Page i GAO-12-660T Commercial Aviation Safety

AVIATION SAFETY

FAA Is Taking Steps to 

Improve Data, but 

Challenges for Managing 

Safety Risks Remain

Statement of Gerald L. Dillingham, Ph.D., Director 

Physical Infrastructure Issues

Testimony 

Before the Subcommittee on Aviation, 

Committee on Transportation and 

Infrastructure, House of Representatives

For Release on Delivery 

Expected at 9:00 a.m. EDT

Wednesday, April 25, 2012

GAO-12-660T

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-660T, a testimony 

before the Subcommittee on Aviation, 

Committee on Transportation and 

Infrastructure, House of Representatives

April 25, 2012

AVIATION SAFETY

FAA Is Taking Steps to Improve Data, but 

Challenges for Managing Safety Risks Remain

Why GAO Did This Study

The U.S. aviation system is one of the 

safest in the world, but fatal accidents, 

though rare, continue to occur. As a 

result of recent accidents and related 

NTSB findings, FAA announced a Call 

to Action Plan in June 2009 to, among 

other things, increase air carrier 

participation in voluntary safety 

programs. In 2010, Congress passed 

the Airline Safety and Federal Aviation 

Administration Extension Act, which, in 

part, called for FAA to better manage 

safety risks. As a result, FAA 

developed a concerted strategy to 

implement new safety programs, 

including increasing air carrier use of 

voluntary safety programs and 

advancing the use of SMS. 

FAA is implementing SMS—a datadriven, risk-based safety approach that 

involves establishing the necessary 

organizational structures, 

accountabilities, policies, and 

procedures. The implementation of SMS 

heightens the importance of obtaining 

and using high-quality aviation safety 

data.

This statement is based on GAO’s 

previous work and focuses on (1) how 

FAA uses data to manage safety risks, 

(2) how FAA ensures it has quality 

data to manage risk, and (3) the 

challenges FAA faces in using data to 

better manage safety risks.

What GAO Recommends

GAO has made a number of 

recommendations to address data 

quality weaknesses. FAA concurred 

with most of these recommendations 

and in some cases has taken steps 

toward addressing them. 

What GAO Found

The Federal Aviation Administration (FAA) uses data reactively and proactively to 

prevent accidents and manage safety risks. For instance, since 1998, FAA has 

partnered with the airline industry to identify precursors and contributing factors, 

and ensure that efforts to improve safety focus on the most prevalent categories 

of accidents and formulate an intervention strategy designed to reduce 

recurrences. Although FAA plans to continue using data reactively to understand 

the causes of accidents and incidents, as part of its adoption of Safety 

Management Systems (SMS), it is shifting to a proactive approach in which it 

analyzes data to identify and mitigate risks before they result in accidents.

Implementing systems and processes that capture accurate and complete data 

are critical for FAA to determine the magnitude of safety issues, assess their 

potential impacts, identify their root causes, and effectively address and mitigate 

them. Though FAA has put in place data quality controls, weaknesses remain in 

some areas. In particular, several FAA databases GAO reviewed in 2010 did not 

have a managerial review process prior to data entry—an important control that 

helps ensure data accuracy and completeness. In response to GAO’s 

recommendations, FAA is taking steps to address its data weaknesses, but 

vulnerabilities that remain potentially limit the data’s usefulness for safety 

analysis.

FAA also continues to experience data-related challenges, including limitations 

with the analysis it conducts and the data it collects and the absence of data in 

some areas. For example, FAA does not have a process to track or assess 

runway excursions, which occur when an aircraft veers off or overruns a runway. 

Runway excursions can be as dangerous as runway incursions, which occur

when an unauthorized aircraft, vehicle, or person is on a runway, and FAA has 

tracked runway incursions for years. GAO previously recommended that FAA 

develop and implement plans to track and assess runway excursions. FAA 

agreed and is currently developing a program to collect and analyze runway 

excursion data and is drafting an order to set out the definitions and risk 

assessment processes for categorizing and analyzing the data. However, 

according to GAO’s review of FAA’s plans, it will be several years before FAA 

has obtained enough detailed information about these incidents to assess risks.

