organizations 
frequently hold meetings with the FAA. Also, we have two directives 
that require exchange of critical aviation safety information. 

[End of section] 

Appendix X: GAO Contacts and Staff Acknowledgments 

GAO Contacts Peter F. Guerrero (202) 512-2834 

Acknowledgments In addition to the individual named above, Aaron 
Casey, Beverly Dulaney, Colin Fallon, David Hooper, Maren McAvoy, Sara-
Ann Moessbauer, Robert White, and Mario Zavala made key contributions 
to this report. 

[End of section] 

Footnotes: 

[1] For the balance of the report we refer to FAA and the military 
services, rather than FAA and DOD. We recognize that DOD has ultimate 
authority for directing the services’ actions on aviation safety 
oversight. Also, unless otherwise noted, the Coast Guard, which is a 
part of Department of Transportation (DOT), is included under the 
discussions of the military services. Despite its peacetime missions, 
the Coast Guard’s aviation safety oversight activities parallel those 
of the military services. 

[2] Traffic Alert and Collision Avoidance Systems (TCAS) alert pilots 
to potential collisions with other airborne aircraft, and Ground 
Proximity Warning Systems (GPWS) alert pilots to impending collisions 
with terrain. 

[3] The Coast Guard normally performs multiple civil missions, such as 
maritime search and rescue, law enforcement, and environmental 
protection. During wartime, the Coast Guard operates under the 
authority of the Department of the Navy. 

[4] Both the Navy and Coast Guard fly their aircraft in close 
proximity to water, often for extended periods of time, which can 
corrode aircraft. For example, Coast Guard helicopters take on water 
from rescue swimmer training and rescue operations and are often not 
protected from moist conditions due to a lack of adequate hangar space. 

[5] For purposes of this report, “similar aircraft” refers to aircraft 
types that civilian and military entities operate, such as the Boeing 
737, 747, and DC 10. In some cases the military versions have been 
modified. 

[6] The Navy is currently installing GPWS and plans to install the 
enhanced version sometime in the future. 

[7] Helicopters can stop, pedal turn, and hover, while fixed wing 
aircraft are often operated in a fairly narrow band of forward motion, 
which makes their near-term flight path more predictable. 

[8] The Department of Defense Standard Practice for System Safety 
defines safety critical as “a term applied to any condition, event, 
operation, process or item whose proper recognition, control, 
performance, or tolerance is essential to safety system operation and 
support (e.g., safety critical function). MIL-STD-882D (Feb. 10, 2000). 

[9] Both FAA and the military services also rely on airframe 
manufacturers to collect and maintain data on potential aviation 
safety risks on similar civil and military aircraft and common parts 
and materials. 

[10] FAA officials said that the agency’s distribution of ADs relies 
on the FAA Civil Aircraft Registry and Civil Operations databases. For 
DOD aircraft, FAA distributes ADs according to DOD’s requests. It is 
FAA’s understanding that DOD wants ADs sent to certain specific 
contact offices, not to the operating units. 

[11] Army officials said that AMCOM receives and reviews all emergency 
ADs from FAA and, when necessary, converts them into Safety of Flight 
and Aviation Safety Action Messages. They further noted that this 
centralized control is necessary to ensure compliance and because they 
do not want such FAA notices going to units that are not affected by a 
given message. 

[12] As of July 18, 2001, FAA’s addressee list for emergency ADs 
included five U.S. military recipients as follows: Naval Air Systems 
Command, Jacksonville, Florida (TPE331 engine); U.S. Army Aviation and 
Troop Command, St. Louis, Missouri (BHT-206 engine); U.S. Air Force, 
Scott Air Force Base (DC-9 and JT8D engine); U.S. Air Force, Oklahoma 
City, Oklahoma (Boeing-737-700); and U.S. Navy, Pentagon (DC-8 and DC-
9). 

[13] Access to FAA’s Web site was disrupted in August 2001 by a 
computer virus. 

[14] FAA is responsible for notifying owners and operators of aircraft 
on the agency’s civil aircraft registry of airworthiness directives. 
Military aircraft are not listed in this directory. 

[15] FAA officials also told us that civil aircraft cable assemblies 
are often designed to be five times stronger than they need to be. 
Furthermore, once aircraft control cables are assembled, they are 
tested in a manner that would reveal weaknesses in the wire rope. 

[16] DOD did not send its notification to FAA’s program office 
primarily responsible for suspect unapproved parts. Rather it followed 
the standard procedure of transmitting it to FAA’s Office of Civil 
Aviation Security and to the DOTIG. 

[17] OIG Investigation of Responses to Information About a Serious 
Flaw in Aircraft Cables, U.S. Department of Transportation, Office of 
the Inspector General (Mar. 2, 2001, Report Number CC-2000-290). 

