United States Government Accountability Office

GAO Testimony 

Before the Subcommittee on Aviation, 

Committee on Transportation and 

Infrastructure, House of Representatives

AVIATION SAFETY 

FAA’s Safety Efforts 

Generally Strong but Face 

Challenges 

Statement of Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues 

For Release on Delivery

Expected at 2:00 p.m. EDT

Wednesday, September 20, 2006

 

GAO-06-1091T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

September 20, 2006

AVIATION SAFETY

FAA’s Safety Efforts Generally Strong but 

Highlights of GAO-06-1091T, a testimony Face Challenges 

before the Subcommittee on Aviation, 

Committee on Transportation and

Infrastructure, House of Representatives 

The U.S. commercial aviation 

industry has had an extraordinary 

safety record in recent years. 

However, expected increases in airtraffic—including the introduction

of new vehicles into the national 

airspace, such as unmanned 

vehicles and very light jets—and 

human resource issues, present 

challenges that have the potential

to strain the existing safety

oversight system. GAO’s testimony 

focuses on these questions: (1) 

How is the Federal Aviation 

Administration (FAA) ensuring that 

the areas of highest safety risk are 

addressed? (2) How is FAA 

ensuring that its staff maintain the

skills and knowledge to 

consistently carry out the agency’s 

oversight programs? and (3) What 

are the key safety challenges facing

FAA? This statement is based on 

our recent reports on FAA’s 

inspection oversight programs,

industry partnership programs, and 

enforcement and training

programs. It is also based on

interviews with FAA and relevant

industry officials. 

What GAO Recommends

To help FAA fully realize the

benefits of its safety oversight 

system, GAO has made several 

recommendations to address the 

weaknesses identified in GAO’s 

reviews. Although FAA has begun 

addressing the recommendations,

many have not been fully

implemented. 

FAA’s aviation safety oversight system includes programs that focus on 

identifying and mitigating risks through a system safety approach and by 

leveraging resources, but as FAA is still developing evaluations for some of 

these programs, it remains unclear the extent to which they are achieving

their intended effects. FAA’s system safety approach for overseeing 

airlines—through the Air Transportation Oversight System (ATOS) and 

Surveillance and Evaluation Program (SEP)—uses inspection staff 

efficiently by prioritizing workload based on areas of highest risk and 

ensuring that corrective actions have been taken. However, recent and 

planned changes that would move inspections of about 100 airlines from 

SEP to ATOS will shift inspector workload and might affect FAA’s capability 

to oversee the industry. FAA also concentrates its limited staff resources on 

the most safety-critical functions and through its designee programs 

delegates other, less critical activities to designees. Designees perform 

about 90 percent of certification-related activities, and thus allow FAA to 

better leverage resources. GAO’s recent work found some weaknesses in 

FAA’s system safety approach and recommended that FAA develop effective 

evaluative processes and accurate nationwide data on its safety oversight 

programs to address these weaknesses so that program managers and other 

officials have assurance that the programs attain their intended effect. FAA 

has begun implementing those recommendations but does not plan to 

evaluate SEP, which it intends to discontinue after December 2007. 

Training—including mandatory training requirements for FAA’s workforce 

as well as designees—is an integral part of FAA’s safety oversight system. 

GAO has reported that FAA has generally followed effective management 

practices for planning, developing, delivering, and assessing the impact of its 

technical training for safety inspectors, although some practices have yet to 

be fully implemented. However, several actions could improve the results of 

its training efforts. For example, FAA develops technical courses on an ad 

hoc basis rather than as part of an overall curriculum for each type of 

inspector, such as inspectors of operations or cabin safety, because the 

agency has not systematically identified the technical skills and 

competencies each type of inspector needs to effectively perform 

inspections. FAA has recognized the need to improve its training program in 

this and other areas. 

FAA faces several key safety challenges, including not meeting its 

performance target for commercial air carrier safety this year because of 

recent fatal accidents. Further, FAA’s ability to oversee aviation safety will

be affected by recent and anticipated trends in inspector and air traffic 

controller attrition. Also, FAA intends to enhance runway safety by relying 

on new technologies that are expected to reduce runway accidents. 

However, schedule delays and cost increases challenge FAA’s ability to 

deploy this technology. Finally, new types of aviation vehicles are changing

the aviation industry and will require new areas of expertise for FAA’s 

inspectors and controllers. 

www.gao.gov/cgi-bin/getrpt?GAO-06-1091T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Gerald L. 

Dillingham, Ph.D., at (202) 512-2834 or 

dillinghamg@gao.gov. 
Mr. Chairman and Members of the Subcommittee: 

Thank you for the opportunity to testify today on issues related to aviation

safety. The U.S. commercial aviation industry has had an extraordinary 

safety record in recent years. In order to maintain a high level of safety, it

is important for the Federal Aviation Administration (FAA) to have a 

safety oversight system that is comprehensive, efficient, and effective and 

can provide an early warning of hazards that can lead to accidents. It is 

equally important to have a skilled, well-trained workforce to implement 

and monitor this safety oversight system. However, expected increases in 

air traffic—including the introduction of new vehicles into the national air 

space, such as unmanned vehicles and very light jets—and human 

resource issues present challenges that have the potential to strain the 

existing safety oversight system. My testimony today focuses on these 

questions: (1) How is FAA ensuring that the areas of highest safety risk are 

addressed? (2) How is FAA ensuring that its staff maintain the skills and 

knowledge to consistently carry out the agency’s oversight programs? and 

(3) What are the key safety challenges facing FAA? We will also discuss 

our related recommendations that FAA has not fully addressed. This 

statement is based on our recent reports on FAA’s inspection oversight 

programs, industry partnership programs, and enforcement and training 

programs. Additionally, we met with FAA officials and relevant industry 

groups and reviewed their documentation to obtain information on 

challenges facing FAA. We conducted this work in accordance with 

generally accepted government auditing standards. 

Following is a summary of our findings: 

• FAA’s safety oversight system has programs that focus on identifying and 

mitigating risk through a system safety approach, leveraging resources, 

and enforcing safety regulations, but concerns exist with each aspect of 

the system. FAA’s system safety approach for overseeing airlines—

through the Air Transportation Oversight System (ATOS) and Surveillance 

and Evaluation Program (SEP)—has many strengths. Both programs, for 

example, use inspection staff efficiently by prioritizing workload based on 

areas of highest risk and ensuring that corrective actions have been taken. 

However, the full potential of SEP is not being realized because the 

inspection workload for the 81 airlines included in SEP is heavily oriented 

to nonrisk based activities. Of additional concern is that recent and 

planned changes to transfer about 100 airlines from SEP to ATOS will 

affect inspector workload that may affect FAA’s capability to oversee the 

aviation industry. FAA leverages resources and saves money through its 

“designee” programs, in which individuals and organizations have been 

Page 1 GAO-06-1091T Aviation Safety 
delegated to act on FAA’s behalf to perform about 90 percent of 

certification-related activities. The designee program allows FAA to better 

concentrate its limited staff resources on the most safety-critical 

functions. However, planned changes to some designee programs that 

would create a new “organizational designation authorization” will result

in FAA focusing on the performance of organizations rather than the 

individuals within the organization who carry out the delegated functions. 

As FAA moves from direct oversight of the individuals performing 

delegated activities, it will be important for the agency to have valid and 

reliable data and strong evaluative processes to monitor any program 

changes that have implications for safety. FAA’s enforcement program, 

which is an outgrowth of its inspection process, is intended to ensure 

industry compliance with safety regulations and is another important 

element of its safety oversight system. A key objective of FAA’s policy of 

assessing legal sanctions against entities or individuals that do not comply 

with aviation safety regulations is to deter future violations. However, we 

found that recommendations for sanctions are sometimes reduced on the 

basis of factors that are not associated with the merits of the case, and the 

economic literature on deterrence suggests that the goal of preventing 

future violations is weakened when the penalties for violations are 

lowered for reasons not related to the merits of the case. For fiscal years 

1993 through 2003, we found that civil monetary penalties were reduced

by 52 percent from a total of $334 million to $162 million. It is important 

for FAA to have effective evaluative processes and relevant data on its 

numerous safety programs so that the agency has assurance the programs 

are having their intended effect, especially as FAA’s oversight becomes 

more indirect and as significant program changes are made. Our most 

recent work has shown the lack of evaluative processes and limitations 

with data for FAA’s SEP program, designee programs, industry partnership 

programs, and enforcement program. 

• FAA has made training an integral part of its safety oversight system and 

has established mandatory training requirements for its workforce as well 

as designees, but several actions could improve the results of its training 

efforts. We have reported that FAA has generally followed effective 

management practices for planning, developing, delivering, and assessing 

the impact of its technical training for safety inspectors, although some 

practices are still early in the implementation phase. For example, in 

developing its training curriculum for inspectors, FAA followed effective 

management practices, such as developing courses that support changes 

in inspection procedures resulting from regulatory changes or agency

initiatives. On the other hand, FAA develops technical courses on an ad 

hoc basis rather than as part of an overall curriculum for each type of 

inspector, such as inspectors of operations or cabin safety, because the 

Page 2 GAO-06-1091T Aviation Safety 
agency has not systematically identified the technical skills and 

competencies each type of inspector needs to effectively perform 

inspections. FAA has recognized the need for improvements to its training 

program in this and other areas and has begun taking some action to 

address these and other training issues. 

