AVIATION SAFETY

Additional Oversight 

Planning by FAA 

Could Enhance Safety 

Risk Management

Report to the Subcommittee on 

Aviation, Committee on Transportation 

and Infrastructure, House of 

Representatives

June 2014

GAO-14-516

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-516, a report to the 

Subcommittee on Aviation, Committee on 

Transportation and Infrastructure, House of 

Representatives

June 2014

AVIATION SAFETY

Additional Oversight Planning by FAA Could Enhance 

Safety Risk Management 

Why GAO Did This Study

The U.S. aviation system is one of the 

safest in the world, reflecting the work 

of FAA, industry, and others to 

continually improve safety. To further 

enhance safety, in 2005, FAA began

adopting a proactive, data-driven, riskbased approach to managing safety,

referred to as SMS, and has proposed 

rules that would require SMS

implementation for certain segments of 

the aviation industry.

GAO was asked to review SMS

implementation in the aviation industry. 

This report addresses (1) the status of 

SMS implementation at FAA and in the 

aviation industry; (2) key challenges 

that FAA and industry face in 

implementing SMS; and (3) actions 

aviation stakeholders believe FAA 

could take to improve SMS 

implementation. GAO reviewed FAA

documents and interviewed FAA

officials. GAO also interviewed

representatives from 20 selected 

aviation stakeholders, including 

commercial air carriers, certificated 

airports, repair stations, and design 

and manufacturing firms. Because the 

stakeholders were non-statistically 

selected based on their size, SMS 

implementation, and the industry 

segment represented, their views

cannot be generalized to the industry 

or any industry segment.

What GAO Recommends

GAO recommends that FAA develop a 

plan for overseeing industry SMS

implementation that includes providing 

guidance and training for FAA 

inspectors by the time final rules are 

published. GAO provided DOT with a 

draft of this report for comment. DOT 

provided technical corrections which 

were incorporated as appropriate.

What GAO Found

The Federal Aviation Administration’s (FAA) Air Traffic Organization completed 

Safety Management System (SMS) implementation in 2010, and five other FAA 

organizations are implementing it now. SMS is an approach to collect and 

analyze safety data to identify hazards, manage risks, and take corrective action 

before an accident occurs. FAA’s implementation activities include developing 

internal SMS guidance and procedures and using them to, among other things, 

identify hazards in the aviation system and provide oversight of the aviation 

industry. For example, FAA’s Flight Standards Service is developing an SMSbased oversight system for the commercial air carriers it oversees. Although 

SMS is not yet required for commercial air carriers, airports, or any other industry 

segment, some are voluntarily implementing SMS as part of several FAA pilot 

projects. Of the 83 commercial air carriers, 77 are in the process of implementing 

SMS. FAA anticipates publishing a final rule in September 2014 requiring 

commercial air carriers to implement SMS. To a lesser extent, other industry 

segments are voluntarily implementing SMS. For example, according to FAA, 9

of the nation’s largest airports are implementing SMS. FAA issued a proposed 

rule for airport SMS implementation, but development of a final rule has been 

delayed, and FAA has not yet determined if it will propose rules for other industry 

segments. Stakeholders and FAA officials speculated that the other industry 

segments may be waiting to implement SMS until FAA issues additional 

guidance or a final rule.

According to FAA officials, completing the rulemaking processes for commercial 

air carriers and airports has been a primary challenge to industry SMS 

implementation. Officials stated that one reason for delay has been difficulty in 

developing the benefit-cost analyses required for significant regulatory action.

However, FAA is revisiting these analyses through the ongoing rulemaking 

process. Uncertainty about FAA plans for SMS oversight was among the key 

challenges for aviation industry SMS implementation. Although some inspector 

training has been provided, representatives from 9 of the 20 stakeholders GAO

interviewed cited concerns that FAA inspectors may not be adequately trained to 

oversee industry SMS activities, and 6 expressed concerns that inspectors 

throughout FAA may not consistently interpret SMS regulations. However, FAA 

has not completed plans for its SMS oversight activities, including inspector

training, and officials stated that they would not do so until the final rule is 

published. Without adequate planning of oversight and training of inspectors, 

FAA could find itself unprepared to meet its oversight responsibilities when final 

SMS rules are published.

Twelve of the 20 aviation stakeholders GAO spoke with identified additional FAA 

actions that could improve their SMS implementation efforts. For example, 4 

stakeholders stated that providing SMS training to their employees was a 

challenge, and 2 suggested that FAA could assist by providing them access to 

FAA’s SMS training. FAA indicated that it is considering industry stakeholder 

training needs and provided training through the pilot projects. Fourteen

stakeholders were pleased with FAA’s collaboration and communication, but 6 of 

them stated that this effort could be broadened. FAA updates its SMS website 

information, and FAA’s most significant industry SMS forum is focusing more on 

SMS implementation.

View GAO-14-516. For more information, 

contact Gerald L. Dillingham, Ph.D., at (202) 

512-2834 or dillinghamg@gao.gov. 
Page i GAO-14-516 Aviation Safety

Letter 1

Background 3

FAA’s Internal Implementation of SMS Continues, While Aviation 

Industry Segments Are in Various Stages of Voluntary 

Implementation 7

FAA and Stakeholders Cited Rulemaking, Data Issues, and 

Stakeholder Uncertainty as Key Challenges to Implementing 

SMS 15

Stakeholders Identified Additional Actions FAA Could Take to 

Improve SMS Effectiveness and Address Implementation 

Challenges 26

Conclusions 29

Recommendation for Executive Action 29

Agency Comments 30

Appendix I Objectives, Scope, and Methodology 31

Appendix II GAO Contact and Staff Acknowledgments 35

Related GAO Products 36

Tables

Table 1: Flight Standards’ Safety Management System 

Implementation Levels for Commercial Air Carriers 10

Table 2: Changes in Stakeholder and FAA Inspector Roles under 

a Safety Management System 18

Table 3: Industry and International Interviewees 32

Table 4: Aviation Industry Stakeholder Interviewees 33

Figures

Figure 1: The Four Components of Safety Management Systems 4

Figure 2: Selected FAA Organizations Implementing a Safety 

Management System and Oversight Responsibilities, as 

of June 2014 7

Contents
Page ii GAO-14-516 Aviation Safety

Figure 3: Rulemaking Timeline for the Commercial Air Carrier 

Safety Management System Requirement, as of June 

2014 11

Figure 4: Rulemaking Timeline for the Certificated Airport Safety 

Management System Requirement, as of June 2014 13

Abbreviations

ANPRM advance notice of proposed rulemaking

ARC aviation rulemaking committee

CFR Code of Federal Regulations

DOT Department of Transportation

FAA Federal Aviation Administration

FOIA Freedom of Information Act

ICAO International Civil Aviation Organization

NTSB National Transportation Safety Board

NextGen Next Generation Air Transportation System

NPRM notice of proposed rulemaking

SMS safety management system

SNPRM supplemental notice of proposed rulemaking

SSP state safety program

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-14-516 Aviation Safety

441 G St. N.W.

Washington, DC 20548

June 25, 2014

The Honorable Frank A. LoBiondo

Chairman

The Honorable Rick Larsen

Ranking Member

Subcommittee on Aviation

Committee on Transportation and Infrastructure

House of Representatives

The U.S. aviation system is one of the safest in the world with an 

extremely low accident rate. This record reflects the efforts of the Federal 

Aviation Administration (FAA), air carriers, airports, aviation 

manufacturers, the National Transportation Safety Board (NTSB), and 

others to continually improve aviation safety. Focus on safety continues to 

be important, particularly in light of projected air traffic growth over the 

next 20 years. In keeping with this anticipated growth, FAA is seeking to 

further enhance safety by shifting to a proactive, data-driven, risk-based 

approach to safety oversight referred to as a safety management system 

(SMS). SMS is a formalized process that involves collecting and 

analyzing data on aviation operations to identify emerging safety 

problems, determining risk severity, and mitigating that risk to an 

acceptable level. SMS is becoming the standard throughout the global 

aviation industry. The International Civil Aviation Organization (ICAO)1

requires SMS for the management of safety risk in air operations, 

maintenance organizations, air traffic services, and airports as well as for 

certain flight-training operations and organizations that design and 

manufacture aircraft. Further, ICAO has published safety management 

requirements for its member countries that mandate that civil aviation 

authorities—such as FAA—establish an SMS.2 FAA’s internal SMS 

approach is designed to meet ICAO requirements. ICAO also directs civil 

aviation authorities to require that certain types of aviation service 

providers implement SMS. The adoption of SMS is important because the 

 1

ICAO is an agency of the United Nations that promotes the safe and orderly development 

of international civil aviation worldwide. ICAO sets standards and regulations necessary 

for aviation safety, security, and efficiency and serves as a forum for collaboration among 

its 191 member states.

2

ICAO refers to SMS as employed by civil aviation authorities as “state safety programs.”
Page 2 GAO-14-516 Aviation Safety

low accident rate increases the importance of analyzing incident and 

other data for root causes and indicators of potential hazards. According 

to FAA, SMS can also address organizational and management issues 

that have been identified as contributing to past accidents.