[18] Federal Employee Retirements: Expected Increase Over the Next 5 
Years Illustrates Need for Workforce Planning [hyperlink, 
http://www.gao.gov/products/GAO-GAO-01-509], Apr. 27, 2001. 

[19] A replacement began work in late August 2001. 

[20] Among the military services, the Army has taken a unique step to 
develop and maintain the continuity of its aviation safety expertise 
by creating a separate career field for aviation safety at the Warrant 
Officer level. The other services typically rotate their military 
personnel through aviation safety positions or assign aviation safety 
as a collateral duty. 

[21] [hyperlink, http://www.gao.gov/products/01-509], April 27, 2001. 

[22] GS-1825—Aviation Safety Series includes positions that involve 
primarily developing, administering, or enforcing regulations and 
standards concerning civil aviation safety, including (1) the 
airworthiness of aircraft and aircraft systems; (2) the competence of 
pilots, mechanics, and other airmen; and (3) safety aspects of 
aviation facilities, equipment, and procedures. These positions 
require knowledge and skill in the operation, maintenance, or 
manufacture of aircraft and aircraft systems. As of September 30, 
2000, FAA also had nine employees in the 1815 Air Safety Investigating 
Series, which are included in the percentages of safety employees 
eligible for retirement cited above. 

[23] Retirement eligibility rates are calculated for those staff 
working as of September 30, 2000. Some of these staff might have 
retired between September 30, 2000, and September 10, 2001, when these 
numbers were calculated. Any other separations or new hires since 2000 
are not reflected in these retirement rates. 

[24] The workload of FAA’s certification staff is a central issue 
receiving attention. FAA currently provides airworthiness 
certification services to the military at no cost. Among the options 
currently being considered is an arrangement under which DOD would 
reimburse FAA for the services it provides. Otherwise, the military 
services would need to develop in-house expertise to certify civil 
aircraft types operated by the military. 

[25] The case studies selected represent a judgmental sample. 

[26] For purposes of this report, we refer to FAA and the military 
services, rather than FAA and DOD. We recognize that DOD has ultimate 
authority for directing the services’ actions on aviation safety 
oversight. Also, unless otherwise noted, the Coast Guard, which is a 
part of the Department of Transportation (DOT), is included under the 
discussions of the military services. Despite its peacetime missions, 
the Coast Guard’s aviation safety oversight activities parallel those 
of the military services. 

[27] OPM’s Central Personnel Data File: Data Appear Sufficiently 
Reliable to Meet Most Customer Needs [hyperlink, 
http://www.gao.gov/products/GAO/GGD-98-199], Sept. 30, 1998. 

[28] The Transport Airplane Directorate issues ADs for airplanes type 
certificated under 14 C.F.R. 25, which includes large commercial 
aircraft and many smaller business jets. The Small Airplane 
Directorate in Kansas City, Missouri, issues ADs for airplanes type 
certificated under a separate regulation (14 C.F.R. 23), which include 
many airplanes in commercial service some of which are considered 
commuter airplanes. Other directorates issue ADs for rotorcraft, 
engines, and propellers. The directorate of the geographical area in 
which the manufacturer is located normally issues ADs for appliances 
and parts. 

[29] Technically, the Army (1) identifies hazards, (2) assesses 
hazards, (3) develops controls and makes decisions, (4) implements 
controls, and (5) supervises and evaluates. The Air Force has further 
divided these steps to create a six-step process: (1) identify 
hazards, (2) assess risks, (3) analyze risk control measures, (4) make 
control decisions, (5) implement risk control, and (6) supervise and 
review [implementation of control measures]. The Coast Guard uses a 
seven-step process: (1) identify mission tasks, (2) identify hazards, 
(3) assess risks, (4) identify options, (5) evaluate risk versus gain, 
(6) execute decision, and (7) monitor situation. FAA’s process 
includes (1) receiving and compiling problem reports; (2) evaluating 
the impact on safety, which includes an assessment of associated risk; 
(3) determining what, if any, corrective action is warranted; and (4) 
implementing corrective action (e.g., issuing an AD). 

[30] Department of Defense Instruction, DOD Safety and Occupational 
Health Program, Number 6055.1, August 19, 1998 and Department of 
Defense Instruction, Accident Investigation, Reporting, and Record 
Keeping, Number 6055.7, October 3, 2000. 

[31] FAA Order 8040.4 requires that safety risk management be used for 
all high consequence decisions ($100 million per year) and requires a 
formal, documented plan/process for each staff office and line of 
business. 

[32] The FAA Aircraft Certification Service also issues Special 
Airworthiness Information Bulletins to communicate information to 
enhance safety, but not to mandate that a specific action be taken. 