• FAA faces a number of key safety challenges, including meeting its 

performance target for commercial air carrier safety, which it will not 

meet in fiscal year 2006 because of recent fatal accidents. The challenge of

meeting its performance target will be exacerbated by other challenges in

human capital management, the acquisition and operation of new safety 

enhancing technologies, and new types of vehicles, such as very light jets 

(VLJ), that may place additional workload strains on FAA inspectors and 

air traffic controllers. FAA’s ability to oversee aviation safety will be 

affected by recent and anticipated trends in inspector and air traffic 

controller attrition. For example, FAA estimates it will lose 10,291, or 

about 70 percent of the controller workforce, over the next 10 years, 

primarily due to retirements. FAA intends to enhance runway safety by 

relying on new advanced technologies that are expected to reduce runway 

accidents. However, schedule delays and cost increases have affected 

FAA’s ability to deploy this technology. Finally, if predictions about new 

types of aviation vehicles are borne out, it will change the aviation 

landscape and will require new areas of expertise for FAA’s inspectors and 

controllers. For example, the industry predicts there may be as many as 

5,000 to 10,000 VLJs operating in the national airspace by 2020, which 

would further congest the national airspace system especially at and near

smaller airports, where VLJs are expected to be prevalent because of their 

smaller size.

The U.S. commercial aviation industry, with less than one fatal accident 

per 5 million flights from 2002 through 2005 has an extraordinary safety 

record. However, when passenger airlines have accidents or serious 

incidents, regardless of their rarity, the consequences can be tragic. In 

addition, according to Bureau of Transportation Statistics data, flight 

arrival delays have increased from 15 percent in 2003 to 22 percent in 2006. 

Increases in flight delays can be viewed as evidence of strain in the 

aviation system, as a loss of efficiency in the air system is a symptom of 

increased strain. Losses of efficiency and the corresponding strain on the 

system could potentially result in hazards that decrease safety. In order to

maintain a high level of aviation safety, it is critical to have wellestablished, efficient, and effective systems in place to provide an early 

warning of hazards that can lead to accidents. 

Background 

Page 3 GAO-06-1091T Aviation Safety 
FAA has established a number of systems and processes to inspect and 

oversee various aspects of passenger airline safety, such as aircraft 

maintenance and flight operations. In 1998, the agency implemented the 

Air Transportation Oversight System (ATOS), which currently oversees 35

commercial airlines and cargo carriers; the goal is for ATOS to oversee all

commercial passenger and cargo airlines. ATOS emphasizes a system 

safety approach that extends beyond periodically checking airlines for 

compliance with regulations to using technical and managerial skills to 

identify, analyze, and control hazards and risks. For example, under ATOS, 

inspectors develop surveillance plans for each airline, based on data 

analysis and risk assessment, and adjust the plans periodically based on 

inspection results. Our review of ATOS’s early implementation found 

weaknesses, which FAA addressed by improving guidance to inspectors 

and increasing data usefulness. 

FAA’s inspection process for the 81 commercial airlines not covered by

ATOS has two components. The National Work Program Guidelines (NPG) 

is the original oversight program for these airlines. Under NPG, an FAAwide committee of managers identifies an annual minimum set of required

inspections to ensure that airlines comply with their operating certificates; 

this process is not risk-based. In 2002, FAA added another component, the 

Surveillance and Evaluation Program (SEP), to the inspection process to 

incorporate principles of ATOS into its oversight of commercial airlines. 

The two components are used together to establish the number and types 

of annual inspections for airlines. Inspections can encompass many 

different activities, such as visually spot-checking an airplane at a gate,

monitoring procedures on a scheduled flight, or observing maintenance 

performed on an aircraft. Each year, FAA headquarters establishes a 

baseline number and type of inspections for each airline through NPG. 

Through SEP, teams of FAA inspectors analyze the results of an airline’s 

prior inspections at periodic meetings and, based on their assessment of 

specific risks, establish other inspections that may be needed. 

Since 1990, FAA has emphasized industry partnership programs that allow 

participants, such as airlines and pilots, to self-report violations of safety 

regulations and help identify safety deficiencies and potentially mitigate or 

avoid fines or other legal action. For example, the Voluntary Disclosure 

Program encourages the self-reporting of manufacturing problems and 

Page 4 GAO-06-1091T Aviation Safety 
safety incidents by participants that can include air carriers and repair 

stations.1

When violations of statutory and regulatory requirements are identified 

through inspections, partnership programs, or other methods, FAA has a 

variety of enforcement tools that it may use to respond to the violations, 

including administrative actions (such as issuing a warning notice or a 

letter of correction that includes the corrective actions the violator is to 

take) and legal sanctions (such as levying a fine or suspending or revoking 

a pilot’s certificate or other FAA-issued certificate). 

The achievement of FAA’s mission is dependent in large part on the skills 

and expertise of its workforce, whose aviation safety activities include air

traffic control, maintenance of air traffic control equipment, and 

certification and inspection of various industry participants. As of 2006, 

714 of FAA’s approximately 3,400 inspectors were dedicated to overseeing

the 35 airlines in ATOS. Approximately 1,100 inspectors2

 oversee other 

entities and individuals, including the remaining 81 commercial airlines 

that are included in the SEP inspection program, about 5,200 aircraft 

repair stations, and approximately 625,000 pilots. FAA’s safety oversight 

programs for other aspects of the aviation industry—including 

manufacturers of aircraft and aircraft parts, repair stations, flight schools, 

aviation maintenance technician schools, pilots, and mechanics—involve

certification, surveillance, and inspection by FAA’s safety inspectors, 

engineers, flight surgeons, and designated representatives. FAA authorizes 

about 13,400 private individuals and 218 organizations (called “designees”) 

to act as its representatives to conduct many safety certification activities 

that FAA considers to be nonsafety critical, such as administering flight 

tests to pilots, inspecting repair work by maintenance facilities, 

conducting medical examinations of pilots, and approving designs for 

aircraft parts. These designees are grouped into 18 different programs and 

are overseen by three FAA offices—Flight Standards Service, Aerospace 

Medicine, and Aircraft Certification Service—all of which are under the 

 1

Other industry partnership programs include the Aviation Safety Action Program, which

allows for the self-reporting of safety incidents by employees of air carriers and repair

stations; the Aviation Safety Reporting Program, which allows any participant in the 

national airspace system, such as air traffic controllers, pilots, and flight attendants, to selfreport safety incidents; and the Flight Operation Quality Assurance Program, whose

participant airlines equip their aircraft to record flight data, which the airlines analyze for 

safety trends that are provided to FAA.

2

The remaining approximately 1,500 inspectors oversee general aviation. 

Page 5 GAO-06-1091T Aviation Safety 
Office of Aviation Safety. In addition, FAA’s Air Traffic Organization (ATO) 

includes the approximately 16,700 air traffic controller workforce3

 and 

nearly 7,200 field maintenance technicians responsible for maintaining 

ATO’s equipment and facilities, which include 21 air traffic control centers, 

518 airport control towers, and 76 flight service facilities. 

While overall commercial aviation safety trends have been generally 

positive over the last several years, recent safety trends may warrant 

scrutiny. On the positive side, the number of serious runway incursions4

has decreased since fiscal year 2002. Specifically, in fiscal year 2002, there

were 37 serious runway incursions, compared with 29 in fiscal year 2005. 

Recent fiscal year 2006 data also continue the downward trend, with 25 

serious runway incursions as of August 1, 2006—fewer than at the same 

time in the previous fiscal year. However, with four fatal accidents in fiscal

year 2006,5

 FAA will not meet its performance target for fiscal year 2006 

for commercial air carrier safety.6

 Although general aviation accidents 

have decreased from 1,715 in 2002 to 1,669 in 2005, general aviation safety

continues to be a concern because it represents a significant number of 

fatal accidents every year. (See fig. 1.) For example, 321 of the 1,669 

general aviation accidents in 2005 were fatal. Additionally, the poorer 

safety records of cargo and air ambulances services, compared with the 

commercial passenger airline accident rate, point out the safety 

vulnerabilities in this area. According to FAA, from 1998 through 2005, the 

accident rate for scheduled air cargo operators declined significantly, but 

was still about 2.5 times higher than the accident rate for scheduled 

passenger operators. Further, in instances where there was not an isolated

injury to a single individual, the accident rate for cargo was about 6.3 

 3

As of June 2006. This number includes about 2,380 traffic management coordinators and 

operations supervisors. 

4

A runway incursion is any occurrence at an airport involving an aircraft, vehicle, person or

object on the ground that creates a collision hazard or results in a loss of separation with 

an aircraft taking off, intending to take off, landing, or intending to land. 