Similarly, GAO has found that efforts to address the occurrence of safety 

incidents in ramp areas were hindered by the lack of data on the nature, extent, 

and cost of such incidents and accidents. FAA collects no comprehensive data 

on incidents in ramp areas, and the National Transportation Safety Board (NTSB) 

does not routinely collect data on ramp accidents unless they result in serious

injury or substantial aircraft damage. FAA’s lack of ramp incident data means that 

FAA is unable to assess the risk of catastrophic accidents in this area. FAA 

agreed with GAO’s recommendation to extend oversight to ramp areas but noted 

that it already provides oversight through its oversight of airlines. FAA expects to 

further enhance that oversight through its proposed ruling to require airports with 

air carrier operations to establish a safety management system. 

View GAO-12-660T. For more information, 

contact Gerald L. Dillingham, Ph.D. at 

(202) 512-2834 or dillinghamg@gao.gov.
 

Page 1 GAO-12-660T Commercial Aviation Safety

Chairman Petri, Ranking Member Costello, and Members of the 

Subcommittee:

Thank you for the opportunity to testify before you today on the safety of 

U.S. commercial aviation. The U.S. aviation system is one of the safest in 

the world, but fatal accidents, though rare, continue to occur. The last 

fatal commercial aviation accident occurred in Buffalo, New York, on 

February 12, 2009, when 50 people perished in a Colgan Air crash. In 

response to this accident, and National Transportation Safety Board 

(NTSB) findings that pilot training and lack of qualifications were 

potentially contributing factors, the Federal Aviation Administration (FAA) 

began a Call to Action Plan in June 2009 to, among other things, increase 

air carrier participation in voluntary safety programs. In 2010, Congress 

passed the Airline Safety and Federal Aviation Administration Extension 

Act (Airline Safety Act),1 which, in part, called for FAA to better manage 

safety risks. As a result, FAA developed a concerted strategy to 

implement new safety programs required by the Airline Safety Act, 

including establishing better processes for managing safety risks and 

advancing Safety Management Systems (SMS).2

SMS is an integrated, data-driven approach to managing safety risk that 

involves establishing the necessary organizational structures, 

accountabilities, policies, and procedures to enhance safety. SMS 

introduces an evolutionary structured process in system safety and safety 

management that obligates organizations to manage safety with the same 

level of priority that other core business processes are managed. This 

applies to both internal FAA operations and external aviation industry 

organizations. The International Civil Aviation Organization (ICAO), of 

which the U.S. is a member state, requires SMS for the management of 

safety risk in air operations, maintenance, air traffic services, and airports.

SMS is becoming a worldwide standard throughout the aviation industry, 

and SMS concepts have generated widespread support as an effective 

approach that can deliver safety benefits. The implementation of SMS 

heightens the importance of obtaining and using high-quality aviation 

safety data. Further, according to a 2008 independent review team 

 

1

Pub. L. No. 111-216, 124 Stat. 2348 (2010).

2

We are currently conducting a study of FAA’s implementation of SMS as well as its 

oversight of the industry’s SMS implementation efforts; we expect to issue a report in 

September of this year.

 
 

Page 2 GAO-12-660T Commercial Aviation Safety

chartered by the Secretary of Transportation,3

My testimony today focuses on (1) how FAA uses data to manage safety 

risks, (2) how FAA ensures it has quality data to manage risk, and (3) the 

challenges FAA faces in using data to better manage safety risks. This 

statement is based on our previous work, including our May 2010 report 

on aviation data quality, our October 2011 report on terminal area safety, 

and our November 2011 report and March 2012 statement for the record 

on initial pilot training.

as commercial aviation 

accidents have become increasingly rare, information that can be used to 

help identify accident and incident precursors has become more critical 

for accident prevention. 