[33] Aviation Rulemaking: Further Reform Is Needed to Address Long-
standing Problems [hyperlink, http://www.gao.gov/products/GAO-01-821], 
July 9, 2001. 

[34] The Coast Guard does not certify the airworthiness of aircraft in 
a similar manner to FAA. While FAA certification is sometimes a 
requirement for the aircraft it purchases, subsequent changes to 
aircraft do not receive such certification. 

[35] There is no requirement that the military services maintain their 
civil derivative aircraft in accordance with FAA standards. However, 
doing so allows an aircraft to be sold for use in civil aviation at a 
later date. 

[36] Under 49 USC 1131 (a)(2)(B), the NTSB will surrender lead 
investigation status on a transportation accident when the attorney 
general, in consultation with the chairman of the Safety Board, 
notifies the board that circumstances reasonably indicate that the 
accident may have been caused by an intentional criminal act. At this 
point, the Federal Bureau of Investigation takes over the 
investigation, and the NTSB only provides requested support. 

[37] Following aircraft accidents, the military services’ “safety 
investigations” are conducted strictly for mishap prevention purposes, 
while “legal investigations” (also known as collateral investigations) 
cover all other issues related to an accident. 

[38] While there is no equivalent “privilege” protection for civil 
aviation, there are some provisions for protecting the disclosure of 
data, such as closing some parts of the court docket and disallowing 
the release of cockpit voice recordings. 

[39] Witness statements taken during “safety investigations” are 
deemed privileged only if a promise of confidentiality is made. 

[40] Privileged material also includes deliberative and pre-decisional 
information that is safeguarded to ensure a candid exchange among 
parties in the “safety investigation” report prior to final approval. 

[41] Aviation Rulemaking: Further Reform Is Needed to Address Long-
standing Problems [hyperlink, http://www.gao.gov/products/GAO-01-821], 
July 9, 2001. 

[42] Kapton is Dupont’s trade name for a specific type of wire 
insulation, known as aromatic polyimide, which is also made by another 
manufacturer. Aromatic polyimide will be referred to throughout this 
report in place of Kapton, its military specification (MIL-W-81381) or 
Boeing’s Military Specification (BMS 13-51). 

[43] The wire was initially produced in 1966 and used in Lockheed L-
1011s, Douglas MD-80s and MD-11s, Boeing 727s, 737s, 747s, 757s, 767s, 
Grumman F-14s, McDonnell F-15s and F/A-18s, and General Dynamics F-16s. 

[44] Arc-tracking temperatures vary according to wire size and the 
amount of electrical current. 

[45] A short circuit occurs when there is an abnormal connection 
between two points of a circuit that results in excess and often 
damaging flow of current between these points. 

[46] In June 1998, the Air Transport Association (ATA) formed the 
Aging Systems Task Force. The group was later cosponsored and 
rechartered by the Aging Transport Systems Rulemaking Advisory 
Committee. 

[47] The six airplane models used were two DC-9s, one DC-10, one 747, 
one L-1011, and one A300. 

[48] This second major inspection effort was entitled the Intrusive 
Inspection Working Group. 

[49] Specifically, TCAS I provides pilots with nonverbal alerts of 
potential collisions, while the more advanced version, TCAS II, 
provides pilots with verbal advice to execute an evasive maneuver 
(e.g., “climb,” “descend,” or “do nothing”) to avoid other aircraft. 

[50] Because FAA expected that a variety of EGPWS technologies could 
be developed that would meet the improved standards, it is currently 
using the broader term “terrain awareness and warning system (TAWS).” 

[51] This applies to 14 C.F.R. 91 (general aviation), 14 C.F.R 121 
(commercial airlines), and 14 C.F.R. 135 (aircraft with six or more 
passenger seats). 

[52] Some aircraft are “re-manufactured” rather than being replaced. 
This involves refurbishing aircraft to varying degrees to install 
updated parts and materials. 

[53] Helicopters can stop, pedal turn, and hover, while fixed wing 
aircraft are often operated in a fairly narrow band of forward motion, 
which makes their near-term flight path more predictable. 

[54] Air Carrier Voluntary Flight Operational Quality Assurance 
Program, Flight Safety Foundation (1992). 

[55] The National Transportation Safety Board (NTSB), the official 
source of information on airline accidents, defines accidents as 
events in which individuals are killed or suffer serious injury, or 
the aircraft is substantially damaged. Incidents are defined as 
occurrences other than accidents associated with the operation of an 
aircraft that affect or could affect the safety of operations (49 
C.F.R. 830.2). In the military, Class A Mishaps are accidents and 
Class B and C Mishaps are serious incidents. 