5

In December 2005, a Southwest Airlines airplane slid off a runway at Chicago’s Midway 

Airport, went through a barrier fence and onto a roadway, killing a passenger in a passing 

automobile. Also in December 2005, a Chalk’s Ocean Airways aircraft experienced an inflight breakup shortly after takeoff in Miami, resulting in 20 fatalities. On January 16, 2006,

a Continental Airlines ground worker was fatally injured in El Paso, Texas. In August 2006, 

a Comair flight crashed while attempting take-off from the Lexington, Kentucky, airport, 

resulting in 49 fatalities.

6

FAA’s performance target for fiscal year 2006 is 0.018 fatal accidents per 100,000 

departures over the last 3 years.

Page 6 GAO-06-1091T Aviation Safety 
times higher than for commercial passenger aviation.7

 In addition, from 

January 2002 to January 2005, there were 55 emergency medical services 

or air ambulance accidents, with 54 fatalities, the highest number of 

accidents since the 1980s.

8

 In addition, FAA did not meet its performance 

target with regard to operational errors9

 for fiscal years 2003 through 2005.

While operational errors continued an upward trend in 2006, FAA was 

below the fiscal year 2006 target of 4.27 operational errors per million 

activities as of June 2006.

 7

According to FAA, accidents impacting a single person, although they may be serious, are

isolated to ground workers or a single passenger who may walk into a propeller or who 

may fall while boarding or deplaning. Removing these isolated risk accidents from the data

helps achieve a more informative comparison of accident data, according to the agency. 

8

Comprehensive activity data regarding emergency medical services operations (for 

example, exposure rates and missions flown) are limited because the sources for these 

data are generally poor. Therefore, accident rates cannot be calculated. 

9

An operational error is a violation of FAA separation standards that define minimum safe 

distances between aircraft, between aircraft and other physical structures, and between 

aircraft and otherwise restricted airspace. 

Page 7 GAO-06-1091T Aviation Safety 
Figure 1: Number of General Aviation Accidents and Fatalities, 2000 through 2005 

FAA’s safety oversight system has programs that focus on identifying and 

mitigating risk through a system safety approach, leveraging resources, 

and enforcing safety regulations, but the programs lack fully developed 

evaluative processes. As mentioned previously, FAA oversees commercial 

airlines by one of two programs—ATOS, which includes 35 airlines, and 

SEP, which includes the remaining 81 airlines. Both programs emphasize a 

system safety approach of using risk analysis techniques, which allow for 

the efficient use of inspection staff and resources by prioritizing workload 

based on areas of highest risk and require that inspectors verify that 

corrective actions are taken. For example, FAA has developed risk 

assessment worksheets for both programs that guide inspectors through 

identifying and prioritizing risks associated with key airline areas, such as 

flight operations and personnel training. Information from the worksheets 

is then used to target resources to mitigating those risks. 

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2000 2001 2002 2003 2004 2005

Number of accidents / Number of fatalities

Year

Fatalities

Non-fatal accidents

Fatal accidents

Source: NTSB.

FAA’s Safety 

Oversight System 

Includes Programs 

That Focus on Risk 

Management and 

Leveraging 

Resources, but 

System Is Hindered by 

Data Limitations and 

Lack of Evaluations 

Page 8 GAO-06-1091T Aviation Safety 
In recent work we found that the benefits of FAA’s system safety approach 

for the inspection of airlines covered under SEP could be enhanced if FAA 

more completely implemented the program and addressed other 

challenges.10 Most of FAA’s inspections of those airlines were not riskbased. For example, as shown in figure 2 from fiscal years 2002 through 

2004, SEP—a risk-based approach—guided only 23 percent of the 

inspection activities for the top 25 SEP airlines in terms of the number of 

enplanements. The remaining 77 percent of inspection activities were 

identified through NPG, a process that is not risk-based or system safety 

oriented. Although inspectors can replace NPG-identified activities with 

SEP-identified activities that they deem address a greater safety risk, we 

found that FAA inspectors interpret agency emphasis on NPG as 

discouraging this practice. To address this issue, we recommended that

FAA improve communication with and training of inspectors in areas of 

system safety and risk management. In response to our recommendations, 

FAA revised its guidelines to require inspectors and managers to ensure 

that risk information is used and updated its SEP training course to reflect 

that change. Since FAA’s focus on system safety represents a cultural shift 

in the way the agency oversees the aviation industry, it will be important 

for FAA to monitor the implementation of system safety and risk 

management principles. We recommended that FAA establish a 

continuous evaluative process for its activities under SEP, but the agency 

does not intend to set up a process since it expects to eliminate the SEP 

program after December 2007, which is its deadline for moving all 

commercial airlines to the ATOS program. If the deadline slips, we believe 

our recommendation remains valid.

 10GAO, Aviation Safety: System Safety Approach Needs Further Integration into FAA’s 

Oversight of Airlines, GAO-05-726 (Washington, D.C.: Sept. 28, 2005). 

Page 9 GAO-06-1091T Aviation Safety 
Figure 2: SEP- and NPG-Initiated Required Inspections for the Top Airlines Covered

by the Programs, Fiscal Years 2002-2004

Note: Top airlines ranked in terms of number of enplanements. 

Furthermore, FAA’s plans to dissolve the SEP program after moving all 

commercial airlines to ATOS will shift the inspectors workloads and 

present a challenge to FAA’s inspection oversight process. As FAA shifts 

airlines to ATOS, it will also move inspectors to the program. Unlike SEP 

inspectors, ATOS inspectors are dedicated to an airline and generally

cannot be used to inspect other entities. SEP inspectors, on the other 

hand, have other duties in addition to overseeing airlines—such as 

certifying and approving aircraft types; overseeing repair stations, 

designees, and aviation schools; and investigating accidents. For example, 

our analysis of FAA data indicated that, for fiscal years 2002 through 2004,

about 75 percent of SEP inspectors had responsibility for more than 3 

entities, and about half had responsibility for more than 15. As inspectors 

are transitioned to ATOS, the remaining SEP inspector workforce will 

have to add those other entities to their workload. Furthermore, ATOS 

requires more inspectors per airline than SEP. For example, when FAA 

recently transitioned four airlines to ATOS,11 the total size of the four 

inspection teams increased 30 percent, from 73 to 95 inspectors. With the 

expansion of the ATOS program, it will be important to monitor the 

magnitude of the shift in resources and the effect it may have on FAA’s 

overall capability to oversee the industry as well as any changes to the 

current ATOS program that may be required by the expansion.12

 11The airlines are Champion, American Eagle, ExpressJet, and SkyWest. 

12For example, we found that when Champion Airlines became part of ATOS in January

2005, FAA has, in this one case, revised its procedures to allow the Northwest Airlines 

inspection team to share its data analyst and manager with the Champion inspection team. 

Page 10 GAO-06-1091T Aviation Safety 
FAA’s Oversight Focuses 

on Leveraging Inspector 

Resources, Which Results 

in Less Direct Oversight of 

the Industry 

An important part of FAA’s safety oversight system are designee programs, 

through which FAA authorizes about 13,400 private individuals and 218 

organizations to act on its behalf to conduct safety certification activities 

that FAA considers to be non-safety critical. We reported that designees 

perform about 90 percent of certification-related activities, thus greatly 

leveraging the agency’s resources and enabling inspectors to concentrate 

on what FAA considers the most safety-critical activities.13 However, 

concerns about the consistency and adequacy of designee oversight by 

FAA have been raised by experts and other individuals we interviewed. 

For example, designees and industry officials that we spoke with indicated

that FAA’s level of oversight and interpretation of rules differ among 

regions and among offices within a region, which limits FAA’s assurance 

that designees’ work is performed uniformly in accordance with FAA’s 

standards and policy, the primary goal of which is the safety of U.S. 

aviation. To improve management control of the designee programs, and 

thus increase assurance that designees meet FAA’s performance 

standards, we recommended that FAA develop mechanisms to improve 

the compliance of FAA program and field offices with existing policies. In 

response to our recommendations, FAA has, among other things, 

established a designee quality assurance office to address inconsistent and 

nonstandard oversight issues among offices. FAA has also developed a 

survey that will collect information from individuals who recently worked 

with designees, such as pilots who recently received their license through 

a designee, to gather information that can be used to continually improve 

designee programs. 

To increase FAA’s assurance that its designees are meeting FAA’s safety 

standards, it will be important for FAA to continue these activities, which 

are in the early stages of development or implementation, especially as the 

agency moves to replace certain designee programs with an organizational 

designation authorization (ODA). ODA would expand the number and 

types of organizational designees and further transform FAA’s role to that 

of monitoring the performance of others. In October 2005, FAA issued a 

final rule that established the ODA program and provides for the phasing 

out of organizational designees by November 2009. By that time, the 

current 218 organizational designees will have to apply for and be granted

status as an ODA.14 In August 2006, FAA issued an order that establishes 

 13GAO, Aviation Safety: FAA Needs to Strengthen the Management of Its Designee

Programs, GAO-05-40 (Washington, D.C.: Oct. 8, 2004). 