To this end, FAA is (1) engaged in implementing SMS internally across 

selected organizations within the agency, (2) has undertaken SMS pilot 

projects for certain segments of the aviation industry, and (3) has 

developed proposed regulations that would require commercial air 

carriers and certificated airports to implement SMS.3

 In 2012, we 

reported on FAA’s internal implementation of SMS.4

 For this report, you 

asked us to focus on the status of SMS implementation in the aviation 

industry. We examined the status of SMS implementation in four industry 

segments—commercial air carriers, certificated airports, design and 

manufacturing firms, and repair stations. We also examined the current 

status of FAA’s internal SMS implementation efforts and FAA’s 

development of SMS regulations. Specifically, this report addresses the 

following questions:

1. What is the status of SMS implementation within FAA and for key 

segments of the aviation industry, including certificated airports, 

commercial air carriers, repair stations, and design and manufacturing 

firms? 

2. What are the key challenges FAA and the aviation industry face in 

implementing SMS? 

3. What additional actions do aviation stakeholders believe FAA could 

take to improve SMS implementation and potential effectiveness?

 3

FAA issues operating certificates under 14 C.F.R. Part 121 to air carriers offering 

scheduled, commercial air carrier service on airplanes with a capacity of 10 or more 

passengers or a maximum payload capacity of more than 7,500 pounds. For purposes of 

this report, we will refer to these as commercial air carriers. FAA issues operating 

certificates to airports that (1) service unscheduled air carrier aircraft with more than 30 

seats; or (2) serve scheduled air carrier operations with more than 9 seats under 14 C.F.R 

Part 139.1(a)(1) and (2). For purposes of this report we will refer to these as certificated 

airports. According to the 2013-2017 National Plan of Integrated Airport Systems there are 

545 part 139 certificated airports in the United States. FAA issues type certificates to 

design and manufacturing firms under 14 C.F.R. Part 21 for the design and manufacturing 

of aircraft, engines, propellers, and other aircraft parts. FAA issues certificates to repair 

stations under 14 C.F.R. Part 145.

4

GAO, Aviation Safety: Additional FAA Efforts Could Enhance Safety Risk Management, 

GAO-12-898 (Washington D.C.: Sept. 12, 2012).
Page 3 GAO-14-516 Aviation Safety

To assess the status of SMS implementation within FAA and four key 

segments of the aviation industry, we reviewed FAA orders, advisory 

circulars, and pilot program reports as well as FAA guidance for internal 

SMS implementation and for implementation in the aviation industry. We 

also interviewed FAA officials and industry trade group representatives. 

To determine the key challenges FAA and the aviation industry face in 

implementing SMS, we interviewed FAA officials and representatives 

from 20 selected aviation stakeholders—commercial air carriers, 

certificated airports, repair stations, and design and manufacturing 

firms—that participated in SMS pilot projects. These 20 stakeholders, 5 

from each industry segment, were non-statistically selected based on 

size, SMS implementation, and industry sub-segment represented. 

(Results of these interviews cannot be projected to all companies in any 

of the given industry segments). We also reviewed documents from 

FAA’s rulemaking projects for commercial air carriers and certificated 

airports. To identify additional actions FAA could take to improve SMS 

implementation and potential effectiveness, we interviewed the industry 

stakeholders described above and foreign aviation authorities that are 

overseeing SMS implementation, including Australia’s Civil Aviation 

Safety Authority, the European Aviation Safety Agency, and Transport 

Canada. In addition, we interviewed two Canadian airlines and one 

Canadian airport that have implemented SMS. We also interviewed FAA 

officials to obtain their perspectives on potential actions. See appendix I 

for a more detailed description of our scope and methodology.

We conducted this performance audit from May 2013 to June 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe the 

evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

When fully implemented, SMS provides a continuous approach to 

managing safety risk, which FAA expects will improve aviation safety. 

SMS is not an additional safety program that is distinct from existing 

activities that accomplish an entity’s safety mission, such as quality 

management, quality assurance, or similar activities. Rather, SMS 

provides a set of decision-making processes and procedures to plan, 

organize, direct, and control business activities in a manner that 

enhances safety and ensures compliance with regulatory standards. 

According to FAA, the overarching goal of SMS is to improve safety by 

Background
Page 4 GAO-14-516 Aviation Safety

helping ensure that the outcomes of any management or system activity 

incorporate informed, risk-based decision making. 

SMS consists of four key components: (1) safety policy, (2) safety risk 

management, (3) safety assurance, and (4) safety promotion. (See fig.1.) 

Together, these four components are intended to provide a systematic 

approach to achieving acceptable risk levels. FAA provides its personnel 

with guidance on the principles underpinning these components in its 

official orders and other internal FAA guidance. To the industry, FAA 

currently provides SMS guidance via advisory circulars, an SMS 

newsletter, focus groups, and a dedicated page for the SMS program 

office on the FAA website.

Figure 1: The Four Components of Safety Management Systems

FAA is undertaking the transition to SMS in coordination with the 

international aviation community, working with ICAO to adopt applicable 

global standards for safety management. ICAO first mandated SMS 

worldwide for air traffic service providers in 2001. ICAO later specified 

that member states should mandate SMS implementation for airports, air 

carriers, and others by 2009. FAA began SMS implementation in 2005, 

but FAA officials informed ICAO that the agency and industry would not

be able to meet the 2009 deadline. The United States filed a “difference” 

with ICAO—indicating that it does not yet completely comply with the 

standard—with the understanding that implementation is under way and 
Page 5 GAO-14-516 Aviation Safety

that FAA is in the midst of a rulemaking to require SMS for commercial air 

carriers and certificated airports. There have been other actions within the 

United States to encourage SMS implementation. For instance, in 2007, 

NTSB recommended that FAA require all commercial air carriers to 

establish an SMS5 and in 2011 added SMS for all modes of transportation 

to its Most Wanted List.6 NTSB identified SMS as one of the most critical 

changes needed to reduce the number of accidents and save lives. 

FAA’s implementation of SMS will affect how the agency oversees the 

aviation industry. Historically, FAA oversight of airlines, airports, and 

other regulated entities has involved oversight of such things as 

operations and maintenance. Once SMS requirements for industry are in 

place, FAA will continue this oversight, but will also apply SMS principles 

to its processes for oversight. Specifically, the agency will provide 

oversight of the safety management systems of service providers, such 

as commercial air carriers and certificated airports, to help ensure that 

they are managing safety within their operations through SMS.

Internally, FAA has directed the Air Traffic Organization, Airports 

Organization, Aviation Safety Organization (Aviation Safety), the Office of 

Commercial Space Transportation, the Next Generation Air 

Transportation System (NextGen) Office,7 and the Office of Security and 

Hazardous Materials Safety to implement SMS. Within Aviation Safety, 

the Aircraft Certification Service (Aircraft Certification), 8 and the Flight 

 5

NTSB Recommendation A-07-010.

6 NTSB’s Most Wanted List highlights safety issues identified from NTSB accident 

investigations to increase awareness about the issues and recommended safety solutions.

7

The Office of NextGen was originally a part of the Air Traffic Organization. NextGen is a 

long-term initiative to incrementally modernize and transform the national airspace 

system. The objective of the NextGen initiative is to transform the current radar-based 

system to one centered on satellite-based navigation, automated position reporting, and 

digital communications.

8

FAA’s Aircraft Certification Service is responsible for administering safety standards 

governing the design, production, and airworthiness of civil aeronautical products; 

overseeing design, production, and airworthiness certification programs to ensure 

compliance with prescribed safety standards; providing a safety performance 

management system to ensure continued operational safety of aircraft; and working with 

aviation authorities, manufacturers, and other stakeholders to help them successfully 

improve the safety of the international air transportation system.
Page 6 GAO-14-516 Aviation Safety

Standards Service (Flight Standards),

9 among others, are also 

implementing SMS.

Oversight of the aviation industry’s implementation of SMS will be 

conducted by FAA’s inspector workforce, some of whom have been 

involved in SMS pilot programs. The inspector workforce includes 

approximately 4,000 Flight Standards aviation safety inspectors around 

the country who oversee certificate holders, including commercial air 

carriers and repair stations, among others. Approximately 950 aircraft 

certification engineers and inspectors are responsible for overseeing firms 

that design and manufacture aircraft, aircraft engines, propellers, and 

other parts and equipment. The nation’s certificated airports are 

overseen by approximately 40 airport certification inspectors assigned to 

regional offices.

In 2009, FAA issued an Advance Notice of Proposed Rulemaking 

(ANPRM) to solicit comments on establishing a regulatory framework to 

require SMS for various sectors of the aviation industry, including 

commercial air carriers, repair stations, and design and manufacturing 

firms.10 FAA received public comments on the ANPRM but withdrew it11

following a 2010 congressional mandate for FAA to issue a rule requiring 

air carriers to implement SMS.12 FAA subsequently issued a Notice of 

Proposed Rulemaking (NPRM) in November 2010 that would require 

SMS for commercial air carriers.13 FAA simultaneously developed a 

proposed rule for certificated airports and issued an NPRM in October 

2010 that would also require SMS at those facilities.14 The status of 

 9

FAA’s Flight Standards Service sets standards for certification and provides oversight of 

airmen, air operators, air agencies, and designees. It is also responsible for accomplishing 

certification, inspection, surveillance, investigation, and enforcement; setting regulations 

and standards; and managing the system for registration of civil aircraft and all airmen 

records.