[56] These data typically include the parameters required to be 
collected on the aircraft’s flight data recorder plus many more 
parameters. 

[57] Aviation Safety: Efforts to Implement Flight Operational Quality 
Assurance Programs (RCED-98-10, Dec. 2, 1997). 

[58] Airlines submit data to FAA, which determines if these data are “
voluntary.” For example, any data generated as part of a compliance 
requirement must be given to FAA. 

[59] The Federal Aviation Reauthorization Act of 1996 requires FAA to 
protect aviation safety and security information that is submitted 
voluntarily (49 U.S.C. 40123). 

[60] Airlines have the advantage of analyzing FOQA data from aircraft 
that typically “fly very prescribed procedures from point A to point B.”
In contrast, military aircraft are operated using a wide range of 
maneuvers that vary by aircraft type and mission, while comparable 
maneuvers are simply not done in civil aircraft. As a result, the 
military may find it more difficult to analyze FOQA data. 

[61] Each of the military services has a safety chief responsible for 
overseeing safety issues, including aviation. 

[62] Transportation Safety: Information Concerning Why a 1980 Aircraft 
Report Was Not Provided Earlier to the National Transportation Safety 
Board [hyperlink, http://www.gao.gov/products/GAO/OSI-00-2R], Nov. 3, 
1999. 

[63] According to FAA, the philosophy at the time and until shortly 
after the TWA Flight 800 accident was that no ignition sources be 
allowed inside of fuel tanks. It was not until August 1996 that a 
Boeing 747 flight test was conducted to investigate what effect the 
center tank heating would have on fuel vapor flammability. FAA was 
aware that aircraft operated with the fuel tank in the flammability 
range under certain conditions. This is why FAA regulations require 
the elimination of ignition sources. However, NTSB has recommended a 
different approach to the problem; namely “inerting” the fuel so that 
it would not explode even if it came into contact with an ignited 
source. 

[64] Subcommittee on Administrative Oversight and the Courts, 
Committee on the Judiciary, U.S. Senate. 

[65] FAA officials also told us that civil aircraft cable assemblies 
are often designed to be five times stronger than they need to be. 
Furthermore, once aircraft control cables are assembled, they are 
tested in a manner that would reveal weaknesses in the wire rope. 

[66] OIG Investigation of Responses to Information About a Serious 
Flaw in Aircraft Cables, U.S. Department of Transportation, Office of 
the Inspector General (Mar. 2, 2001, Report Number CC-2000-290). 

[67] FAA attributed its reluctance to a September 1999 challenge from 
an attorney representing members of the aviation community regarding 
the agency’s authority to issue such notifications. The attorney cited 
concerns that field notifications are purely advisory in nature, that 
no corrective action is mandatory, and that the companies named in 
field notifications are not afforded the opportunity to respond to the 
issues—-violating their due process rights. 

[68] FAA’s Office of Civil Aviation Security, Internal Security 
Investigation Program, often provides investigative services at the 
request of other FAA organizational units on a wide range of subjects, 
including unapproved aircraft parts. 

[End of section] 

GAO’s Mission: 

The General Accounting Office, the investigative arm of Congress, 
exists to support Congress in meeting its constitutional 
responsibilities and to help improve the performance and accountability 
of the federal government for the American people. GAO examines the use 
of public funds; evaluates federal programs and policies; and provides 
analyses, recommendations, and other assistance to help Congress make 
informed oversight, policy, and funding decisions. GAO’s commitment to 
good government is reflected in its core values of accountability, 
integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through the Internet. GAO’s Web site [hyperlink, 
http://www.gao.gov] contains abstracts and fulltext files of current 
reports and testimony and an expanding archive of older products. The 
Web site features a search engine to help you locate documents using 
key words and phrases. You can print these documents in their entirety, 
including charts and other graphics. 

Each day, GAO issues a list of newly released reports, testimony, and 
correspondence. GAO posts this list, known as “Today’s Reports,” on its 
Web site daily. The list contains links to the full-text document 
files. To have GAO e-mail this list to you every afternoon, go to 
[hyperlink, http://www.gao.gov] and select “Subscribe to daily E-mail 
alert for newly released products” under the GAO Reports heading. 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. General Accounting Office: 
441 G Street NW, Room LM: 
Washington, D.C. 20548: 

To order by Phone: 
Voice: (202) 512-6000: 
TDD: (202) 512-2537: 
Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]: 
E-mail: fraudnet@gao.gov: 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Public Affairs: 

Jeff Nelligan, managing director, NelliganJ@gao.gov: 
(202) 512-4800: 
U.S. General Accounting Office: 
441 G Street NW, Room 7149:
Washington, D.C. 20548: 

[End of document]