14Examples of companies that are organizational designees include Boeing, Gulfstream, 

United Airlines, and Continental Airlines, as well as smaller companies.

Page 11 GAO-06-1091T Aviation Safety 
procedures for the ODA program, including the capability to expand the 

activities that may be delegated out. Under the program, FAA will focus on 

the performance of organizations rather than the individuals within the 

organization who carry out the delegated functions. As FAA makes these 

changes to its designee programs that remove FAA from direct oversight 

of the individuals performing the delegated activities, it will be important 

for the agency to adhere to its policy of using designees only for less 

safety-critical work. It will also be important for FAA to have the data and 

evaluative processes, which we discuss later in this testimony, to 

effectively monitor the new program. 

FAA is also becoming increasingly removed from overseeing airline 

maintenance. In recent years, in an attempt to reduce costs, airlines have

increasingly contracted out maintenance. For example in 2000, 44 percent 

of major air carriers’ maintenance expenses were attributable to 

outsourcing; in 2004, it had increased to 54 percent. However, FAA’s 

inspection activities have remained focused on air carriers’ in-house 

maintenance, according to DOT’s Inspector General.15

FAA’s enforcement process, which is intended to ensure industry 

compliance with safety regulations, is another important element of its 

safety oversight system. FAA assesses legal sanctions against entities or 

individuals that do not comply with aviation safety regulations. Such 

sanctions are intended to deter future violations. However, we found that 

the effect of FAA’s legal sanctions on deterrence is unclear, and that 

recommendations for sanctions are sometimes changed on the basis of 

factors not associated with the merits of the case.16 For fiscal years 1993 

through 2003, attorneys in FAA’s Office of the Chief Counsel authorized a 

52 percent reduction in the civil monetary penalties assessed (from a total 

of $334 million to $162 million). FAA officials told us the agency 

sometimes negotiate lower fines, thereby reducing sanctions to close 

cases more quickly and reduce FAA attorneys’ caseloads. Economic 

literature on deterrence suggests that although negative sanctions (such as 

fines and certificate suspensions) can deter violations, if violators expect

sanctions to be reduced, they may have less incentive to comply with 

Enforcement Is an 

Important Element of 

FAA’s Safety Oversight 

System, but Deterrent 

Effect of Sanctions Is 

Unclear 

 15DOT Inspector General, Air Carriers’ Use of Aircraft Repair Stations (Washington, D.C.; 

July 8, 2003). 

16GAO, Aviation Safety: Better Management Controls Are Needed to Improve FAA’s Safety

Enforcement and Compliance Efforts, GAO-04-646 (Washington, D.C.: July 6, 2004). 

Page 12 GAO-06-1091T Aviation Safety 
regulations. In effect, it becomes more difficult to achieve the goal of 

preventing future violations when the penalties for present violations are 

lowered for reasons not related to the merits of the case. 

Recent changes that FAA has made to its enforcement program may lead

to more uniformly set fines and, thus, potentially less need to revise fines. 

Prior to September 2005, the initial recommendation to use administrative 

actions (such as warning notices and letter of correction) or legal 

sanctions (such as fines or suspension of operating certificates) was based 

on the judgment of the inspectors. If inspectors recommended a legal 

sanction, they then consulted FAA’s sanction guidance policy to determine 

the amount of the proposed penalty. In September 2005, FAA adopted 

changes to its enforcement program that incorporated system safety risk 

management principles and established explicit criteria for inspectors to 

use in making an initial enforcement recommendation. As soon as FAA 

investigators have gathered sufficient information to categorize the safety

risk and the conduct (i.e., whether it was intentional, reckless, or 

systemic), they prepare a risk statement that describes the hazard created

by the act and the potential consequence of that hazard. An example of a 

risk statement is “an aircraft that operates in Class B airspace without a 

clearance providing separation from other aircraft could cause a mid-air 

collision.” The investigators then review the risk statement to determine 

the severity of the hazard (using a scale of catastrophic, critical, marginal, 

or negligible) and the likelihood of the worst credible outcome (using a 

scale of frequent, occasional, or remote). Based on these assessments, 

investigators apply a decision tool that determines the type of action (legal 

or administrative) to take against an individual or business. Inspectors no 

longer have the responsibility of recommending a specific fine level. It is 

too early to determine if these changes to the enforcement program have 

resulted in a more uniform application of penalties and fewer penalty 

reductions. 

Effective processes for evaluating FAA’s safety oversight programs, along 

with accurate nationwide data on those programs would provide FAA’s 

program managers and other officials with assurance that the programs 

are having their intended effect, especially as FAA’s oversight becomes 

more indirect. Such processes and data are also important because FAA’s 

workforce is dispersed worldwide—with thousands of staff working out of 

more than 100 local offices—and because FAA’s use of a risk-based 

system safety approach represents a cultural shift from its traditional 

inspection program. The experiences of successful transformations and 

change management initiatives in large public and private organizations 

Data Limitations and Lack 

of Evaluations Limit FAA’s 

Ability to Manage Risk and 

Are Particularly Critical as 

FAA’s Oversight Becomes 

More Indirect 

Page 13 GAO-06-1091T Aviation Safety 
suggest that it can take 5 to 7 years or more until such initiatives are fully 

implemented and cultures are transformed in a sustainable manner. As a 

result, evaluation is important to understanding if the cultural shift has 

effectively occurred. Our most recent work has shown that FAA had not 

evaluated its safety programs, and we recommended that the agency

establish continuous evaluative processes for the SEP program, designee 

programs, industry partnership programs, and enforcement program. FAA 

has made recent progress in implementing some of these 

recommendations. For example, FAA has scheduled audits of all its 

designee programs, to be completed by the end of fiscal year 2009, and 

established a delegation steering group that first met in August 2006 and 

will be responsible for agencywide monitoring of the designee programs 

for compliance with program policies and evaluating the effectiveness of 

the designee programs. Additionally, as FAA implements its new 

enforcement policy, it has established procedures to monitor the new 

policy on a quarterly basis and to recommend process improvements 

based on the information collected. However, FAA does not plan to 

evaluate the SEP program because it intends to discontinue the program 

after December 2007. 

Yet, FAA’s ability to evaluate its programs is hindered by its lack of useful 

nationwide data. For example, we found that FAA’s oversight of designees 

was hampered, in part, by the limited information of designee’s

performance contained in the various designee databases.17 These 

databases contain descriptive information on designees, such as their 

types of designations and status (i.e., active or terminated). More complete 

information would allow the agency to gain a comprehensive picture of 

whether staff are carrying out their responsibilities to oversee designees. 

To improve management control of the designee programs, and thus 

increase assurance that designees meet the agency’s performance 

standards, we recommended that FAA improve the consistency and 

completeness of information in the designee databases. To address this 

recommendation, FAA has established the Designee Integration User 

Group, which expects to begin work in September 2006 on an automated 

information tool that will track data on all designees. We also found 

problems with the accuracy or completeness of data in the SEP and 

 17These databases are the Program Tracking and Reporting Subsystem, National Vital 

Information Subsystem, Designee Information Network, and Airmen Medical Certification 

Information Subsystem. 

Page 14 GAO-06-1091T Aviation Safety 
enforcement programs, which FAA has recently taken steps to begin 

addressing. 

FAA’s use of a risk-based system safety approach to inspections requires 

inspectors to apply data analysis and auditing skills to identify, analyze, 

assess, and control potential hazards and risks. To effectively identify 

safety risks, inspectors must be well-trained in the system-safety approach

and have sufficient knowledge of increasingly complex aircraft, aircraft 

parts, and systems. It is also important that FAA’s large cadre of designees

is well-trained in federal aviation regulations and FAA policies. FAA has 

made training an integral part of its safety inspection system by 

establishing mandatory training requirements for its workforce as well as 

designees. Although FAA provides inspectors with extensive training in 

federal aviation regulations; inspection and investigative techniques; and 

technical skills, such as flight training for operations inspectors, we have 

identified weaknesses with the training program. The agency provides 

designees with an initial indoctrination that covers federal regulations and 

agency policies, and refresher training every 2 to 3 years. 

We have reported that FAA has generally followed effective management 

practices for planning, developing, delivering, and assessing the impact of

its technical training18 for safety inspectors, although some practices have 

yet to be fully implemented.19 Appendix I describes the extent to which 

FAA follows effective management practices in each of these four areas.

Some examples follow: 

Training Is an Integral 

Part of FAA’s Safety 

Oversight System, but 

Several Actions Could 

Improve Results 

• In developing its training curriculum for inspectors, FAA has developed 

courses that support changes in inspection procedures resulting from 

regulatory change or agency initiatives. On the other hand, FAA develops 

technical courses on an ad hoc basis rather than as part of an overall 

curriculum for each inspector specialty—such as air carrier operations, 

 18We define technical training as training in aviation technologies. FAA includes in its 

definition of technical training topics such as system safety and risk analysis, inspector job 

skills, data analysis, and training in software packages. 