1074 Fed. Reg. 36414 (July 23, 2009).

1176 Fed. Reg. 14592 (Mar. 17, 2011).

12Airline Safety and Federal Aviation Administration Extension Act of 2010, Pub. L. No. 

111-216, § 215, 124 Stat 2348, 2366 (The 2010 Act).

1375 Fed. Reg. 68224 (Nov. 5, 2010).

1475 Fed. Reg. 62008 (Oct. 7, 2010).
Page 7 GAO-14-516 Aviation Safety

rulemaking efforts for repair stations and design and manufacturing firms 

are discussed below. 

Five FAA organizations are proceeding with SMS implementation. A sixth 

organization, Air Traffic, completed implementation in 2010. Figure 2 

shows the FAA organizations that are implementing SMS as well as 

industry segments included in this report that these selected

organizations oversee.

Figure 2: Selected FAA Organizations Implementing a Safety Management System and Oversight Responsibilities, as of June

2014

FAA’s Internal 

Implementation of 

SMS Continues,

While Aviation

Industry Segments 

Are in Various Stages 

of Voluntary 

Implementation 

FAA Organizations 

Continue SMS

Implementation
Page 8 GAO-14-516 Aviation Safety

The Air Traffic Organization completed SMS implementation in 2010 and 

now uses SMS-based processes to identify hazards, enact mitigations, 

and assess the extent to which the mitigations are working.15 Since we 

last reported on their progress in 2012, the other organizations—Aviation 

Safety, the Airports Organization, the NextGen Office, and the Office of 

Commercial Space Transportation—have continued SMS implementation 

by developing SMS guidance and establishing internal SMS procedures, 

and an additional organization, the Office of Security and Hazardous 

Materials Safety has begun SMS implementation.

• Aviation Safety—including two of its components, Flight Standards 

and Aircraft Certification—are developing or updating SMS guidance 

and plans, according to FAA officials.16 For example, Flight Standards 

is developing for an SMS-based oversight system for commercial air 

carriers.

• The Airports Organization established procedures for conducting 

safety risk management for certain airport actions that require FAA 

approval.

• At the time of our last report, the NextGen Office and the Office of 

Commercial Space Transportation were implementing SMS in line 

with FAA’s strategic goal in its 2009-2013 Flight Plan to implement 

SMS policy in all appropriate FAA organizations.17 In May 2013, FAA 

issued a revised order that directed these two organizations to

implement SMS.

• In addition, an FAA order directed another organization, the Office of 

Security and Hazardous Materials Safety, to implement SMS.

18 That 

organization is updating its inspections and investigations manual to 

be more consistent with SMS principles and is coordinating with other 

FAA organizations’ SMS efforts to identify hazards in the transport of 

hazardous materials. 

 15The Air Traffic Organization began SMS implementation in 2005, much earlier than 

other FAA organizations. 

16Other components of Aviation Safety are also implementing SMS, but we limited our 

review to Flight Standards and Aircraft Certification because they are responsible for 

oversight of commercial air carriers, repair stations, and design and manufacturing firms.

17FAA, 2009-20013 Flight Plan (Washington, D.C.)

18FAA Order 8000.369A. National Policy: Safety Management System, May 8, 2013. 
Page 9 GAO-14-516 Aviation Safety

Voluntary implementation of SMS varies by industry segment, while FAA 

continues rulemaking to require SMS implementation by commercial air 

carriers19 and certificated airports. Beginning in 2007, FAA initiated 

various pilot projects for commercial air carriers, certificated airports, 

repair stations, and design and manufacturing firms, among others, to

encourage voluntary SMS implementation and to guide rulemaking 

activities. The pilot projects varied among FAA organizations. The 

Airports Organization and Aircraft Certification pilot projects were 

conducted for fixed periods of time, while the Flight Standards pilot 

project, which began in 2007, is ongoing. Flight Standards officials said 

that the pilot project for commercial air carriers would end after the final 

rule is published and that they hope to transition the pilot project for the 

remaining certificate holders (e.g., repair stations) into a more formal 

program. Participant selection for the pilots also varied. FAA selected the 

participants for the Aircraft Certification pilot for design and manufacturing 

firms, while the Flight Standards and Airports Organization pilot project

participants volunteered to participate. The pilot projects are more fully 

described in forthcoming sections of this report. 

While most commercial air carriers—the first industry segment for which 

SMS implementation will be mandatory—are moving forward with 

implementation, a small proportion of certificated airports, repair stations, 

and design and manufacturing firms have begun SMS implementation. 

For example, less than 1 percent of the more than 4,700 repair stations 

are currently implementing SMS. These three industry segments, 

according to FAA officials and industry stakeholders, may be waiting for 

additional guidance or rules, which may not be finalized for a number of 

years, if the time frames for finalizing the air carrier and airport SMS rules 

are any indication.

Seventy-seven of the 83 U.S. commercial air carriers are at varying levels 

of SMS implementation as FAA nears completion of the final SMS rule. 

Flight Standards developed four SMS implementation levels to 

benchmark the progress of commercial air carriers (see table 1 below for 

additional details on the Flight Standards SMS implementation levels). In 

general, Flight Standards officials work with commercial air carriers to 

determine their SMS implementation level. Flight Standards reports the 

 19This report does not address SMS implementation at other types of air carriers, such as 

commuter airline operators.

Although Not Currently 

Required, Some Aviation 

Stakeholders Are 

Voluntarily Implementing 

SMS

Commercial Air Carriers
Page 10 GAO-14-516 Aviation Safety

SMS level for each participating stakeholder in its monthly SMS 

newsletter. According to the March 2014 SMS newsletter, of the 77

commercial air carriers implementing SMS, the vast majority of them (58) 

were at SMS level one or two, 10 were at level three, and 9 were at the 

final continuous improvement level.20

Table 1: Flight Standards’ Safety Management System Implementation Levels for Commercial Air Carriers

Level Description

One: planning and organization Top management commits to providing the resources necessary for full implementation of SMS 

throughout the organization. The organization completes a gap analysis to determine which 

elements in the SMS framework are not already being performed. Based on the gap analysis, 

the organization creates an SMS implementation plan to describe how the organization will close 

any identified gaps.

Two: reactive process The organization develops and implements basic safety risk management and safety assurance 

processes. These processes include information acquisition, processing, and analysis as well as 

the establishment of a risk control and corrective action tracking system.

Three: proactive process The organization has a functioning SMS. It applies safety risk management to the initial design of 

systems, processes, organizations, and products; the development of operational procedures; 

and planned changes to operational processes. This application of safety risk management 

includes analysis of systems and tasks, identification of potential hazards, and development of 

risk controls. Upon completion of level three, all required components are documented, 

demonstrated, and operational.

Four: continuous improvement Processes are in place, and their performance and effectiveness have been verified. The 

complete safety assurance process, including continuous monitoring, and the remaining features 

of the other safety risk management and safety assurance processes are functioning. A major 

objective of a successful SMS is to attain and maintain this continuous improvement status for 

the life of the organization.

Source: GAO analysis of FAA information. | GAO-14-516

The Airline Safety and Federal Aviation Administration Extension Act of 

201021 stipulated that FAA issue a final SMS rule for commercial air 

carriers. In November of 2010, FAA published an NPRM that would 

require all commercial air carriers to implement an SMS that meets the 

requirements of the new regulation and is acceptable to FAA within 3 

years of the effective date of the final rule.

22 According to FAA, it did not 

 20Air carriers that have entered the final continuous improvement SMS level include 

American, American Eagle, Compass, Delta, Hawaiian, Miami Air, PSA, United, and US 

Airways.

21Pub. L. No. 111-216, § 215, 124 Stat. 2348. 2366 (2010).

22This NPRM would amend Title 14 of the Code of Federal Regulations (CFR) by adding a 

new Part 5. 
Page 11 GAO-14-516 Aviation Safety

meet the statutory deadline of August 1, 2012, to issue the final rule due 

to the lengthy internal DOT review process and complexity of the required 

benefit-cost analysis.23 The DOT Significant Rulemaking Report for June

2014 indicated that FAA anticipates publishing the final rule in September 

2014. (See fig. 3.) Commercial air carriers that have already begun to 

implement SMS must ensure that their efforts comply with the 

requirements of the final rule. 

Figure 3: Rulemaking Timeline for the Commercial Air Carrier Safety Management System Requirement, as of June 2014

 23We did not evaluate DOT’s review process for rulemaking or FAA’s benefit-cost analysis 

because we determined those issues to be outside the scope of our study. Benefit-cost 

analysis is required under Executive Order 12866 of September 30, 1993 for significant 

regulatory action. The Order defines significant regulatory action as “any regulatory action 

that is likely to result in a rule that may: (1) have an annual effect on the economy of $100 

million or more or adversely affect in a material way the economy, a sector of the 

economy, productivity, competition, jobs, the environment, public health or safety, or 

State, local or Tribal governments or communities; (2) create a serious inconsistency or 

otherwise interfere with an action taken or planned by another agency; (3) materially alter 

the budgetary impact of entitlements, grants, user fees or loan programs or the rights and 

obligations of recipients thereof; or (4) raise novel legal or policy issues arising out of legal 

mandates, the President’s priorities, or the principles set forth in the Executive Order.
Page 12 GAO-14-516 Aviation Safety

While FAA’s rulemaking to require SMS at all 545 certificated airports has 

been delayed, FAA officials estimated that 9 of the nation’s largest 

certificated airports were voluntarily implementing SMS as of April 2014.