4 We updated the information from these reports—

such as the status of our recommendations and programs or initiatives 

FAA planned to implement—as necessary during March and April 2012. 

We also conferred with FAA officials on the new information included in 

this statement. The GAO publications cited in this statement contain 

detailed explanations of the methods used to conduct our work, which we 

performed in accordance with generally accepted government auditing 

standards.

 

3

Independent Review Team, Managing Risks in Civil Aviation: A Review of the FAA’s 

Approach to Safety (Washington, D.C.: Sept. 2, 2008). The team was chartered to assess 

FAA’s safety culture and approach to safety management.

4

See GAO, 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); Aviation Safety: Enhanced Oversight and Improved Availability of 

Risk-Based Data Could Further Improve Safety, GAO-12-24 (Washington, D.C.: Oct. 5, 

2011); Initial Pilot Training: Better Management Controls Are Needed to Improve FAA 

Oversight, GAO-12-117 (Washington, D.C.: Nov. 4, 2011); and Aviation Safety: FAA Has 

An Opportunity to Enhance Safety and Improve Oversight of Initial Pilot Training, 

GAO-12-537T (Washington, D.C.: Mar. 20, 2012).
 

Page 3 GAO-12-660T Commercial Aviation Safety

For decades, FAA, other federal regulators, and the aviation industry 

have used data in a reactive fashion—that is, to identify the causes of 

aviation accidents and incidents5

Since 1998, FAA has partnered with the airline industry through the 

Commercial Aviation Safety Team (CAST) to identify precursors and 

contributing factors and ensure that efforts to improve safety focus on the 

most prevalent categories of accidents. CAST has reduced the risk in 

commercial aviation by focusing on areas such as controlled flight into 

terrain, loss of control, and runway incursions. CAST analyzes accident 

and incident data to identify precipitating conditions and causes, and then 

formulates an intervention strategy designed to reduce the likelihood of a 

recurrence. According to CAST, 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. 

(Fig. 1 illustrates the number of fatal and nonfatal commercial air carrier 

accidents from 1998 through 2010.)

and take actions to prevent their 

recurrence. Aviation accident data are collected by NTSB, but FAA also 

collects some accident data and uses various databases and voluntary 

reporting programs to collect incident data, such as for runway 

incursions—the unauthorized presence of an aircraft, vehicle, or person 

on a runway. FAA also gathers and analyzes data through its inspection 

and certification programs to ensure industry compliance with safety 

regulations. (App. I provides more information on the databases 

discussed in this statement.)

 

5

An aviation accident, as defined by 49 C.F.R. § 830.2, occurs when in the course of the 

operation of an aircraft—between the time anyone boards with intention of flight and until 

the last person disembarks—any person suffers death or serious injury, or the aircraft 

receives substantial damage. An aviation incident occurs when an aircraft encounters a 

safety hazard, or potential safety hazard, yet is not classified as an accident due to a 

lesser degree of injury or damage.

FAA Uses Reactive 

and Proactive Data 

Analysis to Prevent 

Accidents and 

Manage Risk
 

Page 4 GAO-12-660T Commercial Aviation Safety

Figure 1: Number of Commercial Air Carrier Accidents, 1998-2010

Note: Fatal accidents include those aircraft involved in the September 11, 2001, terrorist attacks. Data 

for 2010 are considered preliminary.

Similarly, FAA analyzes data on incidents, such as those where there is a 

risk of a catastrophic accident. For example, data on runway incursions, 

other surface incidents, and airborne incidents6

 

6

Airborne incidents could include a pilot leveling off at an incorrect altitude and flying too 

closely to another aircraft or a failure to coordinate between air traffic control facilities as 

an aircraft approaches an airport. 

are collected at airports 

that have air traffic control towers. FAA analyzes those data to categorize 

incidents according to the actions or inactions of air traffic controllers, 

pilots, or others, such as pedestrians or vehicle operators, and 

determines the severity of those incidents. These data are then used to 

assess the root causes of incidents to identify potential remedies. Using 

this process, FAA has taken steps to improve safety in the terminal area 

since 2007 and has both reduced the number of serious runway 

incursions—where collisions are narrowly avoided or where there was a 
 

Page 5 GAO-12-660T Commercial Aviation Safety

significant potential for a collision—and undertaken successful efforts to 

increase the reporting of incidents.