19GAO, Aviation Safety: FAA Management Practices for Technical Training Mostly

Effective; Further Actions Could Enhance Results, GAO-05-728 (Washington, D.C.: Sept. 7,

2005). We compared FAA’s management of its inspector technical training efforts with 

effective management practices in GAO, Human Capital: A Guide for Assessing Strategic

Training and Development Efforts in the Federal Government, GAO-04-546G 

(Washington, D.C.: Mar. 1, 2004). 

Page 15 GAO-06-1091T Aviation Safety 
maintenance, and cabin safety—because the agency has not systematically 

identified the technical skills and competencies each type of inspector 

needs to effectively perform inspections. 

• In delivering training, FAA has established clear accountability for 

ensuring that inspectors have access to technical training, has developed a

way for inspectors to choose courses that meet job needs and further 

professional development, and offers a wide array of technical and other 

courses. However, both FAA and its inspectors recognize the need for 

more timely selection of inspectors for technical training. 

To address some of these issues, we recommended, among other things, 

that FAA ensure that inspector technical training needs are identified and

met in a timely manner by systematically assessing inspectors’ technical 

training needs and better aligning the timeliness of training to when 

inspectors need the training to do their jobs. In addition, we have 

identified gaps in the training provided to SEP inspectors, and have 

recommended that FAA improve inspectors’ training in areas such as 

system safety and risk management to ensure that these inspectors have a

complete and timely understanding of FAA’s policies in these areas. We 

identified similar competency gaps related to designee oversight. For 

example, FAA does not require refresher training on how to oversee 

designees, which increases the risk that inspectors do not retain the 

information, skills, and competencies required to perform their oversight 

responsibilities. We recommended that FAA provide additional training for

staff who directly oversee designees. 

FAA has begun to address these recommendations. For example, FAA 

plans to release five Web-based courses by the end of 2006, which will 

allow the agency to provide training closer to the time that employees 

need it. Also, FAA has instituted an electronic learning management 

system that provides for employee input to their own learning plans. FAA 

has also updated the SEP training course to reflect recent policy changes 

that emphasize the importance of risk management. Finally, FAA has 

begun developing a new designee oversight training course that is planned 

to be ready by the summer of 2007.

It is important that FAA’s inspection workforce, designees, and FAAcertified aviation mechanics are knowledgeable about the latest 

technology changes. While we did not attempt to assess the technical 

proficiency that FAA’s workforce requires and will require in the near 

future, FAA officials said that inspectors do not need a substantial amount 

of technical training courses because inspectors are hired with a high 

Page 16 GAO-06-1091T Aviation Safety 
degree of technical knowledge of aircraft and aircraft systems. They 

further indicated that inspectors can sufficiently keep abreast of many of 

the changes in aviation technology through FAA and industry training 

courses and on-the-job training. Similarly, we did not identify any specific 

gaps in the competencies of designees. However, in its certification 

program for aviation mechanics, we found that FAA standards for 

minimum requirements for aviation courses at FAA-approved aviation 

maintenance technician schools and its requirements for FAA-issued 

mechanics certificates do not keep abreast with the latest technologies. In

2003, we reported that those standards had not been updated in more than 

50 years.20 We recommended that FAA review the curriculum and 

certification requirements and update both. In response to this 

recommendation, Vision 100—Century of Aviation Reauthorization Act, 

which was passed December 12, 2003, required FAA to update the 

standards 1 year after enactment of the law and to conduct reviews and 

updates every 3 years after the initial update. FAA issued an Advisory 

Circular in January 2005 that described suggested curriculum changes; 

however, the agency has not updated the certification requirements for 

mechanics. 

FAA faces a number of key safety challenges, including meeting its 

performance target for commercial air carrier safety, which it will not 

meet in fiscal year 2006 because of recent fatal accidents. With four fatal 

commercial air carrier accidents in fiscal year 2006, the agency will not 

meet its target of 0.018 fatal accidents per 100,000 departures.21 Moreover, 

for the past 3 years, FAA did not meet its performance target for severe 

operational errors, which occur when aircraft do not maintain safe 

distances in the air; as of June 2006, the agency was slightly below its 

target level of 4.27 severe operational errors per million activities. In 

addition, although general aviation accidents have, on the whole, 

decreased in recent years, general aviation safety is also a concern 

because of the large number of fatal accidents every year—an average of

334 fatal accidents have occurred annually since 2000. Furthermore, other 

FAA Faces a Number 

of Challenges in 

Overseeing Aviation 

Safety 

 20GAO, Aviation Safety: FAA Needs to Update the Curriculum and Certification 

Requirements for Aviation Mechanics, GAO-03-317 (Washington, D.C.: Mar. 6, 2003). 

21After a fourth fatal accident occurred in August 2006, FAA estimated that 0.023 fatal 

accidents per 100,000 departures had occurred over the last 3 years. Since the fatal 

accident rate is small and could significantly fluctuate from year to year due to a single 

accident, FAA’s performance measure is a 3-year average, which helps to smooth the 

fluctuation that may occur in any given year. 

Page 17 GAO-06-1091T Aviation Safety 
industry sectors, such as cargo operations22 and on-demand air 

ambulances,23 have poor safety records, as mentioned earlier. It will be 

important for FAA to develop the appropriate strategies to deal with the 

challenges posed by these safety records and to continuously monitor 

safety information to identify trends and early warnings of other safety 

problems. 

Also as described earlier, FAA also faces a number of challenges to several

of its oversight programs. Specifically, FAA’s rapid expansion of ATOS, by 

transferring about 100 airlines and additional inspectors to the program 

over about 2 years, will cause shifts in inspector workload that may affect 

the agency’s ability to oversee other parts of the industry. Furthermore, 

some activities, such as FAA’s creation of ODAs and the trend for airlines 

to outsource maintenance, will remove FAA from direct oversight. It will 

be important for FAA to have robust data and continuous evaluative 

processes to monitor such activities and program changes in order to 

ensure they are not having a negative effect on safety. 

Meeting the challenges posed by recent safety trends and program changes 

will be exacerbated by other challenges in human capital management; the 

acquisition and operation of new safety enhancing technologies; and new 

types of vehicles, such as very light jets (VLJ), that may place additional 

workload strains on FAA inspectors and air traffic controllers. 

FAA’s ability to oversee aviation safety will be affected by recent and 

anticipated trends in attrition of its inspectors compounded, in some 

cases, by delays in hiring and increased workload. For example, for fiscal 

years 2005 through 2010, FAA estimated that over 1,100 safety inspectors 

who oversee commercial airlines and general aviation will leave the 

agency, with an average loss due to attrition of about 195 inspectors per 

year. However, FAA’s efforts to hire more inspectors have been hindered 

by a budget situation in 2005 that resulted in a hiring freeze during part of

that year. During the hiring freeze, FAA filled safety-critical positions, such 

FAA Faces Challenges in 

Human Resources

 22The risk factors that may affect the safety record of cargo carriers include operating a 

large number of flights at night and the age of cargo aircraft. FAA estimates the median age

of in-service passenger jets was 6.25 years, compared with the median age of cargo jets of 

over 25 years. 

23We have ongoing work for this subcommittee that is examining in detail FAA’s oversight 

of air ambulances. 

Page 18 GAO-06-1091T Aviation Safety 
as principal inspectors, through internal appointments. As other safety 

inspectors left, they were not replaced and their workload was divided 

among the remaining inspectors. 

Concerned about the need for additional safety inspectors, for fiscal year 

2006, Congress provided additional funding over the budget request to 

FAA with the expectation that the funding would increase the safety staff 

by 248. This increase in funding would allow for hiring an additional 182 

safety inspectors in Aviation Flight Standards (AFS) and an additional 66 

inspectors and engineers in Aircraft Certification Service (AIR). However, 

as a result of a rescission and unfunded pay raises for fiscal year 2006, 

FAA lacks the funds to hire 67 staff of the expected 248 new staff. As a 

result, FAA’s revised hiring target is 139 AFS staff and 42 AIR staff. As of 

August 2006, FAA has hired an additional 25 AFS and 28 AIR staff. (See fig.

3.) According to FAA, it has a pipeline of applicants and expects to reach 

its goal of filling the 181 slots by the end of the fiscal year. However, the 

actual number of aviation safety inspector slots needed is unknown, 

because FAA lacks staffing standards for safety inspectors. The National 

Academy of Sciences, under a congressional mandate, has just completed 

a study for FAA to estimate staffing standards for inspectors to ensure 

proper oversight over the aviation industry. 

Figure 3: Number of Additional Staff for AFS and AIR, Fiscal Year 2006

During the coming decade, FAA will need to hire and train thousands of 

air traffic controllers to replace those who will retire and leave for other 

reasons. FAA estimates it will lose 10,291 controllers, or about 70 percent 

of the controller workforce, for fiscal years 2006 through 2015, primarily 

Office

Additional staff

funded by Congress

Total

AFS 

248

182

66

181

139

42

53

25

AIR 28

Source: GAO analysis of FAA information.