Between 2008 and 2012, the Airports Organization conducted three

voluntary SMS pilot studies to provide airports opportunities to gain 

knowledge about SMS and provide feedback to FAA in its rulemaking 

efforts. The pilot studies also allowed certificated airports to share their 

SMS implementation practices with other airports. Thirty-one certificated

airports of various sizes participated in at least one of the pilot studies.

24

Twenty-one of the 22 airports in the first pilot study and 1 airport that did 

not participate in any of the pilot studies received a grant to develop an 

SMS plan. To further encourage SMS implementation, in August 2013, 

the Airports Organization published guidance that provides some 

certificated airports access to federal funds for certain SMS activities, 

including making SMS management software eligible for funding through 

the Airport Improvement Program.

25 FAA officials indicated that another 

goal of the guidance was to ensure that airports would be aware of the 

basic elements required for SMS implementation plans and manuals. 

FAA began the SMS rulemaking process for certificated airports in July 

2008 and in October 2010 published an NPRM to require that all 

certificated airports develop and maintain an SMS that is approved by 

FAA. According to FAA officials, the nature of the comments received on 

the NPRM led them to significantly modify the proposed rule, and provide 

another period for public comment. As a result, in December 2012, FAA 

announced that it would amend the next scheduled step in the rulemaking 

process and issue a supplemental notice of proposed rulemaking 

(SNPRM), which was originally scheduled for publication in December 

2013, rather than publish a final rule. FAA is considering changes in the 

proposed rule’s applicability and to some proposed requirements, 

including SMS implementation options for various sizes of certificated 

 24The first pilot project, which included 22 airports, focused on airport creation of SMS 

manuals and implementation plans; the second pilot project was a proof of concept and 

involved 3 airports; and the third pilot focused on SMS implementation at 14 of the airports 

that had participated in one or both of the first two pilots. 

25Program guidance letter 13-06, Safety Management Systems (SMS). Eligible airports 

include airports certificated under 14 C.F.R. Part 139 that are also included in the National

Plan of Integrated Airport Systems (NPIAS). The NPIAS identifies existing and proposed 

airports that are significant to national air transportation and thus eligible to receive federal 

grants under the Airport Improvement Program.

Certificated Airports
Page 13 GAO-14-516 Aviation Safety

airports. FAA has not yet issued the SNPRM, but in June 2014 FAA 

estimated that the SNPRM would be published for public comment in 

October 2014. With FAA’s decision to issue an SNPRM, it is likely that 

required SMS implementation for certificated airports will not occur for 

some time. Figure 4 summarizes key dates related to SMS rulemaking for 

certificated airports, as indicated in the DOT Significant Rulemaking 

Report for June 2014.

Figure 4: Rulemaking Timeline for the Certificated Airport Safety Management System Requirement, as of June 2014

Few repair stations are currently implementing SMS, and FAA has not yet 

determined if it will conduct rulemaking to require SMS at repair stations. 

As of March 2014, just 15 repair stations (of more than 4,700) were 

implementing SMS through the Flight Standards SMS pilot project, 

according to an FAA newsletter. As it does with air carriers, Flight 

Standards uses the four SMS implementation levels to benchmark and 

determine the progress of repair station SMS implementation. 26 Thirteen

were at SMS level one or two. Our interviews with 5 repair stations that 

 26FAA does not track SMS implementation by repair stations that do not participate in the 

pilot project. 

Repair Stations
Page 14 GAO-14-516 Aviation Safety

participated in the pilot program suggested that there may be fewer than 

14 repair stations currently implementing SMS because representatives 

we interviewed from 4 of the repair stations indicated that they had either 

ceased or never actually initiated their SMS efforts. Among the reasons 

these repair station representatives cited for not moving forward included 

a lack of FAA support. For example, representatives from one repair 

station told us that FAA did not respond to their questions on SMS policy 

changes and did not provide feedback on the gap analysis they 

performed. FAA officials indicated that there are reasons that more repair 

stations may want to implement SMS. Flight Standards officials said that 

once the commercial air carrier SMS rule is finalized, repair stations might 

want to implement their own SMS so that it could be recognized by the 

commercial air carriers they may contract with. A senior FAA official noted 

that because the commercial air carrier SMS rule will include identifying 

risks posed by repair stations, it would have an impact on repair station 

operations. Additionally, as other countries complete SMS rulemaking, 

some repair stations may want to implement SMS for international 

business reasons. 

Several design and manufacturing firms were implementing SMS as of 

April 2014, while an FAA rulemaking committee studies SMS 

incorporation into the design and manufacturing environment of 

approximately 3,000 firms. Aircraft Certification conducted an SMS pilot 

project for design and manufacturing firms from 2010 to 2012 with 11 

participants. The participants were selected to represent the diversity of 

the industry in terms of size and types of products designed and/or 

manufactured. According to an FAA official, approximately 6 pilot project 

participants were continuing SMS implementation as of April 2014. In our 

discussions with several design and manufacturing firms that participated 

in the pilot, we found that 2—Honeywell and Boeing—were planning to 

complete SMS implementation in 2015. Honeywell representatives 

indicated that they expect to complete SMS implementation by mid-2015. 

Boeing representatives said their company was implementing an SMS as 

defined to ICAO standards and also expect to complete SMS 

implementation by mid-2015. 

In October 2012, FAA chartered a 2-year aviation rulemaking committee 

(ARC) to, among other things, study SMS incorporation into the design 

and manufacturing firm environment. According to a January 2014 FAA 

Design and Manufacturing 

Firms
Page 15 GAO-14-516 Aviation Safety

plan,27 once the committee has completed its work, FAA will begin a 

rulemaking process that will result in a change to the current rule for 

certificating design and manufacturing firms. The plan anticipates the 

release of an NPRM by January 2016 and publication of a revised final 

rule by June 2017 to require, among other things, design and 

manufacturing firms to implement SMS. However, an FAA official stated 

in April 2014 that FAA had not yet determined when an SMS requirement 

might be proposed for design and manufacturing firms.

FAA officials stated that a primary challenge in developing SMS rules for 

commercial air carriers and certificated airports is developing the benefitcost analyses. FAA officials explained that estimating the expected 

benefits for SMS rules for air carriers and airports relies on analysis of the 

economic cost of past accidents that might not have occurred had SMS 

been in place. However, determining which past accidents might not 

have occurred based on SMS implementation either by air carriers or 

airports or both is complex and somewhat subjective, and this 

determination can be affected by other safety improvements that have 

occurred in recent years or that are being proposed. For example, if 

subsequent to a particular accident, some other safety improvements 

have been implemented that would have reduced its likelihood, only a 

portion of the value of the damage and harm related to that accident can 

be included in the current benefit calculation for future SMS since the 

 27FAA, Detailed Implementation Plan for the Federal Aviation Administration 

Modernization and Reform Act of 2012, Pub. L. No. 112-95, § 312, January 31, 2014. 

FAA and 

Stakeholders Cited 

Rulemaking, Data 

Issues, and 

Stakeholder 

Uncertainty as Key 

Challenges to 

Implementing SMS

FAA Cited Challenges in 

Completing SMS 

Rulemaking 
Page 16 GAO-14-516 Aviation Safety

likelihood of the same accident occurring has already been somewhat 

mitigated. Additionally, an airport industry trade organization expressed 

concerns in its public comments on the airport NPRM that the proposed 

rule incorrectly assumed that certain accidents would be mitigated by an 

airport SMS because those occurrences happened on airport grounds but 

in areas controlled by air carriers. The trade organization reviewed 53 of 

the 89 accidents included in the FAA analysis. In the trade organization’s 

view, 37 of these 53 accidents had little or limited connection to safety 

actions that an airport might take within its SMS. The likelihood of the 

accident or incident occurring could therefore be mitigated by the air 

carrier’s SMS implementation. Some accidents might also be avoided 

based on joint implementation of SMS systems by both the air carriers 

and airports. In such cases, expected benefits have to be apportioned 

across the benefit-cost analyses of the two separate SMS systems—that 

is, the SMS for air carriers and the SMS for airports—otherwise expected 

benefits would be double counted. In addition, a number of comments on 

the proposed rules for both the air carrier and airports questioned the 

estimated costs imposed on aviation stakeholders related to the 

implementation of the SMS systems. FAA, as part of its rulemaking 

process, revisited the benefit-cost analysis after reviewing public 

comments on the proposed rules. 

Another challenge FAA faces in implementing SMS rules is planning for 

how data collected for proactive safety efforts will be used. Over the 

years, we have identified numerous challenges related to FAA data and 

made a number of recommendations, some of which FAA has addressed,

to improve the use of data that FAA collects. One recommendation of 

particular significance to SMS implementation, however, has yet to be 

fully implemented. In 2010, we recommended that FAA develop a 

comprehensive plan that addresses how data fits into FAA’s 

implementation of a proactive approach to safety oversight. We indicated 

that the plan should fully describe the relevant data challenges, analytical 

approaches to be used, staffing requirements, and the efforts to address 

them.