Although FAA will continue using data in a reactive manner to understand 

the causes of accidents and incidents, it is shifting emphasis to a 

proactive approach in which it analyzes data to identify and mitigate risks 

to prevent future accidents as part of its adoption of SMS. As a result, 

data that can be used to help identify accident and incident precursors—

such as data on an incident that is voluntarily reported by pilots, air traffic 

controllers, or others to FAA or air carriers—have become more critical 

for accident prevention, according to the independent review of FAA’s 

safety oversight in 2008.7

 CAST is also now moving beyond the forensic 

approach of examining past accident data to a more proactive approach 

that will focus on risk prediction and mitigation strategies and aims to 

reduce the U.S. commercial fatality risk by 50 percent from 2010 to 2025. 

FAA’s effort to integrate aviation safety data—the Aviation Safety 

Information Analysis and Sharing (ASIAS) system, which connects 46 

safety databases across the industry and has 45 participating airlines—is 

integrated into the CAST process. ASIAS enables better safety 

information management and data sharing as it proactively extracts from 

public and non-public data sources, including accidents, incidents, and 

voluntary reporting. FAA has demonstrated the potential of using 

integrated safety data to better understand the causes of certain safety 

events and identify mitigating strategies. For example, FAA fused data 

from government and industry sources to identify underlying factors 

contributing to numerous nuisance warnings pilots were receiving from 

their terrain awareness warning systems (TAWS). By combining all of the 

data, FAA was able to identify needed changes in the way it handles air 

traffic as well as improvements in the design of the TAWS software. FAA 

also plans to use data proactively to model the impact of the Next 

Generation Air Transportation System (NextGen)8

 

7

Independent Review Team, Managing Risks in Civil Aviation. 

on the safety of the 

national airspace system, to proactively identify risks that might emerge 

with the introduction of NextGen changes. Figure 2 illustrates the type of 

transition FAA plans as the agency shifts its emphasis to a proactive 

assessment of emerging safety risks.

8

NextGen is a new satellite-based air traffic management system that by 2025 will replace 

the current radar-based system and is expected to enhance the safety and capacity of the 

air transport system.
 

Page 6 GAO-12-660T Commercial Aviation Safety

Figure 2: FAA’s Emphasis Is Shifting from a Reactive to a Proactive Approach to 

Data Analysis in Order to Manage Risk

As part of its oversight system for commercial air carriers, FAA collects 

and analyzes data to ensure that the industry complies with safety 

regulations. FAA uses the Air Transportation Oversight System (ATOS), a 

risk-based data-driven system, to oversee maintenance and operations at 

all air carriers.9

 

9

For more information on ATOS, see Department of Transportation Inspector General, 

FAA Needs to Improve Risk Assessment Processes for Its Air Transportation Oversight 

System (Dec. 16, 2010).

Under the ATOS concept, FAA inspectors use data 

analysis to focus their inspections on areas that pose the greatest risk. 

ATOS also permits inspectors to shift the focus of their inspections in 

response to changing conditions within air carriers’ operations. In 

contrast, FAA’s oversight program for the remaining operators (i.e., air 

taxi, general aviation, etc.) focuses on inspectors completing a prescribed 

number of inspection activities annually and is primarily based on 

checking operator compliance with regulations.
 