FAA revised

target

Hired as of

August 2006

Page 19 GAO-06-1091T Aviation Safety 
due to retirements.24 To replace these controllers and to accommodate 

forecasted increases in air traffic and expected productivity increases, 

FAA plans to hire a total of 11,800 new controllers over the next 10 years,

or 1,180 per year, on average.25 By the end of fiscal year 2006, FAA expects 

to hire 930 controllers. As of August 2006, FAA had hired 920. Figure 4 

shows the estimated losses each year as well as the number of planned 

hires. 

Figure 4: Estimated Controller Losses and Planned Hires, Fiscal Years 2006-2015

Recent events may exacerbate the staffing situation. New data indicate 

that controllers are retiring at a faster rate than FAA anticipated. In its 

0

200

400

600

800

1,000

1,200

1,400

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Number of controllers

Source: FAA.

Fiscal year

Estimated losses

Planned hires

 24The high percentage of retirements is attributable to the 1981 controller strike, when 

President Ronald Reagan fired over 10,000 air traffic controllers, and the consequent need 

to quickly rebuild the controller workforce. From 1982 through 1991, FAA hired an average

of 2,655 controllers per year. These controllers will become eligible for retirement during

the next decade. 

25FAA, A Plan for the Future, 2006-2015 (Washington, D.C.: June 2006). 

Page 20 GAO-06-1091T Aviation Safety 
2004 workforce report, FAA projected 341 retirements for fiscal year 2005; 

465 controllers actually retired—36 percent more than FAA’s estimate. In 

addition, a new contract with the air traffic controllers union was recently

implemented by FAA after lengthy negotiations. Under this new contract,

most current air traffic controllers would continue to receive their existing 

base salaries and benefits, which may remove a financial incentive to 

continue working past their retirement eligibility date, while newly hired 

controllers would be hired at lower wage rates, which may affect FAA’s 

ability to hire new controllers. FAA has maintained that this contract will

result in significant cost savings, freeing up resources for other critical 

agency needs. It is too soon to know what effect, if any, the new contract 

may have on retirement decisions. 

In addition to the challenge of hiring large numbers of controllers, FAA 

will face a challenge in training its new hires expeditiously so that it can 

plan to have the right number of controllers in the right facilities when 

they are needed. According to FAA, its ability to train the new controllers 

depends upon several factors, including hiring a relatively even number of 

controllers each year, reducing the time it takes to hire a controller, and 

reducing the duration of training. FAA estimates that because of the long 

training time, it must hire enroute controllers26 an average of 3 to 5 years in 

advance of when they are needed. FAA is taking actions to address these 

issues. For example, in line with our recommendation, a recent change to

the training program allows individuals who complete collegiate 

requirements under the Air Traffic Collegiate Training Initiative27 to bypass 

the first 5 weeks of initial FAA Academy training required for controllers. 

FAA also faces the challenge of ensuring that control facilities have 

adequate staffing based on their unique traffic demands and the accuracy

of FAA’s retirement forecast. Historically, FAA has computed staffing 

standards, which are the number of controllers needed on a systemwide 

basis, but distribution of these totals to the facility level was a negotiated 

process. The staffing standards did not take into account the significant 

differences in complexity and workload among FAA’s 300 terminal and 

enroute control facilities, which can lead to staffing imbalances. FAA has 

begun developing and implementing new staffing standards that use an

 26Enroute air traffic controllers issue clearances and instructions for airborne aircraft. 

27To bypass initial Academy training, individuals must have successfully completed an 

aviation-related program of study from a school under FAA’s collegiate training initiative 

program. FAA has agreements with 13 schools for this program. 

Page 21 GAO-06-1091T Aviation Safety 
algorithm that incorporates traffic levels and complexity of traffic at the 

facility level to determine the number of controllers needed, according to

an FAA official. As FAA further refines its process for determining 

controller staffing needs, the ultimate objective is to assess the traffic level 

and complexity on a sector-by-sector basis to develop more accurate

controller staffing requirements. 

To enhance runway safety, FAA intends to rely on new technologies—

beginning with the Airport Movement Area Safety System (AMASS) and 

Airport Surface Detection Equipment Model X (ASDE-X)—that are 

expected to reduce runway accidents.

28 AMASS and ASDE-X are 

instrumental in mitigating runway incursions and operational errors. 

However, FAA faces challenges—such as a reduced number of airports 

scheduled to receive the equipment, schedule delays, and cost increases—

that affect its reliance on the technologies. 

FAA’s original plans called for 34 airports to receive AMASS29 and 35 

airports to receive ASDE-X (see app. II).30 In total, 59 airports were to 

receive one or both technologies, but this number was reduced to 44 in 

August 2006 after FAA canceled plans to deploy ASDE-X at 15 of the 

originally scheduled airports. FAA plans to take these 15 systems and 

upgrade certain airports that already have AMASS based on the rationale

that maximum benefit is achieved by deploying ASDE-X to airports with 

larger traffic counts or more complex operations. This decision leaves 15 

airports (see fig. 5) that were supposed to receive ASDE-X without either

advanced technology system. Since the anticipated future increase in air 

traffic from commuter airlines and very light jets are likely to be at smaller 

airports that lack the advanced technologies, it will be important for FAA 

to periodically re-evaluate its deployment strategy. 

FAA Faces Challenges in 

Implementing Advanced 

Technology to Increase Air 

Traffic Safety 

 28AMASS processes data from Airport Surface Detection Equipment Model 3 (ASDE-3)

systems and uses visual and sound signals to warn controllers of potential conflicts

between arriving aircraft, and aircraft and vehicles on the ground. ASDE-X is the upgraded

digitally based technology that enables air traffic controllers to detect potential runway 

conflicts by providing detailed coverage of movement on runways and taxiways. Both

systems warn the controllers of potential incursions. Among the systems, only ASDE-X 

works in poor weather conditions. 

29By December 2003, FAA had installed AMASS at the 34 airports. 

30Ten airports that were scheduled to receive ASDE-X already had AMASS. 

Page 22 GAO-06-1091T Aviation Safety 
Figure 5: Airports Scheduled to Receive ASDE-X before Deployment Was Canceled

by FAA 

In addition to reducing the number of facilities selected to receive the 

newer technology, FAA has amended the cost and extended the 

implementation dates for the ASDE-X program (see fig. 6). The 35 ASDE-X 

systems were originally scheduled to be implemented by 2007. As of 

August 2006, FAA had moved that date to 2011. FAA estimates the total 

facilities and equipment cost of the ASDE-X program at about $550 

million, which is approximately $40 million more than we reported in 

2005.

31 The costs of these new technologies mean that they may never be 

deployed at all airports; therefore, it will be important for FAA to continue 

prioritizing and maximizing its resources. 

 31GAO, National Airspace System: FAA Has Made Progress but Continues to Face 

Challenges in Acquiring Major Air Traffic Control Systems, GAO-05-331 (Washington,

D.C.: June 10, 2005). 

Page 23 GAO-06-1091T Aviation Safety 
Figure 6: Changes in Cost and Schedule Targets for ASDE-X 

To ensure a national airspace system that is safe, efficient, and capable of

meeting a growing demand of air transportation that is expected to triple 

by 2025, the Joint Planning and Development Office (JPDO) was created 

within FAA to plan for and coordinate the longer-term transformation to 

the “next generation air transportation system” (NGATS). JPDO was 

created in 2003 to develop an integrated plan for NGATS and to include in

the plan, among other things, a description of the demand and required 

performance characteristics of the future system, as well as a high-level,

multiagency road map and concept of operations for the future system. 

FAA and JPDO face the challenge of adequately involving stakeholders in

the development of NGATS to ensure that the system meets users’ needs, 

especially air traffic controllers who will be end users of the new 

technology and responsible for using it to maximize safety and efficiency. 

In the past, air traffic controllers were permanently assigned to FAA’s 

major system acquisition program offices and provided input into air 

traffic control modernization projects. In June 2005, FAA terminated this 

arrangement because of budget constraints. According to FAA, it now 

plans to obtain the subject-matter expertise of air traffic controllers or 

other stakeholders as needed in major system acquisitions. It remains to 

be seen whether this approach will be sufficient to avoid problems such as 

FAA experienced when inadequate stakeholder involvement in the 

development of new air traffic controller workstations (known as the 

Standard Terminal Automation Replacement System (STARS)) 

contributed to unplanned work, significant cost growth, and schedule 

delays.32

2001 estimate

Cost targets 

Last-site

implementation

targets

Source: GAO analysis of FAA information.

2005 estimate Current estimate, 2006

$424.3

2007

$510.2

2009

$549.8

2011

Dollars in millions

FAA Faces Challenges in 

Having Controllers

Prepared for the Next 

Generation Air 

Transportation System 

 32GAO-05-331. 