28 Because SMS relies on data for maximum benefit, we concluded 

that a comprehensive data plan by FAA would help expand its capability 

to improve aviation oversight. DOT concurred with this recommendation, 

and although FAA has taken actions such as implementing data quality 

 28GAO, Aviation Safety: Improved Data Quality and Analysis Capabilities Are Needed as 

FAA Plans a Risk-Based Approach to Safety Oversight, GAO-10-414 (Washington, D.C.: 

May 6, 2010).
Page 17 GAO-14-516 Aviation Safety

controls consistent with our standards for data quality, it has not yet 

completed the recommended plan. For example, it has not outlined how it 

will analyze or use data gathered under SMS, assessed the staffing 

requirements it will need to conduct the data analysis, and indicated a 

timeline to complete a plan. GAO believes this recommendation remains 

valid.

SMS implementation challenges have been identified during FAA’s SMS 

pilot projects and the rulemaking processes for commercial air carriers 

and certificated airports. We also identified some of these challenges in 

our prior SMS work.29 We selected five frequently cited challenges to 

discuss with aviation stakeholders: data sharing and protection, resource 

constraints, implementation costs, FAA oversight, and collaboration with 

other aviation stakeholders. Our discussions with 20 selected aviation 

stakeholders that participated in at least one FAA SMS pilot project 

confirmed that these challenges still exist for some stakeholders.

30 Based 

on these discussions, we found that a majority of the selected 

stakeholders identified uncertainties about FAA’s oversight plans (17 

stakeholders); uncertainties about SMS implementation costs (14 

stakeholders); and data protection (16 stakeholders) as challenges. In 

addition, we found that uncertainty about the FAA’s final rule 

requirements raised some additional concerns with the stakeholders we 

interviewed, and half of the stakeholders said that of the four SMS 

components, the safety risk management is the most challenging to 

implement because of the time and analyses required to identify and 

mitigate risks.

Seventeen stakeholders identified their uncertainty about FAA’s plans 

and preparation for oversight of industry’s SMS implementation as a 

challenge, with 12 identifying it as a great or very great challenge. 

Specifically, they reported a lack of information about FAA’s intended 

oversight plans, training for FAA inspectors responsible for oversight, and 

 29GAO-12-898.

30We made a non-statistical selection of 20 aviation stakeholders that participated in 

FAA’s SMS pilot projects—five commercial air carriers, five certificated airports, five 

design and manufacturing firms, and five repair stations. We asked each of the 20 

stakeholders to characterize the five selected challenge on the following five point scale; 

“not a challenge”, “slight challenge,” moderate challenge,” “a great challenge,” and “a very 

great challenge.”

Aviation Stakeholders 

Cited Uncertainty over 

FAA Oversight, 

Implementation Costs, 

Data Protection Issues, 

and Final Rule 

Requirements among 

Their Key Challenges

Uncertainty about FAA’s SMS 

Oversight Plans
Page 18 GAO-14-516 Aviation Safety

the potential for inconsistent regulatory interpretation because FAA has 

not shared that information with stakeholders. Just as the move to SMS 

will change how stakeholders manage risk, FAA’s oversight approach will

also need to undergo some changes. (See table 2.) According to FAA, 

while its inspectors will continue to check for compliance with safety 

regulations and retain enforcement authority, oversight will also include 

reviewing the SMS guidance and records and ensuring that processes for 

identifying and mitigating risks are being carried out.

Table 2: Changes in Stakeholder and FAA Inspector Roles under a Safety Management System

Role Current safety approach Safety management system approach

Aviation Stakeholder The stakeholder responds to regulatory 

requirements and builds compliance with 

regulations into its work procedures and safety 

programs

The stakeholder proactively manages risk, while 

maintaining compliance with regulatory requirements. The 

stakeholder looks beyond compliance to identify potential 

risks that may or may not be covered by regulation, 

assesses the risks, and if necessary takes actions to 

mitigate those risks to create a safer operating 

environment.

FAA Inspector Inspectors review stakeholders’ actions to ensure 

they comply with applicable regulations.

Inspectors evaluate if the risk management programs the 

stakeholder has in place are being utilized. As necessary,

they also conduct traditional inspections to check for 

regulatory compliance.

Source: GAO analysis of information provided by FAA and Transport Canada. | GAO-14-516

Internal control standards,

31 an FAA rulemaking committee, and the ICAO 

Safety Management Manual all state the need to establish plans to 

ensure that goals and objectives are met. Additionally, we have 

previously found that communicating internal control efforts on a timely 

basis to internal and external stakeholders, such as FAA inspectors and 

aviation industry stakeholders, helps ensure that effective oversight can 

take place. A 2009 SMS aviation rulemaking committee recommended 

that FAA ensure that sufficient planning, policy and guidance, and 

workforce training are in place prior to SMS implementation to 

accommodate efficient, timely, objective and consistent oversight. Internal 

control standards also state that personnel should be provided with the 

right training and tools to perform their duties, and the ICAO Safety 

Management Manual notes the significance of training to successful SMS 

implementation and indicates that priority for training must be given to 

 31GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1 

(Washington, D.C.: November 1999).
Page 19 GAO-14-516 Aviation Safety

personnel involved in implementation or oversight of SMS. While 

acknowledging that its oversight role will be changing, FAA has not yet 

completed plans for overseeing industry’s implementation of SMS, 

including plans to develop guidance and train inspectors about their SMS 

oversight functions and responsibilities. Nine of the aviation industry 

stakeholders and three industry trade groups we interviewed expressed 

concerns that FAA inspectors will not be prepared to oversee industry 

implementation of SMS. These concerns related primarily to a lack of 

SMS training for FAA inspectors. FAA officials told us that they plan to 

finalize SMS rules before addressing oversight issues.

Based on the NPRM, commercial air carriers would have 3 years after the 

effective date of the final rule to comply with SMS implementation 

requirements. When the final rule for commercial air carriers becomes 

effective, FAA inspectors will assume oversight responsibility to ensure 

that commercial air carriers comply with the final rule. Included with this 

responsibility is approving commercial air carriers’ SMS plans. According 

to Flight Standards data, as of November 2013, over 2,700 of 

approximately 3,900 of their inspectors had completed initial training in 

SMS activities.32 This includes inspectors who oversee commercial air 

carriers. However, even though the publication of the final SMS rule for 

air carriers is expected before the end of the year—currently planned for 

September 2014—Flight Standards has not yet established guidance for 

inspectors for overseeing commercial air carriers’ implementation of SMS 

or updated its inspector training program to incorporate such guidance. In 

addition, even though a large number of inspectors have received initial 

SMS training, stakeholders remain concerned about inspectors’ 

knowledge of SMS as well as the potential for inconsistent interpretation 

of SMS requirements.

At the same time, the 77 commercial air carriers that have been 

voluntarily implementing SMS will need to review their SMS to ensure

compliance with the final rule and may request FAA guidance during that 

process to determine whether and what modifications need to be made. 

Given that most commercial air carriers already have started 

implementing SMS, the demand for inspector guidance or assistance may 

come quickly. For example, inspectors might be asked to review a 

 32According to a Flight Standards official, not all inspectors are required to complete SMS 

training because their current duties may not include commercial air carrier oversight.
Page 20 GAO-14-516 Aviation Safety

commercial air carrier’s SMS to ensure that all required components are 

included. Without taking proactive preparations for oversight before 

requiring SMS, FAA could find itself with oversight responsibilities for 

which it is not fully prepared. Consequently, the intended benefits of 

implementing this proactive approach to managing risk could be limited.

For other industry segments, notably airports and design and 

manufacturing firms, that are likely to be next to face an SMS 

requirement, FAA has taken initial steps to train inspectors working in 

those areas. In 2008, the Airports Organization provided 3 days of basic 

SMS instruction to airport safety inspectors during the organization’s 

annual recurrent training. Officials in the Airports Organization 

acknowledged that, should FAA finalize an SMS rule for certificated 

airports, up-to-date training will need to be developed and delivered to the 

approximately 40 airport safety inspectors, including training in detailed 

inspection procedures for oversight of an airport’s SMS. Likewise, 

Aircraft Certification plans for some of its staff to review the Flight 

Standards initial SMS training course to determine what type of SMS 

training is necessary for some of its estimated 950 aircraft certification 

engineers and inspectors. 

In addition to training, six aviation stakeholders we interviewed expressed 

concerns about potentially inconsistent regulatory and other

interpretations by FAA inspectors. This concern was identified by smaller 

stakeholders we interviewed as well as those that hold multiple 

certificates overseen by different FAA organizations. For example, one 

stakeholder we interviewed indicated that the company holds certificates 

for multiple facilities in multiple FAA districts, and is concerned that 

inspectors from different districts may have different interpretations of the 

SMS rules once they are implemented. We found in 2010 that ensuring 

consistency in regulatory interpretations has been a long-standing issue 

for FAA. This was also identified in the SMS ARC final report as an issue 

that FAA should address prior to SMS implementation. In 2012, FAA 

formed another aviation rulemaking committee to address consistency in 

regulatory interpretation by Flight Standards and Aircraft Certification. The 

committee made six recommendations to improve the consistency of 

regulatory interpretation and improve communication with industry. In July 

2013, FAA provided a preliminary implementation plan to address the 

recommendations and indicated a detailed implementation plan with 

milestones would be developed, but provided no time frames for when 

that detailed plan would be released.
Page 21 GAO-14-516 Aviation Safety

Similarly, two stakeholders that operate both domestically and overseas 

expressed concerns about whether FAA’s SMS regulations will be 

consistent with the ICAO framework that the regulations are designed to 

meet and harmonized with the SMS requirements of other countries. 

These stakeholders are concerned that potential inconsistencies could 

pose problems if different standards exist in different countries. For 

example, one repair station with overseas operations we spoke to said 

that any SMS they may be required to implement to meet FAA regulations

must also comply with the SMS requirements in other countries where 

this repair station operates. The need for international acceptance of a 

service provider’s SMS was also identified as an issue for FAA to address 

in the SMS ARC’s final report in 2010.

Aviation stakeholders we interviewed largely had not conducted cost 

assessments of their SMS efforts (only 5 of 20 had done so), and the 

difficulty in assessing these costs could present a challenge to those 

considering voluntary implementation of SMS. Fourteen of the 20 

stakeholders told us that identifying and assessing SMS costs was a 

challenge. Further complicating cost estimates, three stakeholders 

indicated that implementation costs are spread throughout the 

organization and that isolating those specifically related to SMS would be 

difficult. For example, one stakeholder indicated that because the 

computer systems it purchased to support SMS also support other 

operational objectives, it has not attempted to separate out SMS costs. In 

addition, seven stakeholders said that the absence of a final rule 

specifying SMS requirements made assessing costs difficult. 

Though stakeholders we spoke with were generally unable to determine 

the cost of implementing SMS, they were able to identify some types of 

related expenditures. We asked each of them about specific costs 

related to SMS implementation, and they reported incurring the following 

types of costs:

• 14 trained employees on SMS or SMS concepts,

• 10 incurred recordkeeping costs,

• 10 purchased computer systems, and

• 7 hired new employees.

Other costs identified by stakeholders included those related to safety 

promotion and mitigating hazards identified through SMS implementation. 

Uncertainty about SMS 

Implementation Costs 
Page 22 GAO-14-516 Aviation Safety

Industry stakeholders we spoke with had concerns about sharing and 

protecting their safety data; 16 of the 20 stakeholders we interviewed 

identified this as a challenge, with 7 identifying this challenge as great or 

very great. In March 2010, the SMS ARC final report identified this as an 

issue and recommended that prior to the promulgation of an SMS rule, 

protections be put in place to ensure that safety information and 

proprietary data are protected from disclosure and use for other 

purposes, such as enforcement actions. 

The 2012 FAA Modernization and Reform Act (the 2012 Act) included a 

provision that placed a limitation on the disclosure of safety information 

under the federal Freedom of Information Act (FOIA) for information 

gathered for the purposes of developing and implementing an SMS.33 

However, information provided by or to publicly owned airports is also 

subject to state FOIA laws, which are not covered under the protections in 

the 2012 Act. Commercial air carriers, repair stations, and design and 

manufacturing firms are privately owned and not directly subject to state 

FOIA laws. However, any data airports collect and any data shared with 

airports could, according to FAA officials and industry experts, be subject 

to state FOIA laws, because most certificated airports in the U.S. are 

owned by a public entity such as a state, city, port, or other local or 

regional government body. According to officials in the Airports 

Organization, a federal legislative resolution to override state laws is not a 

feasible option. These officials reported that in some locations, airports 

have begun to work with state legislative bodies to address the issue of 

data protection and disclosure.

Without legal protections to prevent data disclosure, stakeholders told us 

they feel at risk in a variety of potential scenarios related to SMS 

implementation.

• Litigation for damage (real or perceived) caused by incidents 

disclosed through SMS—Eight stakeholders we spoke with, as well as 

the 2010 SMS ARC, indicated that protections are needed not only to 

prevent the disclosure of safety data through the state FOIA process, 

but also from disclosure as part of litigation. For example, a 

certificated airport must meet the regulatory requirements of 14 C.F.R. 

Part 139. One standard included in Part 139 is that holes in airport 

 33Pub. L. No. 112-95 § 310, 126 Stat. 11, 65 (2012).

Concerns about Collecting and 

Sharing SMS Data
Page 23 GAO-14-516 Aviation Safety

pavement must not exceed 3 inches in depth.34 An airport 

representative we met with indicated that if a hole less than 3 inches 

deep is noted through a reporting system implemented under SMS, 

the airport may postpone that repair until a later time as it is within the 

maximum depth allowed under the regulations and the risk is 

acceptable. Additionally, it would not likely negatively impact the 

operations of a large aircraft on the runway. However, it could pose a 

hazard for smaller general aviation aircraft. If the airport does not 

make that repair and the hole factors into an accident involving a 

general aviation aircraft, the extent of the airport’s responsibility and 

legal liability is uncertain and may become the subject of a lawsuit. 

Because the intent of SMS is to correct hazardous conditions before 

an accident occurs, stakeholders want protections that address their 

vulnerability to potential litigation.

• Misinterpretation of safety data by a third party—If safety data is 

released to the public under a state FOIA, the aviation industry is 

exposed to potential misinterpretation, misuse, and further 

dissemination of the data by third parties. For example, one 

stakeholder expressed concern that safety data could be obtained, 

reviewed, analyzed, or disseminated by a third party without the 

proper context, including how and why the data were collected and 

the limitations of their use. Without the proper context, this 

stakeholder stated that dissemination would lead to misinterpretation, 

which may then be further disseminated by others such as policy 

makers or the media. 

• Enforcement actions by FAA or other regulatory bodies—As we 

discussed earlier, the safety risk management component of SMS 

includes systems that allow individuals to identify potential safety 

hazards, assess the risks arising from those hazards, and develop 

mitigation plans to reduce or eliminate those risks. ICAO guidance 

indicates that in an SMS environment, procedures should be in place 

to ensure information obtained under SMS will not be used for 

enforcement actions. However, four stakeholders expressed concern 

that data about potential hazards could be used beyond SMS. For 

example, a repair station’s SMS would address identified hazards 

and, if necessary, develop a mitigation plan to address those hazards. 

However, if an identified hazard also constitutes a regulatory violation, 

the company might be subject to FAA enforcement action. The SMS 

ARC recommended in 2010 that FAA should establish a policy or 

 3414 C.F.R. § 139.305(a)(2).
Page 24 GAO-14-516 Aviation Safety

regulation that provides limits on enforcement actions applicable to 

information that is identified or produced by SMS. Currently, FAA 

foregoes civil penalty actions when violations are promptly disclosed 

to FAA under a voluntary disclosure program, subject to some 

limitations. FAA believes that the open sharing of apparent violations 

and a cooperative approach to solving problems will enhance and 

promote aviation safety. Current FAA policy covers commercial air 

carriers, repair stations, and design and manufacturing firms, but not 

certificated airports. It is unclear if FAA will extend this coverage to 

information provided as part of SMS efforts not currently covered.

In 2012, we also found the protection of data to be a concern35 and 

recommended that FAA consider strategies to address concerns that may 

adversely affect data collection and data sharing—essential to realizing 

the benefits of SMS. FAA began discussions with airports and airport 

associations in 2013 to determine what type of SMS data should be 

considered for protection. FAA also received and considered comments 

from airports and airport organizations about data collection, protection, 

and sharing in response to the NPRM for airports. We concluded in our 

September 2012 report that the success of SMS relies heavily on the 

sharing of safety data and that without appropriate protections, the 

willingness of the aviation industry to share safety data will likely be 

jeopardized. Although protections exist for safety data from commercial 

air carriers, FAA has determined that a similar legislative approach is not 

feasible for data from certificated airports. However, according to FAA, 

some airports are working to address data protections under state laws 

through outreach to state agencies and legislators.

Four of the stakeholders we spoke with felt that delays in the rulemaking 

process were detrimental to their implementation of SMS while others 

were confident that their SMS implementation would meet forthcoming 

requirements. Representatives from two industry stakeholders we spoke 

with told us that they did not want to move forward in implementing SMS 

until rulemaking is complete, largely because they first want to know what 

the requirements will be. They explained that they were concerned about 

the time and resources required to rework the SMS should it not meet the 

final rule requirements. 

 35GAO-12-898.

Uncertainty about Final Rule 

Requirements
Page 25 GAO-14-516 Aviation Safety

Fourteen of the stakeholders we interviewed were concerned that the 

SMS requirement would not be scalable and flexible, that is, one which is 

sufficient to apply to a broad range of organizations from small operators 

to large ones with multiple facilities and certifications. Some of the 

concerns were based on the stakeholders’ views that FAA tends to 

fashion one-size-fits-all regulations or regulations that focus on one 

subset of a stakeholder group. For example, stakeholders cited a 

concern that FAA will establish regulatory requirements that are 

achievable for larger operators but may require more significant efforts by 

small operators. The NPRM for the commercial air carrier SMS 

requirement states that the proposed regulation is designed to be 

performance-based. FAA explained that because the regulation would be 

performance-based, it would allow commercial air carriers to comply 

through a variety of methods (suggesting flexibility) and to accommodate 

a variety of business sizes and models (suggesting scalability). The 

NPRM for the SMS requirement at certificated airports states that FAA 

envisions SMS as an adaptable and scalable system. FAA explained that 

an SMS could be developed by an organization to meet its unique 

operating environment. Accordingly, FAA stated in the NPRM that it 

would prescribe only the general framework for an SMS.

Several stakeholders also expressed concerns about how SMS 

regulations would affect their current efforts to improve safety. For 

example, one design and manufacturing firm we spoke with reported that 

it began using system safety techniques similar to those used in SMS in 

the 1990s. Although this stakeholder participated in an FAA pilot, the firm 

has developed an SMS approach in house based on the ICAO model. 

Fourteen stakeholders reported that prior to implementing SMS they had 

undertaken their own proactive safety or quality assurance efforts. FAA’s 

SMS ARC recommended in 2010 that SMS regulations allow for the 

incorporation of existing safety management efforts already in place in 

order to prevent duplicative safety efforts. FAA indicated that such 

programs could be used to build an operational SMS. Other stakeholders 

expressed concern that the content of the final rule may require them to 

adopt practices that may not improve safety in their company while 

imposing additional burdens. For example, one stakeholder hoped it 

would not be required to document every hazard identified and mitigated, 

stating that such documentation did not necessarily improve safety.

We also asked all 20 industry stakeholders which of the four components

of SMS would be the most challenging to implement, and more 

stakeholders (10) cited safety risk management than any other

component. As previously discussed, safety risk management is designed 

Safety Risk Management 

Challenge
Page 26 GAO-14-516 Aviation Safety

to examine a company’s operational functions and operational 

environment to identify hazards and analyze associated risks. The intent 

of this process is to focus on the areas of greatest risk from a safety 

perspective and on mitigation, taking into account such factors as 

complexity and operational scope. Specifically, stakeholders indicated 

that conducting a risk analysis can be time consuming. A robust analysis 

includes identifying a wide range of risks, and determining which would 

require mitigation—a process that some stakeholders were concerned 

may keep stakeholder staff away from other duties. A number of 

stakeholders also noted the difficulty in identifying risks in some cases, 

including industry changes that may have an impact on risk. 

Although 12 of the 20 aviation stakeholders we interviewed are continuing 

with their SMS implementation,36 they identified actions FAA could take to 

improve SMS effectiveness and help address the challenges of 

implementation. These suggestions target SMS training, guidance, and 

collaboration and communication. 

Although we did not ask specifically about any internal training programs 

developed by the 20 aviation stakeholders we spoke with, four 

stakeholders cited some difficulties with obtaining needed SMS training 

for their staff, including allocating time and resources for the training and 

finding training that was specific to their segment of the industry. Further, 

a 2012 study by the Transportation Research Board of FAA’s airport pilot 

studies found that pilot participants identified time restrictions and funding 

 36One stakeholder representative indicated that despite being selected for an SMS pilot 

project, the stakeholder never began SMS implementation because FAA did not follow up 

with them after an initial meeting. 

Stakeholders 

Identified Additional 

Actions FAA Could 

Take to Improve SMS 

Effectiveness and 

Address 

Implementation 

Challenges

SMS Training for Industry
Page 27 GAO-14-516 Aviation Safety

as obstacles to developing an SMS training plan for airport personnel.

37 

ICAO recommends that civil aviation authorities, like FAA, facilitate the 

SMS education or training of its stakeholders where feasible or 

appropriate. To that end, stakeholders suggested an action that FAA 

could take to mitigate stakeholder difficulties in this area. Specifically, two 

stakeholders we interviewed felt that allowing their staffs to attend the 

same training as FAA personnel could be beneficial in addressing 

differences in regulatory interpretation and for increasing industry’s 

understanding of FAA’s definitions and concepts as they relate to SMS. 

According to FAA officials, they have considered the training needs of 

industry stakeholders and provided some training through the pilot 

projects.

Although, as required by ICAO, FAA has provided, as well as updated, 

guidance to help stakeholders to implement SMS, some stakeholders 

saw a need for additional guidance and updates. For example, one 

stakeholder noted that FAA should create one risk matrix to be used by 

all organizations. Two stakeholders suggested standardizing SMS 

definitions across FAA. Another stakeholder suggested that FAA create a 

single document on the SMS framework. FAA has already responded to 

these concerns with an April 2012 order designed to establish common 

language standards for some SMS terminology; the order also provides a 

single risk matrix for the agency.38 Stakeholders also suggested that FAA 

develop additional guidance to aid them in documenting work processes, 

assessing organizational hazards, and estimating SMS costs. FAA plans 

to disseminate additional SMS guidance for air carriers and airports when 

final rules for these industry segments are published. The final rule for air 

carriers is expected to be published in September 2014. 

Fourteen of the 20 stakeholder representatives we interviewed were 

pleased with their collaboration and communication with FAA during the 

pilot projects; six stakeholders, however, noted that FAA could take 

additional actions to improve collaboration and communication in line with 

 37Transportation Research Board, Airport Cooperative Research Program, ACRP 

Synthesis 37, Lessons Learned from Airport Safety Management Systems Pilot Studies, 

Washington, D.C., 2012. 

38FAA Order 8040.4A, FAA National Policy: Safety Risk Management, April 30, 2012. 

SMS Guidance

Collaboration and 

Communication
Page 28 GAO-14-516 Aviation Safety

ICAO’s guidance for SMS. This guidance recommends establishing an 

appropriate communication platform to facilitate SMS implementation, 

particularly for SMS requirements and guidance material. FAA has used 

numerous methods to communicate about and encourage collaboration 

regarding SMS. These methods include the SMS newsletter, SMS focus 

groups, participation in the Safety Management International 

Collaboration Group,39 and the various SMS pilot projects. However, 

some stakeholders suggested that additional opportunities exist for the 

agency to share lessons learned. For example, one stakeholder was not 

aware of any FAA communications on its progress regarding the data 

protection and sharing issue, and three others thought that FAA needed 

to encourage the industry to share lessons learned through existing 

forums. Two stakeholders suggested using the Commercial Aviation 

Safety Team 40 as an example of, and the Aviation Safety Information 

Analysis and Sharing system41 as a potential tool for, improved SMS 

collaboration between FAA and commercial air carriers. Two stakeholders 

also recommended broadening current FAA collaboration and 

communication efforts by opening membership in SMS focus groups and 

other working groups to additional industry members, such as foreign air 

carriers; increasing the number of conferences and meetings where 

information-sharing can take place; and increasing FAA attendance at 

these forums. The Airports Organization noted that it continually updates 

its SMS website, and Flight Standards indicated that it is allowing its most 

significant forum with the aviation industry, InfoShare, to focus more on 

SMS implementation and management.

 39The Safety Management International Collaboration Group was founded by FAA, the 

European Aviation Safety Agency, and Transport Canada Civil Aviation. It is a joint effort 

among many regulatory authorities to promote a common understanding of safety 

management principles and requirements and facilitating their implementation across the 

international aviation community. 

40The Commercial Aviation Safety Team is a joint government-industry effort to reduce the 

commercial aviation fatality risk in the United States using an integrated, data-driven 

strategy. According to the team, its work—along with new aircraft, regulations, and other 

activities—reduced the commercial aviation fatal accident rate by 83 percent from 1998 to 

2008 and is an important aspect of FAA’s efforts to improve aviation safety by sharing and 

analyzing data.

41Initiated in 2007, FAA’s Aviation Safety Information Analysis and Sharing system is a 

collaborative government-industry information sharing and analysis initiative that aids in 

the monitoring and identification of potential safety issues. The system features data from 

a wide variety of data sources, from both public (non-confidential) and protected 

proprietary (confidential) aviation data.
Page 29 GAO-14-516 Aviation Safety

Maintaining a high level of safety in the U.S. aviation industry is a shared 

responsibility among FAA, air carriers, airports, and other stakeholders. 

FAA continues to implement SMS internally, in accordance with ICAO 

requirements, and industry stakeholders such as commercial airlines, 

certificated airports and others have begun to voluntarily adopt SMS in 

advance of regulations requiring its implementation. The successful 

implementation of SMS, with its proactive, risk-based approach to 

maintaining aviation safety, could help ensure the continued safety of the 

U.S. aviation system. However, the lack of a comprehensive plan for 

using data, which we recommended in 2010, may limit the effectiveness 

of SMS once it is implemented. Although FAA has taken steps to 

implement data quality controls that meet our standards, it has not 

disclosed its plans for using data collected or to ensure that it has the 

requisite staffing to make use of the data to be collected from commercial 

air carriers, certificated airports, and others. We continue to believe that 

the success of SMS relies on data for maximum benefit and that such a 

data plan will strengthen FAA’s capability to improve aviation oversight. In 

addition, the SMS ARC recommended in March 2010 that, among other 

things, FAA must ensure sufficient planning, guidance, and workforce 

training are in place prior to SMS implementation. Without providing the 

necessary training and guidance to its inspector workforce, FAA may not 

be adequately prepared to ensure the benefits of SMS as industry sectors 

are required to implement it. Although FAA continues to encourage 

voluntary implementation of SMS, it also must be prepared to exercise its 

oversight functions, once final rules requiring SMS implementation are in 

place, to ensure that industry is developing and utilizing processes to 

identify, document, and mitigate safety risks. This includes providing 

clarification and guidance to air carriers, airports and others as they 

develop their own SMS’s once final rules for each industry segment are in 

place.

To maximize the effectiveness and potential benefits of SMS

implementation, we recommend that the Secretary of Transportation 

direct the FAA Administrator to take the following action:

• Develop a plan to provide oversight of industry implementation of 

SMS, a plan that includes providing guidance and training to the 

relevant FAA inspectors by the time final SMS rules for industry 

sectors (commercial air carriers, certificated airports, repair stations, 

design and manufacturing firms) are published.

Conclusions

Recommendation for 

Executive Action
Page 30 GAO-14-516 Aviation Safety

We provided DOT with a draft of this report for review and comment. 

DOT provided technical corrections and clarifications, which we 

incorporated as appropriate.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Transportation, the FAA Administrator, and 

other interested parties. In addition, the report is available at no charge on 

the GAO website at http://www.gao.gov. 

If you or any of your staff members have any questions about this report, 

please contact me on (202) 512-2834 or at dillinghamg@gao.gov. 

Contact points for our Offices of Congressional Relations and Public 

Affairs may be found on the last page of this report. Key contributors to 

this report are listed in appendix II.

Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues

Agency Comments
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-14-516 Aviation Safety

Our objective was to review the implementation of safety management 

systems (SMS) in the U.S. aviation industry and provide an update on 

SMS implementation within the Federal Aviation Administration (FAA). To 

do so, we addressed the following questions:

1. What is the status of SMS implementation within FAA and for key 

segments of the aviation industry, including certificated airports, 

commercial air carriers, repair stations, and design and manufacturing 

firms? 

2. What are the key challenges FAA and the aviation industry face in 

implementing SMS? 

3. What additional actions do aviation stakeholders believe FAA could 

take to improve SMS implementation and potential effectiveness?

To assess the status of SMS implementation within FAA and for key 

segments of the aviation industry, we reviewed FAA orders and advisory 

circulars on SMS and reports on its SMS pilot projects for commercial air 

carriers,1 certificated airports,2 repair stations, and design and 

manufacturing firms and from the SMS rulemaking projects for certificated 

airports and commercial air carriers. We also reviewed FAA information 

on industry SMS implementation status. In addition, we interviewed FAA 

officials and industry trade group representatives. To update the status of 

FAA’s implementation of SMS, we reviewed FAA guidance, 

implementation plans, and other documents published or revised since 

our 2012 report and interviewed FAA officials and trade group 

representatives.

To determine the key challenges FAA and the aviation industry face in 

implementing SMS as well as additional actions FAA and other 

stakeholders may take to improve the implementation and potential 

effectiveness of SMS, we interviewed officials from FAA, FAA employee,

and industry groups. To obtain an international perspective on the 

challenges and additional actions, we interviewed representatives from 

 1

These are defined as air carrier operations involving airplanes with a capacity of 10 or 

more passengers or a maximum payload capacity of more than 7,500 pounds for which 

FAA has issued operating certificates under 14 C.F.R. Part 121.

2

These are defined as airports that (1) service unscheduled air carrier aircraft with more 

than 30 seats or (2) serve scheduled air carrier operations with more than 9 seats and for 

which FAA has issued operating certificates under 14 C.F.R. Part 139.1(a)(1) and (2).

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 32 GAO-14-516 Aviation Safety

foreign aviation authorities, specifically the European Aviation Safety 

Agency, Transport Canada, and the Civil Aviation Safety Authority of 

Australia. In addition, we also interviewed two Canadian airlines and one 

Canadian airport that have implemented SMS. Table 3 lists industry and 

international interviewees.

Table 3: Industry and International Interviewees

Group Interviewee

FAA employee organizations National Air Traffic Controllers Association

Professional Aviation Safety Specialists

Aviation industry groups Aeronautical Repair Station Association

Airlines 4 America

American Association of Airport Executives

Regional Airline Association

International entities Civil Aviation Safety Authority (Australia)

European Aviation Safety Agency

Transport Canada

Flair Airlines (Canada)

WestJet (Canada)

Region of Waterloo International Airport (Canada)

Source: GAO. | GAO-14-516

To obtain the industry stakeholder perspective for each of our objectives, 

we collected and analyzed information through structured interviews of a 

total of 20 industry stakeholders—5 airlines, 5 airports, 5 repair stations, 

and 5 design and manufacturing firms—that participated in FAA’s SMS

pilot projects3

. We selected the certificated airports based on their hub 

size, geographic location, and whether we interviewed them for our prior 

study. We did not include certificated airports that we interviewed from 

that study. We chose the commercial air carriers based on carrier type 

(mainline or regional; cargo or charter), the level of SMS implementation 

they had reached by the time of our interview, and whether we 

interviewed them for the prior study; two of the air carriers we selected 

were interviewed for our 2012 study. For the repair stations, we choose 

 3

One repair station we selected indicated that although FAA selected them to participate 

in the pilot, it did not begin the pilot project. However, it has implemented safety and 

quality assurance programs.
Appendix I: Objectives, Scope, and 

Methodology

Page 33 GAO-14-516 Aviation Safety

five firms based on level of SMS implementation and the aircraft category 

(e.g., transport, commuter, or acrobatic) to which they provide services. 

We chose this selection factor as a result of research completed by the 

Center for Aviation Research, which found that SMS compliance for 

repair stations could be based on aircraft category.4 For design and 

manufacturing firms, we chose five firms based on the extent of SMS 

implementation, recommendations from industry stakeholders, and types 

of products they design or manufacture, or both. We conducted all 

stakeholder interviews with a standardized data collection instrument to 

maintain consistency across the interviews. To ensure that our interview 

questions were clear and reliable, we conducted two pretests with 

knowledgeable individuals and refined the interview questions based on 

those results. Because these 20 stakeholders comprise a nonrepresentative sample, the results from these interviews cannot be 

projected to the universe of these industry segments. Table 4 lists these 

selected industry stakeholders. 

Table 4: Aviation Industry Stakeholder Interviewees

Industry segment Stakeholder

Commercial air carriers Miami Air

SkyWest Airlines

Southwest Airlinesa

United Airlinesb

United Parcel Service

Certificated airports Cheyenne Regional/Jerry Olson Field

Dubuque Regional

Hartsfield-Jackson Atlanta International

Kona International at Keahole

San Antonio International

Design and manufacturing firms Airmotive

Boeing Commercial Airplanes

Gulfstream

Honeywell

Jamco America

 4

Damon Lercel, Ph.D., Center for Aviation Safety Research, Parks College of 

Engineering, Aviation, and Technology, Saint Louis University, SMS Repair Station 

Applicability Survey: Initial Results, 2013.
Appendix I: Objectives, Scope, and 

Methodology

Page 34 GAO-14-516 Aviation Safety

Industry segment Stakeholder

Repair stations Able Engineering

Aircraft Ducting Repair Inc.

Bombardier WV

KCI Aviation

Pratt & Whitney (Bridgeport, WV)

Source: GAO. | GAO-14-516

a

Airtran merged with Southwest in 2012.

b

Continental Airlines merged with United in 2010.

We conducted this performance audit from May 2013 to June 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions, based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 35 GAO-14-516 Aviation Safety

Gerald L. Dillingham, Ph.D., (202) 512-2834, or dillinghamg@gao.gov

In addition to the contact named above, Heather MacLeod (Assistant 

Director), Amy Abramowitz, James Geibel, David Hooper, Christopher 

Jones, Delwen Jones, Brooke Leary, Josh Ormond, Pamela Vines, and 

Elizabeth Wood made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 36 GAO-14-516 Aviation Safety

Aviation: Status of DOT’s Actions to Address the Future of Aviation 

Advisory Committee’s Recommendations. GAO-13-657. Washington, 

D.C.: July 25, 2013.

Aviation Safety: Status of Recommendations to Improve FAA’s 

Certification and Approval Processes. GAO-14-142T. Washington, D.C.: 

October 30, 2013.

Department of Transportation: Key Issues and Management Challenges, 

2013. GAO-13-402T. Washington, D.C.: March 14, 2013.

General Aviation Safety: Additional FAA Efforts Could Help Identify and 

Mitigate Safety Risk. GAO-13-36. Washington, D.C.: October 4, 2012.

Aviation Safety: Additional FAA Efforts Could Enhance Safety Risk 

Management. GAO-12-898. Washington, D.C.: September 12, 2012.

Aviation Safety: FAA Is Taking Steps to Improve Data, but Challenges for 

Managing Safety Risks Remain. GAO-12-660T. Washington, D.C.: April 

25, 2012.

Aviation Safety: Enhanced Oversight and Improved Availability of RiskBased Data Could Further Improve Safety. GAO-12-24. Washington, 

D.C.: October 5, 2011. 

Aviation Safety: Certification and Approval Processes Are Generally 

Viewed as Working Well, but Better Evaluative Information Needed to 

Improve Efficiency. GAO-11-14. Washington, D.C.: October 7, 2010.

Aviation Safety: Improved Data Quality and Analysis Capabilities Are 

Needed as FAA Plans a Risk-Based Approach to Safety Oversight.

GAO-10-414. Washington, D.C.: May 6, 2010.

Related GAO Products

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