Page 7 GAO-12-660T Commercial Aviation Safety

Implementing systems and processes that capture accurate and complete 

data is critical for FAA to determine the magnitude of safety issues, 

assess their potential impacts, identify their root causes, and effectively 

address and mitigate them. As such, FAA has various processes in place 

to help ensure data quality and is taking steps to address remaining 

weaknesses. For example, FAA established an agency-wide order on 

data management that specifies the roles and associated responsibilities 

for data management within the agency.10

In accordance with the data management order, FAA’s Office of Aviation 

Safety established a data management framework that includes a fourstep process for importing data from other FAA offices and external 

sources. This process includes

This order applies to all 

sharable information from FAA and other sources used to perform the 

agency’s mission.

• data acquisition—obtaining information from various data owners,

• data standardization—validating data by comparing a new data set 

with previous data sets to identify inconsistencies,

• data integration—translating data values into plain English and 

correcting data errors, and

• data loading—importing data into the agency’s own systems.

FAA has furthermore put in place data quality controls that we consider 

good practices for handling data, although weaknesses remain in some 

areas. For example, FAA has developed training for users on data 

systems and restricted access to the data. The FAA databases we 

reviewed in 2010 also had at least some controls in place to ensure that 

erroneous data are identified, reported, and corrected. However, several 

of the databases lacked an important control in that managers do not 

review the data prior to entry into the system. This quality control is 

important because it could affect accuracy and completeness.11

 

10FAA Order 1375.1E, Information/Data Management (Nov. 16, 2011).

FAA has 

controls in place and is taking steps to address its data weaknesses; 

11GAO, Assessing the Reliability of Computer-Processed Data, GAO-09-680G

(Washington, D.C.: July 2009).

FAA Has Various 

Processes in Place to 

Help Ensure Data 

Quality
 

Page 8 GAO-12-660T Commercial Aviation Safety

however, vulnerabilities remain that potentially limit the usefulness of 

FAA’s data for some of the safety analyses planned to support SMS. In 

2010, we made several recommendations to FAA to help improve and 

expand its capability to use data for aviation safety oversight. For 

example, we recommended that FAA extend standard quality controls, as 

appropriate, to the databases that support aviation safety oversight. 

Although FAA concurred with our recommendations, it has not fully 

implemented them.12

FAA has put in place various quality controls for its data, but it continues 

to experience data challenges—including limitations with the analysis it 

conducts and data it collects, as well as the absence of data in some 

areas. Some of these limitations hinder the agency’s ability to 

comprehensively and accurately assess and manage risk, as seen in the 

following examples:

• FAA’s changes to reporting policies impact its ability to accurately 

determine operational error trends. The rate and number of airborne 

operational errors—errors made by air traffic controllers—have 

increased considerably in recent years, with the rate nearly doubling 

for errors in the terminal area from 2008 to 2011. Multiple changes to 

reporting policies and processes during this time make it difficult to 

know the extent to which the recent increases in operational errors 

are due to more accurate reporting, an increase in the occurrence of 

safety incidents, or both. For example, FAA removed air traffic 

controller names from reports in the Air Traffic Quality Assurance 

(ATQA) database, which may encourage controllers to share more 

information about incidents. (See fig. 3.) Without determining the 

potential impact of these policy changes, FAA cannot ensure accurate 

and consistent measures of operational errors and cannot assess the 

risks posed over time. FAA believes that these changes likely caused 

the increases in operational errors but has not yet conducted an 

analysis to validate the linkage.

 

12GAO-10-414. 

Data Limitations and 

Lack of Data 

Challenge FAA’s 

Ability to Manage 

Safety Risks
 

Page 9 GAO-12-660T Commercial Aviation Safety

Figure 3: FAA Changes to Reporting Practices and Recent Trends in Operational Errors

Note: Graphic only includes operational errors at air traffic control towers and terminal radar approach 

control (TRACON) facilities. FAA officials attributed at least some portion of the spike in reported 

incidents during the second quarter of fiscal year 2010 to approximately 150 events that occurred as 

a result of the misinterpretation of an arrival waiver at one TRACON facility.

• Incomplete data on operational errors are assessed, making it difficult 

to account for all potential risk. Operational errors can be captured in 

multiple reporting systems. For instance, an air traffic controller’s 

failure to maintain minimum separation between two aircraft—a loss 

of separation—could be reported to the ATQA database by a 

supervisor13

 

13ATQA data may also be recorded by support specialists, managers, and incident 

investigators.

and will also be captured automatically by airplane 

tracking technology—the Traffic Analysis and Review Program 

(TARP)—if it is in use at the relevant facility. However, FAA’s current 

process for analyzing data on losses of separation captured by these 

systems only assesses those incidents that occur between two or 
 

Page 10 GAO-12-660T Commercial Aviation Safety

more radar-tracked aircraft. By excluding incidents such as those that 

occur between the aircraft and terrain or aircraft and protected 

airspace, FAA is not considering the systemic risks associated with 

many other airborne incidents. We recommended last year that FAA 

expand its current risk assessment process,14

• Lack of coordination among data systems may affect FAA’s ability to 

conduct comprehensive data analyses. As previously mentioned, 

multiple programs and systems capture safety data. Some of these 

programs—including the Air Traffic Safety Action Program (ATSAP), 

ATQA, and the Risk Analysis Process (RAP) that considers ATQA 

and TARP data—also assign contributing factors to the incidents they 

review. (See fig. 4.) Though both ATSAP and RAP look at some of the 

same types of incidents (e.g., airborne losses of separation), they had

not coordinated on a common set of contributing factors to describe 

and analyze the incidents. As a result, it is difficult to compare the 

data and conduct comprehensive analyses. According to FAA 

officials, they are currently developing a common set of contributing 

factors for ATSAP and RAP, as well as a translation capability that will 

allow for the inclusion of historical data on contributing factors in 

future analyses.

and FAA responded 

that it will include these incidents in its risk assessment process 

before the end of 2013.

 

14GAO-12-24. 
 

Page 11 GAO-12-660T Commercial Aviation Safety

Figure 4: Information Flow into ATSAP Is Separate from Other Systems FAA Uses 

to Track Air Traffic Safety Incidents

• Lack of a robust, complete, and secure data repository of pilot records 

raises questions about data reliability. Because the training and 

experience of some pilots have been factors in several commercial 

aviation accidents, there have been efforts to increase the amount of 

information airlines have before hiring pilots. The Pilot Records 

Improvement Act of 199615 requires airlines to conduct background 

checks on pilots before hiring them, and the Airline Safety Act 

requires that FAA develop a centralized pilot records database that air 

carriers must access to review pilot qualifications and past 

performance data before hiring pilots. According to the Department of 

Transportation Inspector General (IG), FAA met the act’s initial 

milestone in developing a centralized electronic pilot records database 

that will include records previously maintained by air carriers.16

 

1549 U.S.C. § 44703(h). See GAO, Aviation Safety: Better Guidance and Training Needed 

on Providing Files on Pilots’ Background Information, 

However, the IG indicated that FAA needs to address the level of 

GAO-02-722 (Washington, D.C.: 

Aug. 30, 2002).

16DOT IG, Progress and Challenges in Responding to Key Provisions of the Airline Safety 

Act (Mar. 20, 2012).
 

Page 12 GAO-12-660T Commercial Aviation Safety

detail that should be captured from air carrier pilot training records—

such as determining whether recurrent flight training will be included, 

determining how to transition from the current practices to the new 

database without disrupting information flow, and deciding how to 

ensure the reliability of data. The IG also noted that FAA lacks a 

centralized process to receive and respond to carriers’ requests for 

pilot records.

• Lack of ramp incident data means FAA is unable to assess the risk of 

catastrophic accidents in this area. In 2007, we reported that efforts to 

address the occurrence of safety incidents in ramp areas were 

hindered by the lack of data on the nature, extent, and cost of ramp 

incidents and accidents.17 FAA still collects no comprehensive data on 

incidents in the ramp area and NTSB does not routinely collect data 

on ramp accidents unless they result in serious injury or substantial 

aircraft damage.18 The Occupational Safety and Health Administration 

(OSHA), the primary source of ramp fatality data, collects only data 

from accidents involving an employee death or the hospitalization of 

at least three employees.19 The lack of ramp incident data will pose a 

challenge as airports move to implement SMS. We recommended in 

2011 that FAA extend oversight to the ramp areas.20

• Lack of a process to track and assess runway excursions denies FAA 

the ability to assess the risks of these incidents. Runway excursions 

can be as dangerous as incursions; according to the Flight Safety 

Foundation, excursions have resulted in more fatalities than 

incursions globally. (Fig. 5 illustrates the difference between runway 

incursions and excursions.) FAA does not have a process to track 

FAA agreed with 

our recommendation but noted that it already oversees ramps through 

its oversight of airlines. FAA expects to further enhance that oversight 

through its proposed ruling to require airports with air carrier 

operations to establish a safety management system.

 

17See GAO, Aviation Runway and Ramp Safety: Sustained Efforts to Address Leadership, 

Technology, and Other Challenges Needed to Reduce Accidents and Incidents, 

GAO-08-29 (Washington, D.C.: Nov. 20, 2007).

18NTSB officials said they current collect data on accidents in the ramp area that meet the 

definition of an aircraft accident as defined by 49 C.F.R. § 830.2.

19OSHA data on worker fatalities in the ramp area show the annual number of deaths to 

have varied between 3 and 11 from 2000 to 2010.

20GAO-12-24. 
 

Page 13 GAO-12-660T Commercial Aviation Safety

excursions, unlike for runway incursions. We recommended in 2011 

that FAA develop and implement plans to track and assess runway 

excursions. FAA agreed and will be developing a program to collect 

and analyze runway excursion data and is drafting an order to set out 

the definitions and risk assessment processes for categorizing and 

analyzing the data. However, according to our review of FAA’s plans, 

it will be several years before FAA has obtained enough detailed 

information about these incidents in order to assess risks.

Figure 5: Illustration of Runway Incursions and Excursions

• Lack of complete data on active pilot schools and pilot examiners 

makes it difficult for FAA to ensure that safety standards are being 

met. Inspections are a part of FAA’s oversight of Part 141 pilot 

schools21 and pilot examiners22

 

21The roughly 3,400 U.S. pilot schools can be divided into three categories: (1) 

noncollegiate flight instructor-based schools, (2) noncollegiate vocational pilot schools, 

and (3) collegiate aviation schools. Vocational pilot schools elect to apply for an operating 

certificate from FAA to provide pilot training under Part 141 regulations, which require 

these schools to meet prescribed standards with respect to training equipment, facilities, 

student records, personnel, and curriculums. Most of the collegiate aviation schools also 

provide pilot training under a Part 141 certificate. Flight instructor-based schools are not 

subject to direct FAA oversight beyond the initial certification and subsequent renewal of 

the flight instructor’s certificate.

— gatekeepers for the initial pilot 

training process. However, it was unclear from our analysis of FAA 

22Pilot examiners are private individuals (and organizations) FAA uses to supplement its 

workforce to examine and test pilot applicants for a fee paid for by the applicant. Known 

as designees, pilot examiners are generally appointed by FAA’s local district personnel for 

either 3 years (for an individual) or 5 years (for an organization).
 

Page 14 GAO-12-660T Commercial Aviation Safety

inspection data for pilot schools and pilot examiners whether FAA met 

its oversight requirements because we could not determine the 

number of active entities that should have been inspected each year. 

FAA does not maintain a historical listing of pilot schools and 

examiners, and, thus, we could not define the universe of active 

entities that was required to be inspected. Because of this data 

limitation, we could not determine the completion percentage of the

inspections for either group. In November 2011, we recommended 

that FAA develop a comprehensive system for measuring its 

performance in meeting its inspection requirements for pilot schools 

and examiners.23

In closing, Mr. Chairman, FAA regulates one of the safest aviation 

systems in the world. To its credit, FAA continues to strive for even higher 

levels of safety. Shifting to a data-driven, risk-based safety oversight 

approach means that FAA needs data that are appropriate, complete, and 

accurate to be able to identify system-wide trends and manage emerging 

risks. Furthermore, when implementing changes in safety data reporting 

systems, or processes used to assess and analyze data to determine 

risk, FAA needs to take into account how such changes might impact 

trend analysis. Today, I have pointed out some of the challenges FAA 

faces in improving its data. While FAA is working diligently to improve its 

data in some instances, more work remains to address limitations and to 

collect additional data where necessary.

FAA acknowledged our recommendation and noted 

that (1) it needed to clarify its inspection requirements for pilot schools 

in the revision of its national oversight policy guidelines, and (2) its 

new designee management system, which would include oversight of 

pilot examiners, will provide more comprehensive data once it is 

developed.

24

Chairman Petri, Ranking Member Costello, and Members of the 

Subcommittee, this concludes my prepared statement. I would be 

pleased to answer any questions at this time.

 

 

23GAO-12-117. 

24In addition to the recommendations we made to FAA that are discussed in this 

statement, we made others in GAO-10-414, GAO-12-24, and GAO-12-117 to improve 

FAA’s capability to use data and enhance its oversight of pilot certification, pilot training, 

and terminal area safety. FAA concurred with all of these recommendations and is 

working toward implementing them. We will continue to monitor FAA as it addresses our 

recommendations.
 

Page 15 GAO-12-660T Commercial Aviation Safety

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

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

addition, contact points for our Offices of Congressional Relations and 

Public Affairs may be found on the last page of this statement. Individuals 

making key contributions to this testimony include Brandon Haller 

(Assistant Director), Pamela Vines, Martha Chow, Vashun Cole, Kevin 

Egan, Colin Fallon, Molly Laster, Brooke Leary, Erica Miles, Richard 

Scott, Teresa Spisak, and Jessica Wintfeld.

GAO Contact and 

Staff 

Acknowledgments 
Appendix I: Summary of Databases 

Referenced in Statement

Page 16 GAO-12-660T Commercial Aviation Safety

Database

Responsible 

entity Description

Safety-related data 

collected Format

Aviation Safety 

Information Analysis and 

Sharing (ASIAS)

FAA Integrates aviation safety data from 46 

safety databases and 45 participating 

airlines

Accidents, incidents, 

advisory information, 

aircraft information, 

statistical data

Narrative and 

quantitative

Air Transportation 

Oversight System 

(ATOS) 

FAA Primary database for collecting part 121 

air carrier oversight data

Inspection results Narrative and 

quantitative

Air Traffic Quality 

Assurance (ATQA) 

database

FAA Contains information recorded by air 

traffic controller supervisors, support 

specialists, and managers

Surface and airborne 

incidents

Narrative and 

quantitative

Air Traffic Safety Action 

Program (ATSAP)

FAA Non-punitive, voluntary safety reporting 

program for air traffic controllers

Air-traffic controller safety 

issues, including loss of 

separation

Primarily 

narrative, 

some 

quantitative 

information

Traffic Analysis and 

Review Program (TARP)

FAA Error detection system that automatically 

captures data on airborne losses of 

separation 

Airborne losses of 

separation that occur while 

the aircraft is under the 

control of air traffic control 

towers and terminal radar 

approach controls

Quantitative

Sources: FAA and GAO.

Note: FAA uses numerous other databases to provide safety oversight, many of which are referenced 

in our previous work. For more information about these databases, see GAO-10-414, GAO-12-24, 

and GAO-12-117.

Appendix I: Summary of Databases 

Referenced in Statement

(540242)
Appendix I: Summary of Databases 

Referenced in Statement

Page 17 GAO-12-660T Commercial Aviation Safety

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