Page 24 GAO-06-1091T Aviation Safety 
The changing aviation landscape poses further challenges for FAA. It is 

expected that within the next few years several hundred VLJs33 will be in 

operation. FAA estimates that if 2 percent of airline passengers switch to 

VLJs, air traffic controllers will have to handle three times more take-offs

and landings than currently. Additionally, the industry predicts there may 

be as many as 5,000 to 10,000 VLJs operating in the national airspace 

system by 2020. VLJ manufacturers are reporting advance sales of 

thousands of these new jets, their customers include air taxis, charter 

operators, and private owners. In July 2006, FAA granted the first 

provisional certificate for a VLJ to Eclipse Aviation Corporation. The 

provisional certificate allows existing planes to be flown, but new ones 

cannot be delivered to customers until the FAA grants a type certificate.

According to Eclipse Aviation, it has orders for over 2,350 aircrafts. 

DayJet, which provides on-demand jet service, expects to be operating 50 

Eclipse VLJs by the end of 2007. In September 2006, FAA granted the first 

type certificate to Cessna Aircraft Company. (See fig. 7.) Five other 

companies are in the process of being issued certificates by FAA. If this 

sector expands as quickly as expected, FAA inspectors could face 

workload challenges to expeditiously issue and monitor certificates. In 

addition, air traffic controllers could face the challenge of further 

congested air space, especially at and near smaller airports, where VLJs 

are expected to be prevalent because of their smaller size and shorter 

runway requirements. 

FAA’s Inspector and 

Controller Workload Will 

Be Challenged by 

Emerging Industries and 

Established Sectors That 

May Need More Safety 

Oversight 

 33Very light jets are jet aircraft weighing 10,000 pounds or less maximum certificated takeoff weight and certificated for single pilot operations. Aircraft possess at least some of the 

following features: (1) advanced cockpit automation, such as moving map GPS and 

multifunction displays; (2) automated engine and systems management; and (3) integrated

auto-flight, autopilot and flight-guidance systems. 

Page 25 GAO-06-1091T Aviation Safety 
Figure 7: Cessna’s Citation Mustang VLJ

Unmanned aerial vehicles34 (UAV) are another emerging sector that will 

add to FAA’s workload and may require additional FAA expertise. While

historically UAVs have been used primarily by the Department of Defense 

in military settings outside the United States, there is growing demand to 

operate UAVs domestically in the national airspace system. (See fig. 8.) 

Federal agencies such as the Customs and Border Protection Service and 

the Federal Emergency Management Agency and state and local law 

enforcement agencies are interested in UAVs for purposes such as border

security, search and rescue, firefighting, and other law enforcement and 

homeland security initiatives. Some of these activities are taking place 

today. For example, Customs conducts surveillance along the border with 

Mexico. UAVs are also an emerging sector of the commercial aviation 

industry, and possible commercial uses include fire detection and 

Source: FAA.

 34Unmanned aerial vehicles do not carry a human operator; they are either programmed for 

autonomous flight (called a “drone”) or are flown remotely by a ground operator.

Page 26 GAO-06-1091T Aviation Safety 
firefighting management, digital mapping, communications and broadcast 

services, and environmental research and air quality management control. 

Currently, few regulations or guidelines exist for UAVs or UAV-related 

technology. FAA issues a certificate of authorization for the operation of a 

UAV and the airspace is restricted during the period of operation.35 In 2006, 

FAA has issue 62 certificates of authorization for UAVs and another 35

applications are pending review. FAA is receiving numerous inquiries from 

federal agencies, and from local, county, and state governments about how 

to operate UAVs in the national airspace system. FAA has established an 

Unmanned Aircraft Program Office, responsible for developing the 

regulatory framework and plan for the safe integration of UAVs into the 

national airspace system. FAA faces the challenge of working with 

industry to develop consensus standards for command and control 

redundancies in case there is a disruption in communication with the UAV, 

and detect and avoid capabilities so that UAVs can sense and avoid other 

aircraft. Such standards will be necessary before UAVs can be routinely 

integrated into the national airspace system. Until UAVs are completely 

integrated into the national airspace system, FAA will continue to evaluate 

each flight on a case-by-case basis, adding to the agency’s workload. 

 35A certificate of authorization allows an operator to use defined airspace for a specified 

time (up to one year, in some cases) and includes special provisions unique to each 

operation. For instance, a certificate may include a requirement to operate only under 

visual flight rules. 

Page 27 GAO-06-1091T Aviation Safety 
Figure 8: U.S. Air Force’s Global Hawk UAV 

Space tourism is an additional emerging sector that FAA is beginning to 

respond to. Tourist launches are expected to take place at inland locations

and may have more impact on the national airspace system than previous 

unmanned commercial space launches, which occurred at federal launch

sites near or over oceans. While UAVs pose a learning curve for safety 

inspectors, engineers, and air traffic controllers, space tourism launches 

pose a learning curve for FAA’s commercial space engineers who are 

responsible for licensing and monitoring commercial space launches and

nonfederal launch sites (called spaceports). The prospect for commercial 

space tourism materialized in 2004 when SpaceShipOne, developed by

Scaled Composites, flew to space twice, achieving a peak altitude of about 

70 miles to win the Ansari X Prize.36 Several entrepreneurial launch 

Source: Department of Defense.

 36The X Prize Foundation was established in 1995 to award $10 million to the first team to 

launch a suborbital reusable launch vehicle capable of carrying three people to an altitude

of 70 miles, return safely to Earth, and repeat the exercise within 2 weeks using the same 

vehicle. Twenty-seven teams from seven countries competed. 

Page 28 GAO-06-1091T Aviation Safety 
companies are planning to start taking paying passengers on suborbital 

flights within the next few years. Virgin Galactic intends to enter 

commercial suborbital space flight service around 2008, launching from a 

spaceport in New Mexico, and according to the company, plans to carry 

3,000 passengers over 5 years, with 100 individuals having already paid the 

full fare of $200,000. Several other companies, including former Ansari X 

Prize competitors, continue to develop their vehicles for space tourism. 

Several spaceports are being developed to accommodate anticipated 

commercial space tourism flights and are expanding the nation’s launch 

capacity. As of August 2006, the United States had seven federal launch

sites, and seven spaceports, and an additional eight spaceports have been 

proposed (see fig. 9). We will be issuing a report later this year on FAA’s 

oversight of commercial space launches. 

Figure 9: Existing and Proposed Federal and Nonfederal Spaceports in the United States, April 2006 

Wallops Flight Facility Wallops Flight Facility

Mid-Atlantic Regional Spaceport Mid-Atlantic Regional Spaceport

Vandenberg AFB

White Sands Missile Range

Cape Canaveral Spaceport Cape Canaveral Spaceport

-Kennedy Space Center -Kennedy Space Center

-Cape Canaveral Air Force Station -Cape Canaveral Air Force Station

Kodiak Launch Complex

-Spaceport operated -Spaceport operated by

 Florida Space Authority Florida Space Authority

California Spaceport California Spaceport Mojave Spaceport Mojave Spaceport

Spaceport Washington Spaceport Washington

Wisconsin Spaceport Wisconsin Spaceport

Blue Origin (Exclusive Blue Origin (Exclusive

use launch site) use launch site)

West Texas West Texas

Spaceport Spaceport

Gulf Coast Gulf Coast

Regional Spaceport Regional Spaceport South Texas Spaceport South Texas Spaceport

Southwest Regional Southwest Regional

Spaceport Spaceport

Oklahoma Spaceport Oklahoma Spaceport

Spaceport Ala Spaceport Alabama

Edwards AFB Edwards AFB

Wallops Flight Facility

Mid-Atlantic Regional Spaceport

Vandenberg AFB

White Sands Missile Range

Cape Canaveral Spaceport

-Kennedy Space Center

-Cape Canaveral Air Force Station

Kodiak Launch Complex

-Spaceport operated by

 Florida Space Authority

California Spaceport Mojave Spaceport

Spaceport Washington

Wisconsin Spaceport

Blue Origin (Exclusive

use launch site)

West Texas

Spaceport

Gulf Coast

Regional Spaceport South Texas Spaceport

Southwest Regional

Spaceport

Oklahoma Spaceport

Spaceport Alabama

Reagan Test Site 

(Kwajalein Atoll, Marshall Islands)

Sea Launch Platform

(Equatorial Pacific Ocean)

Sources: FAA; GAO.

Federal launch site

Spaceport

Proposed Spaceport

Edwards AFB

Page 29 GAO-06-1091T Aviation Safety 
Maintaining U.S. position as a global leader in aviation safety calls for 

robust participation in the setting of international safety standards. The 

International Civil Aviation Organization (ICAO), a United Nations 

organization, develops standards and recommended practices for aviation 

safety and security for 188 member states.37 In 2002, the Commission on 

the Future of the United States Aerospace Industry38 reported that the 

United States had not devoted enough resources to ICAO and was, 

therefore, losing its position as the de facto standard setter. Furthermore, 

the position of U.S. ambassador to ICAO, which was filled earlier this year, 

had been vacant for more than a year, which may have affected the U.S. 

impact on international aviation issues. To ensure that qualified U.S. 

applicants apply for U.S. positions at ICAO, FAA has supported a number

of activities, including outreach efforts, incentive pay programs, and a 

fellowship program that sends FAA employees to work at ICAO for up to 

12 months. However, as of December 2005, FAA had filled only 13 of the 

31 positions allocated to the United States at ICAO. FAA faces difficulty in

filling the allocated positions for reasons beyond its control. For example, 

while FAA can recruit applicants, it does not make the final hiring 

decisions. With unfilled positions at ICAO, it will remain important for 

FAA to continue these efforts to enhance the presence of the United States

in the international aviation community. 

For further information on this testimony, please contact Dr. Gerald L. 

Dillingham at (202) 512-2834 or dillinghamg@gao.gov. Individuals making 

key contributions to this testimony include Teresa Spisak, Jessica Evans, 

Colin Fallon, David Hooper, and Rosa Leung. 

FAA Needs to Retain Its 

Leadership Role in 

International Safety 

Standard Setting 

GAO Contact and 

Staff 

Acknowledgments 

 37ICAO also addresses issues such as air navigation, airspace capacity, and environmental 

concerns such as engine noise and emissions. 

38Final Report of the Commission on the Future of the United States Aerospace Industry

(Arlington, Va.; November 2002). 

Page 30 GAO-06-1091T Aviation Safety 
Page 31 GAO-06-1091T Aviation Safety 

Appendix I: Extent to Which FAA Follows 

Effective Management Practices for 

Inspector Training 

Figure 10: Extent That FAA Follows Effective Management Practices in Planning

Technical Training 

Effective management practices Extent followed 

Ensures training goals and related performance measures and 

targets are consistent with overall mission and goals

Ensures human capital professionals work in partnership with 

agency leadership in addressing agency priorities, including 

training, in strategic and annual performance planning processes

Determines skills and competencies its workforce needs to achieve

current and emerging agency goals and identifies gaps -- including

those training strategies can help address

Identifies appropriate level of investment for training and prioritizes

funding so that the most important training needs are addressed first

Ensures agency strategic and tactical changes are promptly 

incorporated into training efforts

Not followed Partially followed Mostly followed Fully followed

Source: GAO.
Figure 11: Extent That FAA Follows Effective Management Practices in Developing

Technical Training 

Effective management practices Extent followed 

New courses developed to meet emerging demands and 

improve performance

Course development teams enable stakeholders to provide input

Guidelines provide progressive course development steps with 

ongoing evaluation at each step

 

Merits of different course delivery methods are considered 

Criteria used for decisions regarding outside training providers

Analysis of training needs and course development linked to 

overall curriculum approacha

Not followed Partially followed Mostly followed Fully followed

Source: GAO.

a

This management practice is not specifically identified in our assessment guide. However, a

management approach that assesses training needs holistically rather than on a course-by-course 

basis can provide for a more systematic assessment of whether and how training will help meet 

organizational needs. 

Page 32 GAO-06-1091T Aviation Safety 
Figure 12: Extent That FAA Follows Effective Management Practices in Delivering

Technical Training 

Effective management practices Extent followed 

Clearly delineates accountability for achieving agency training goals

Uses a suitable and timely process for selecting inspectors for technical 

training given inspectors' current duties and existing skills

Fosters an environment that is conducive to learning

Takes steps to encourage employee buy-in to goals and priorities of 

technical training

Not followed Partially followed Mostly followed Fully followed

Source: GAO.

Page 33 GAO-06-1091T Aviation Safety 
Figure 13: Extent That FAA Followed Effective Management Practices in Evaluating

Its Training Program 

Effective management practices Extent followed 

Systematically plans for and evaluates the effectiveness of 

training and development efforts

Uses the appropriate analytical approaches to assess its 

training and development programs

Uses appropriate performance data (including qualitative and 

quantitative measures) to assess the results achieved through 

training and development efforts

Incorporates evaluation feedback into the planning, design, 

and implementation of its training and development efforts 

Incorporates different perspectives (including those of line 

managers and staff, customers, and experts in areas such as

financial, information, and human capital management) in 

assessing the impact of training on performance

Assesses the benefits achieved through training and 

development programs 

Source: GAO.

Not followed Partially followed Mostly followed Fully followed

Page 34 GAO-06-1091T Aviation Safety 
Page 35 GAO-06-1091T Aviation Safety 

Appendix II: Deployment of Surface 

Detection Equipment at Airports 

Figure 14: Airports with Airport Movement Area Safety System (AMASS) 

Ted Stevens Anchorage International

Hartsfield Jackson Atlanta International Airport 

Boston Logan International Airport

Baltimore Washington International Airport

Cleveland Hopkins International

Charlotte Douglas International Airport

Ronald Reagan Washington National Airport

Denver International Airport

Dallas / Ft. Worth International Airport

Detroit Metro Wayne County

Newark International Airport

John F. Kennedy International Airport

Las Vegas McCarran International Airport

Los Angeles International Airport

New York La Guardia Airport

Kansas City International

Louis Armstrong New Orleans International

Chicago O'Hare International Airport

Portland International

Philadelphia International Airport

Pittsburgh International

San Francisco International

Salt Lake City International Airport

Camp Springs Andrews AFB 

Covington/Cincinnati Northern Kentucky International 

Washington Dulles International Airport

George Bush Intercontinental Airport

Memphis International Airport 

Miami International Airport 

Minneapolis-St. Paul International Airport 

San Diego International Airport

Louisville International Airport-Standiford Field 

Seattle-Tacoma International Airport 

Lambert-St. Louis International Airport

Airport

Source: FAA.
Figure 15: Airport Surface Detection Equipment Model X (ASDE-X) Deployment

Sites 

Bradley International Airport (Hartford, CT)

Boston Logan International Airport

Charlotte Douglas International Airport

Ronald Reagan Washington National Airport

Denver International Airport

Dallas/Ft. Worth International Airport

Detroit Metro Wayne County Airport

Newark International Airport

Ft. Lauderdale/Hollywood Airport

William P. Hobby Airport (Houston, TX)

Washington Dulles International Airport

John F. Kennedy International Airport

Las Vegas McCarran International Airport

Los Angeles International Airport

New York LaGuardia Airport

Orlando International Airport

Chicago Midway Airport

Miami International Airport

General Mitchell International Airport (Milwaukee, WI)

Chicago O'Hare International Airport

Philadelphia International Airport

Theodore Francis Green State Airport (Providence, RI)

San Diego International Airport

Hartsfield-Jackson Atlanta International Airport

Airport

Baltimore Washington International Airport

Honolulu International - Hickam AFB Airport

George Bush Intercontinental Airport

Memphis International Airport

Minneapolis-St. Paul International Airport

Phoenix Sky Harbor International Airport

Louisville International Airport-Standiford Field

Seattle-Tacoma International Airport

Salt Lake City International Airport

John Wayne-Orange County Airport

Lambert-St. Louis International Airport

Source: FAA.

ASDE-X is operational at these sites as of July 2006 

Locations where ASDE-X is replacing ASDE-3 and AMASS 

Page 36 GAO-06-1091T Aviation Safety 
Page 37 GAO-06-1091T Aviation Safety 

Related GAO Products 

Aviation Safety: FAA’s Safety Oversight System Is Effective but Could 

Benefit from Better Evaluation of Its Programs’ Performance. 

GAO-06-266T. Washington, D.C.: November 17, 2005. 

Aviation Safety: System Safety Approach Needs Further Integration into 

FAA’s Oversight of Airlines. GAO-05-726. Washington, D.C.: September 28, 

2005. 

Aviation Safety: FAA Management Practices for Technical Training 

Mostly Effective; Further Actions Could Enhance Results. GAO-05-728. 

Washington, D.C.: September 7, 2005. 

Aviation Safety: Oversight of Foreign Code-Share Safety Program Should 

Be Strengthened. GAO-05-930. Washington, D.C.: August 5, 2005. 

Aviation Safety: FAA Needs to Strengthen the Management of Its 

Designee Programs. GAO-05-40. Washington, D.C.: October 8, 2004. 

Aviation Safety: Better Management Controls Are Needed to Improve 

FAA’s Safety Enforcement and Compliance Efforts. GAO-04-646. 

Washington, D.C.: July 6, 2004. 

Aviation Safety: Information on FAA’s Data on Operational Errors at 

Air Traffic Control Towers. GAO-03-1175R. Washington, D.C.: September 

23, 2003. 

Aviation Safety: FAA Needs to Update the Curriculum and Certification 

Requirements for Aviation Mechanics. GAO-03-317. Washington, D.C.: 

March 6, 2003. 

Aviation Safety: FAA and DOD Response to Similar Safety Concerns. 

GAO-02-77. Washington. D.C.: January 22, 2002. 

Aviation Safety: Safer Skies Initiative Has Taken Initial Steps to Reduce

Accident Rates by 2007. GAO/RCED-00-111. Washington, D.C.: June 30, 

2000. 

(540136) 
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. 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. 
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

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. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

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. Government Accountability 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 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER