AVIATION SAFETY

Additional FAA 

Efforts Could 

Enhance Safety Risk 

Management

Report to Congressional Committees

September 2012

GAO-12-898

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-898, a report to 

congressional committees. 

September 2012

AVIATION SAFETY

Additional FAA Efforts Could Enhance Safety Risk 

Management

Why GAO Did This Study

The nation’s aviation system is one of

the safest in the world, but with air 

travel projected to increase over the 

next 20 years, efforts to ensure the 

continued safety of aviation are 

increasingly important. The FAA is 

seeking to further enhance safety by 

shifting to a data-driven, risk-based 

safety oversight approach—referred to 

as SMS. SMS implementation is 

required for FAA and several of its 

business lines and the agency is taking 

steps to require industry 

implementation. 

As requested, this report addresses 

(1) the status of FAA’s implementation 

of SMS, (2) the extent to which FAA’s 

SMS efforts have been consistent with 

key practices for successful planning 

and implementation of a new program, 

and (3) challenges FAA faces in 

implementing SMS. To address these 

issues, GAO reviewed FAA SMS 

documents, compared FAA efforts to 

key practices, and interviewed agency 

and industry officials. 

What GAO Recommends

GAO recommends that FAA develop 

systems to: track SMS implementation, 

evaluate employee performance as it 

relates to SMS, and assess whether 

SMS meets its goals and objectives; 

conduct a workforce analysis for SMS; 

and consider strategies to address 

airports’ data concerns. The 

Department of Transportation agreed 

to consider the recommendations and 

provided clarifying information about 

SMS, which GAO incorporated. 

What GAO Found

The Federal Aviation Administration (FAA) and its business lines and offices are

in different stages of their implementation of Safety Management Systems 

(SMS). FAA finalized its agency-wide implementation plan in April 2012, and the 

Air Traffic Organization (ATO) has completed its SMS implementation, but other 

FAA SMS efforts are in the early stages. FAA business lines, such as the 

Aviation Safety Organization (AVS) and the Office of Airports (ARP), have SMS 

guidance and plans largely in place and have begun to integrate related practices 

into their operations, but many implementation tasks remain incomplete, and 

officials and experts project that full SMS implementation could take many years. 

There are a number of key practices that can help agencies plan for and 

efficiently implement new projects, including large scale transformations such as 

FAA’s SMS implementation, and FAA has many in place. For example, FAA has 

support from top leadership and a clear project mission. However, FAA has only 

partially addressed other key practices such as developing a project plan to track

SMS implementation, and FAA has not addressed performance-related practices 

such as establishing SMS performance measures or links between employees’

performance standards and SMS. 

Alignment of FAA’s SMS Implementation with Key Practices

Several challenges remain that may affect FAA’s ability to effectively implement 

SMS. FAA is taking steps to address some challenges and stakeholder 

concerns, but challenges related to data sharing and data quality; capacity to 

conduct SMS-based analyses and oversight; and standardization of policies and 

procedures could negatively affect FAA’s efforts to implement SMS in a timely 

and efficient manner. Further, FAA officials stated that SMS implementation will 

require some skills that agency employees do not have, but FAA has not yet

assessed the skills of its workforce to identify specific gaps in employee 

expertise. In addition, while existing federal law protects any data collected for 

SMS, any data airports collect could be subject to state-specific Freedom of 

Information Act laws, a gap that could create a disincentive for airports to fully 

participate in SMS implementation. 

View GAO-12-898. For more information, 

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

512-2834 or dillinghamg@gao.gov. 
Page i GAO-12-898 Safety Management Systems

Letter 1 

Background 4

FAA and Its Business Lines Are at Different Stages of SMS 

Implementation 8

FAA’s SMS Approach Is Consistent with Many but Not All Key 

Practices for Successful Project Implementation 15

Addressing Key Implementation Practices and Other Challenges 

Could Enhance SMS Effectiveness 24

Conclusions 32

Recommendations for Executive Action 33

Agency Comments 33

Appendix I Objectives, Scope, and Methodology 35

Appendix II GAO Contact and Staff Acknowledgments 38

Table

Table 1: Airport Interviews 37

Figures

Figure 1: The Four Components of Safety Management Systems 5

Figure 2: Organizational Structure to Coordinate SMS 

Implementation across FAA Business Lines and Offices 7

Figure 3: FAA’s SMS Guidance Links to International and 

Government-wide SMS Requirements and Guidance 9

Figure 4: Timeline of Key SMS Implementation Activities across 

FAA’s Business Lines and Offices, 2007 to 2013 11

Figure 5: Proposed and Potential Future Applicability of Federal 

Aviation Regulation Part 5 to the Aviation Industry 13

Figure 6: Alignment of FAA’s SMS Implementation with GAOIdentified Key Practices for Successful Organizational 

Transformations 16

Contents
Page ii GAO-12-898 Safety Management Systems

Abbreviations

AIR Aircraft Certification Service 

AFS Flight Standards Service

ANG Office of NextGen

ARP Office of Airports

AST Office of Commercial Space Transportation

ATO Air Traffic Organization

AVP Office of Accident Investigation and Prevention

AVS Aviation Safety Organization

CFR Code of Federal Regulations

FAA Federal Aviation Administration

FOIA Freedom of Information Act

ICAO International Civil Aviation Organization

JPDO Joint Planning and Development Office

NTSB National Transportation Safety Board

SMS Safety Management System

SRM Safety Risk Management

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

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

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

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

necessary if you wish to reproduce this material separately.
Page 1 GAO-12-898 Safety Management Systems

United States Government Accountability Office 

Washington, DC 20548

September 12, 2012

The Honorable John D. Rockefeller, IV

Chairman

The Honorable Kay Bailey Hutchison

Ranking Member

Committee on Commerce, Science, and Transportation

United States Senate

The Honorable John L. Mica

Chairman

The Honorable Nick J. Rahall, II

Ranking Member

Committee on Transportation and Infrastructure

House of Representatives

The Honorable Thomas E. Petri

Chairman

The Honorable Jerry F. Costello

Ranking Member

Subcommittee on Aviation

Committee on Transportation and Infrastructure

House of Representatives

The U.S. airspace system is one of the safest in the world, with no main 

line air carrier passenger fatalities in the U.S. in more than 10 years.1

 

1

Main line air carriers are commercial airlines that use jets with over 90 seats, as 

compared to regional carriers, which use smaller piston, turboprop, and regional jet 

aircraft with up to and including 90 seats. 

This 

record reflects the efforts of the Federal Aviation Administration (FAA), 

airlines, airports, manufacturers, the National Transportation Safety Board 

(NTSB), and others to continually improve aviation safety. However, with 

air travel projected to increase over the next 20 years, efforts to ensure 

the continued safety of aviation are increasingly important. FAA is 

attempting to further enhance aviation safety, in part, by shifting to a datadriven, risk-based safety oversight approach. This approach is becoming 

the standard throughout the global aviation industry and is recognized by 

aviation leaders such as the International Civil Aviation Organization 

 
 

Page 2 GAO-12-898 Safety Management Systems

(ICAO), the Joint Planning and Development Office (JPDO), and others 

as the next step in the evolution of safety.2

FAA is overseeing implementation of this new approach—called a safety 

management system (SMS) approach—both within FAA and throughout 

the U.S. aviation industry and is coordinating these efforts with the 

international aviation community. Safety management systems represent 

a proactive approach to safety and are intended to continually monitor all 

aspects of aviation operations and collect appropriate data to identify 

emerging safety problems before they result in death, injury, or significant 

property damage. Under SMS, FAA will use the aviation safety data it 

collects to identify conditions that could lead to aviation accidents or 

incidents and to address such conditions through changes in the FAA’s

organization, processes, management, and culture. SMS adoption and 

implementation is one of the biggest cultural and procedural 

transformations in FAA history and will likely involve years of continuous 

effort on the part of agency and industry officials.

You asked us to assess FAA’s implementation of SMS. To do so, we 

addressed the following questions: 

(1) What is the status of FAA’s implementation of SMS? 

(2) To what extent have FAA’s SMS efforts been consistent with key 

practices for successful planning and implementation of a new 

program? 

(3) What challenges does FAA face in implementing SMS?

To determine the status of FAA’s implementation of SMS, we reviewed 

FAA’s SMS orders and pilot project guidance, implementation plans, and 

Notices of Proposed Rulemaking for Part 121 air carriers and Part 139 

 

2

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

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

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

its 191 member states. JPDO was established by the U.S. Congress in 2003 to plan and 

coordinate research and development for the Next Generation Air Transportation System 

(NextGen). Pub. L. No. 108-176, §709. JPDO manages partnerships that include agencies 

such as the Departments of Transportation, Defense, and Homeland Security. 
 

Page 3 GAO-12-898 Safety Management Systems

airports.3 We interviewed FAA SMS program managers across FAA 

business lines and offices. We also reviewed international and FAA 

guidance and SMS and NTSB recommendations to FAA related to SMS. 

To assess the extent to which FAA’s efforts have been consistent with 

key practices, we reviewed our reports and other literature on successful 

project planning and implementation, particularly for large-scale 

transformative projects,

4

We conducted this performance audit from September 2011 to 

September 2012 in accordance with generally accepted government 

and identified key practices applicable to FAA’s 

SMS implementation. We then assessed FAA’s actions against the key 

practices by examining such documents as FAA’s guidance and 

implementation plans, and interviewing FAA officials. We determined 

whether each key practice was addressed, partially addressed, or not 

addressed by using criteria developed from prior GAO reports. For 

example, we considered a practice partially addressed if FAA had 

partially implemented, taken steps toward, or started but not completed 

implementing it (see app. I for a discussion of our assessment). To 

identify challenges FAA faces in implementing SMS, we reviewed our 

prior work on long-standing FAA challenges, such as those related to 

training and data, and interviewed aviation industry experts and FAA 

officials. We also reviewed our prior work on performance measurement 

and workforce analysis, and NTSB recommendations related to SMS. To 

obtain industry views on challenges, we interviewed representatives from 

airports and air carriers selected for size and geographic dispersion. We 

also interviewed representatives of aviation industry associations and 

reviewed written comments submitted by aviation stakeholders on two 

FAA-issued Notices of Proposed Rulemaking that would require SMS for 

some airports and air carriers. See appendix I for a more detailed 

description of our scope and methodology.

 

3

FAA issues operating certificates to air carriers offering scheduled, commercial air carrier 

service under 14 CFR Part 121. For the purposes of this report, we will refer to these 

carriers as commercial air carriers. FAA issues airport operating certificates to airports that 

(1) serve unscheduled air carrier aircraft with more than 30 seats; or (2) serve scheduled 

air carrier operations in aircraft with more than 9 seats under 14 CFR Part 139. 1(a)(1) 

and (2). For the purposes of this report, we will refer to these as certificated airports. 

4

See GAO, Results-Oriented Cultures: Implementation Steps to Assist Mergers and 

Organizational Transformations, GAO-03-669 (Washington, D.C.: July 2, 2003) and GAO, 

Motor Carrier Safety: The Federal Motor Carrier Safety Administration Has Developed a 

Reasonable Framework for Managing and Testing Its Comprehensive Safety Analysis 

2010 Initiative, GAO-08-242R (Washington, D.C.: Dec. 20, 2007).
 

Page 4 GAO-12-898 Safety Management Systems

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

SMS provides a top-down approach to managing safety risk, which FAA 

expects will improve aviation safety. SMS is not an additional safety 

program that is distinct from existing activities that accomplish an entity’s 

safety mission, but rather, a process for safety management that 

incorporates systematic procedures, practices, and policies. According to 

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

that the outcomes of any management or system activity incorporate 

informed, risk-based decision making. We reported in 2010 that FAA 

officials believe that successfully implementing SMS is critical to meeting 

the challenges of a rapidly changing and expanding aviation system. To 

achieve a higher level of safety in an already very safe system, FAA 

requires a more forward-thinking approach, which SMS provides, by 

addressing cultural and organizational problems that lead to safety 

hazards, identifying system-wide trends in aviation safety, and managing 

emerging hazards before they result in incidents or accidents.

SMS implementation should bring about a fundamental shift in aviation 

safety oversight. For decades, the aviation industry and federal 

regulators, including FAA, have used data reactively to identify the 

causes of aviation accidents and incidents and take actions to prevent 

their recurrence. While FAA plans to continue to use data to analyze past 

safety events, it is also working to use data proactively to search for risks. 

FAA’s shift to the proactive approach of SMS is important because, as 

accidents have become increasingly rare, less information is available for 

reactive analyses of their causes. As a result, information that can be 

used to help identify accident and incident precursors has become more 

critical for accident prevention. Thus, the open sharing of safety 

information among aviation stakeholders and how FAA’s policies and 

procedures govern the reporting of safety information are essential to the 

success of SMS.

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

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

Together, these four components are intended to provide a systematic 

approach to achieving acceptable levels of risk. FAA provides to its 

personnel detailed guidance on the principles underpinning these 

Background
 

Page 5 GAO-12-898 Safety Management Systems

components and the application of these components to aviation 

oversight in its official orders and other internal FAA guidance. To the 

industry, FAA provides this SMS guidance via advisory circulars and a 

dedicated page for the SMS program office on the FAA website.

Figure 1: The Four Components of Safety Management Systems

FAA is undertaking the transition to SMS in coordination with the 

international aviation community, working with ICAO to adopt applicable 

global standards for safety management. ICAO requires SMS for the 

management of safety risk in air operations, maintenance organizations, 

air traffic services, and airports as well as certain flight-training operations 

and for organizations that design or manufacture aircraft. Further, ICAO 

has published safety management requirements for its member countries 

that mandate that civil aviation authorities—such as FAA—establish 

SMS.5

 

5

ICAO refers to SMS as employed by civil aviation authorities as “State Safety Programs.” 

ICAO first mandated SMS worldwide for air traffic service 

providers, such as air carriers and certified aerodromes, in 2001. ICAO 

later specified that member states should mandate SMS implementation 

for airports, air carriers, and others by 2009. FAA began SMS 

implementation in 2005, but FAA officials informed ICAO that the agency 

and industry would not be able to meet the 2009 deadline. ICAO is 
 

Page 6 GAO-12-898 Safety Management Systems

allowing FAA to take additional time in its efforts to implement SMS, with 

the understanding that implementation is under way and that FAA is in 

the midst of a rulemaking to require SMS for commercial air carriers. 

ICAO officials stated that the United States is one of the leading 

implementers of SMS worldwide and acknowledged that SMS 

implementation in the U.S. aviation system may be more complicated 

than in other countries because of the size and complexity of the U.S. 

aviation industry. ICAO has not specified a date by which FAA is 

expected to comply with the requirements to implement SMS in the 

aviation system. There have also been actions within the United States to 

encourage implementation of SMS. For instance, in 2007, NTSB 

recommended that FAA require all commercial air carriers to establish an 

SMS6

Partially in response to the ICAO requirement, FAA added goals related 

to SMS implementation to its 2009-2013 Flight Plan.

and, in 2011, added SMS for all modes of transportation to the 

NTSB’s Most Wanted List, identifying SMS as one of the most critical 

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

7

FAA has also established groups that work across the agency to 

coordinate the agency’s implementation of SMS. The FAA SMS 

Committee is comprised of managers from each of the four business lines 

and one staff office currently implementing SMS, and reports to the FAA 

SMS Executive Council, which is composed of Associate and Assistant 

These are linked to 

a requirement to implement SMS in three of FAA’s business lines—the 

Air Traffic Organization (ATO), the Aviation Safety Organization (AVS), 

and the Office of Airports (ARP)—and a goal to implement SMS policy in 

all appropriate FAA organizations, which include the Office of Commercial 

Space Transportation (AST) and the Office of NextGen (ANG). FAA is in 

the process of implementing SMS within these business lines and offices 

as well as in industry through rulemakings to require airports and 

commercial air carriers to implement SMS. FAA designated AVS as the 

lead for SMS implementation in September 2008. Within AVS, the Office 

of Accident Investigation and Prevention’s (AVP) Safety Management and 

Research Planning Division coordinates and manages SMS 

implementation and operation across the agency, and so AVP serves as

the official SMS lead for the agency.

 

6

NTSB recommendation A-07-010. 

7

Federal Aviation Administration, 2009-2013 Flight Plan is the agency’s strategic plan.
 

Page 7 GAO-12-898 Safety Management Systems

Administrators, their deputies, and other high-level FAA officials from

each business line or office (see fig. 2). Within some of the business 

lines, there are offices devoted to specific aviation oversight functions that 

are responsible for overseeing detailed implementation of SMS for those 

functions. For example, the Flight Standards Service (AFS), a division of 

AVS that provides safety oversight of commercial air carriers and others, 

is taking steps to require SMS implementation by commercial air carriers 

and is also working to integrate SMS into its internal activities. In addition, 

the Aircraft Certification Service (AIR), a division of AVS that provides 

safety oversight to aviation design and manufacturing firms, is leading 

agency efforts to encourage SMS implementation for that industry sector, 

while ARP is leading agency efforts to require SMS implementation for 

certificated airports.

Figure 2: Organizational Structure to Coordinate SMS Implementation across FAA 

Business Lines and Offices

SMS implementation will require changes to many of FAA’s operations. 

As the agency and industry implement SMS, shifts will be necessary in 

both the skills of FAA and industry staff and the tools that the agency 

uses to monitor safety. FAA’s integration of SMS into its business 

practices will also affect how the agency provides air navigation services 

and oversees the aviation industry. Historically, FAA oversight of airlines, 

airports, and other regulated entities has involved oversight of such things 

as operations and maintenance. FAA will continue this oversight, but will 

also apply SMS principles to its processes for oversight. The agency will 

provide oversight of the safety management systems of service providers 
 

Page 8 GAO-12-898 Safety Management Systems

such as air carriers and airports to help ensure that they are managing 

safety within their operations through SMS. For example, AFS currently 

provides oversight of the operations, maintenance, and safety data of 

commercial air carriers and others. Once SMS is fully implemented, AFS 

will continue to provide this oversight and will also conduct oversight of 

the safety management systems that commercial air carriers and others 

put in place.

ATO completed its implementation of SMS, but FAA and several of its 

other business lines and offices are in the early stages of implementation. 

Most FAA business lines and offices have guidance and plans for SMS 

implementation in place and have begun to integrate SMS-related 

practices into their operations, but many tasks remain and aviation 

officials and experts with whom we spoke project that full SMS 

implementation will take many years.

FAA finalized its agency-wide plan for SMS implementation in April 2012. 

The plan provides a road map for SMS implementation across the agency 

and describes the activities that FAA business lines and offices will need 

to complete by the end of 2015 to integrate SMS into their operations.8

• revising and standardizing safety policies and safety risk

management methodologies across FAA to ensure SMS 

principles are consistently addressed; 

These activities will lead to outcomes including: 

• improving organizational processes so that FAA business lines and 

offices can share safety data and information more easily; and 

• coordinating communications to ensure a common understanding 

of SMS across the agency.

FAA began its agency-wide SMS implementation efforts in 2008, and in 

September of that year issued a policy for implementation of a common 

SMS within FAA. Among other things, the policy sets forth management 

 

8

The year 2015 does not represent an estimated completion date for SMS 

implementation. The implementation plan describes tasks through 2015, but FAA officials 

estimate SMS implementation efforts will continue beyond 2015. 

FAA and Its Business 

Lines Are at Different 

Stages of SMS 

Implementation

FAA Recently Finalized Its 

Agency-Wide 

Implementation Plan, but 

Full SMS Implementation 

Is Likely to Take Many 

Years
 

Page 9 GAO-12-898 Safety Management Systems

principles to guide all of FAA in safety management and safety oversight 

activities and requires AVS, ARP, and ATO to develop and execute 

business line-specific plans for SMS implementation. In late 2008, FAA 

formed the agency-wide FAA SMS Committee to coordinate 

implementation efforts across FAA business lines and offices. Overall, the 

agency has taken a bottom-up approach to implementation, with some 

individual business lines and offices beginning implementation prior to 

agency-wide efforts. FAA has also taken steps to ensure that its plans for 

SMS implementation and policies align with international and 

government-wide requirements and technical guidance on SMS 

implementation, including ICAO’s Standards and Recommended 

Practices, the ICAO Safety Management Manual, and the JPDO SMS 

Standards. For instance, officials stated that they consulted international 

and government-wide guidance on SMS implementation when drafting 

agency implementation plans. (See fig. 3 for more information on 

alignment of FAA requirements with international and government-wide 

requirements and guidance on SMS.)

Figure 3: FAA’s SMS Guidance Links to International and Government-wide SMS Requirements and Guidance

Although FAA has made progress, completion of SMS implementation 

across FAA is likely to take many years. FAA’s agency-wide SMS 

implementation plan includes tasks with estimated completion dates 
 

Page 10 GAO-12-898 Safety Management Systems

through 2015, and some implementation tasks may take even longer to 

complete. For instance, a project plan that AVS officials developed to 

track status of AVS SMS implementation tasks contained in its 

implementation plan includes task completion dates through 2016. 

According to FAA, the overall SMS implementation effort is an 

evolutionary process that will not have a specific completion date. The 

current implementation time frame is consistent with experts’ estimates of 

how long it may take to implement SMS and with other large-scale 

organizational transformations. For example, representatives from The 

MITRE Corporation, which manages a federally funded research center 

for FAA and assisted FAA in selected SMS implementation efforts, stated 

that organizational transformations like SMS can take from 6 to 10 years.

ATO is the only entity among FAA and its business lines to have 

completed SMS implementation. ATO issued its internal SMS guidance in 

March 2007 and finalized both its SMS implementation plan and its 

updated SMS Manual in 2008.9 According to ATO officials, ATO 

completed SMS implementation in March 2010, and the FAA Air Traffic 

Safety Oversight Service validated that ATO’s implementation of SMS 

was complete. Officials stated that implementation within ATO was 

simpler, in part, because it is the only branch of FAA that is considered an 

aviation service provider and therefore did not have to conduct a 

rulemaking for external entities as part of its SMS implementation.10

 

9

As part of FAA’s bottom-up approach to SMS implementation, ATO began 

implementation in 2005, much earlier than other FAA business lines. Officials stated that 

the agency did not initially intend to implement SMS across the entire agency.

With 

the implementation phase complete, ATO is currently in the continuous 

improvement phase of SMS. This means that ATO will continuously use 

the SMS-based processes now in place to identify hazards, enact 

strategies to mitigate the risks associated with those hazards, and assess 

the extent to which the mitigations are working effectively. In addition, 

FAA officials stated that ATO is working to improve its SMS operations, 

will update guidance on SMS, and plans to perform audits of its SMS 

functions on a regular basis. ATO officials added that they are working to 

10The primary service of ATO is to move air traffic safely and efficiently. The controllers, 

technicians, engineers, and support personnel employed by ATO provide air navigation 

services directly to commercial and private aviation stakeholders, as well as the military. 

Since ATO directly employs those providing the aviation service, it was not necessary for 

FAA to conduct a rulemaking in order to require ATO to implement SMS. 

ATO Completed SMS 

Implementation in 2010
 

Page 11 GAO-12-898 Safety Management Systems

share lessons learned from their implementation efforts with other FAA 

business lines and to develop SMS tools and processes that can be 

commonly implemented across all FAA business lines.

With the exception of ATO, most FAA business lines and offices are in 

the early stages of implementation, either in terms of integrating SMS into 

their internal processes or in terms of their efforts to prepare to provide 

oversight for proposed requirements for industry implementation of SMS. 

To date, much of the work of the FAA business lines has focused on 

efforts to draft implementation policies and guidance, train employees, 

and create tools for applying safety analyses and risk-based decisionmaking to safety oversight. (See fig. 4 for more information on the status 

of key SMS implementation efforts across FAA.)

Figure 4: Timeline of Key SMS Implementation Activities across FAA’s Business Lines and Offices, 2007 to 2013

Most FAA Business Lines 

and Offices Are in Early 

Stages of Implementation
 

Page 12 GAO-12-898 Safety Management Systems

AVS began its SMS implementation efforts in August 2006 and finalized 

its SMS implementation plan in January 2012, which was then 

incorporated into FAA’s overall plan for SMS implementation. Since 2006, 

AVS and its seven services and offices have issued orders and other 

guidance on SMS implementation; developed SMS training courses; 

conducted voluntary pilot projects and rulemaking efforts on SMS 

implementation for industry; and worked to begin integrating elements of 

SMS into their operations. For example, AIR officials, who provide 

oversight of aviation design and manufacturing firms, have developed a 

central database that provides standard criteria for analyzing service data 

in a risk-based manner. This should allow AIR inspectors and engineers 

to rate the risk of potential safety issues and prioritize oversight to high 

risk issues.

Some services and offices within AVS are in the midst of efforts to require 

SMS for industry and are also operating voluntary pilot programs to 

promote SMS implementation within industry. A final rule to require SMS 

for commercial air carriers is expected to be issued in September 2012.11

In 2007, AFS launched a pilot program to encourage voluntary 

implementation of SMS by industry.12

According to FAA officials, as part of its rulemaking efforts for commercial 

air carriers, FAA and AVS are developing a new part in the Code of 

Federal Regulations (CFR)—Part 5—that will describe SMS 

implementation requirements for Part 121 certificate holders. In the future, 

FAA may conduct rulemakings to require additional sectors of the aviation 

industry to meet Part 5 requirements (see fig. 5). AVS officials stated that 

 

11The Airline Safety and Federal Aviation Administration Extension Act of 2010 requires 

FAA to issue a final rule for Part 121 air carriers by July 30, 2012. Pub. L. No. 111-216, 

§215(c)(2), 124 Stat. 2348, 2366 (2010). According to FAA officials, the rule will be 

applied to Part 121 operators as well as operators with dual certificates that conduct 

operations under both 14 CFR Parts 121 and 135. The proposed rule will not apply to 

operations conducted solely under 14 CFR Part 135. FAA officials stated that the 

proposed rule is currently being reviewed by the Office of the Secretary of Transportation 

and the Office of Management and Budget prior to final issuance.

12The AFS pilot project included Part 121 air carriers, Part 135 operators, and Part 145 

repair stations. FAA regulations set forth certification procedures for aviation-related 

products and parts under Federal Aviation Regulation Part 21, commuter and on-demand 

aviation operations under Federal Aviation Regulation Part 135, and repair stations under 

Federal Aviation Regulation Part 145. 

Aviation Safety Organization
 

Page 13 GAO-12-898 Safety Management Systems

efforts to establish SMS requirements more broadly across the aviation 

industry will likely take many years.

Figure 5: Proposed and Potential Future Applicability of Federal Aviation 

Regulation Part 5 to the Aviation Industry

Though FAA has not yet required SMS for air carriers or other parts of 

industry, FAA has acted to encourage SMS implementation by industry 

through voluntary pilot projects, and some aviation stakeholders have 

chosen to implement SMS in advance of any federal requirement. Some 

sectors of the aviation industry are farther along in their implementation of 

SMS than others. For instance, FAA officials stated that a large majority 

of commercial air carriers are in the process of implementing SMS.13 As 

of June 2012, over 90 percent of commercial air carriers operating under 

Part 121 were participating in the AFS pilot program, which provides air 

carriers with direct implementation support from FAA officials under a 

more relaxed implementation time frame than is anticipated under an 

eventual implementation regulation. Of these air carriers, three have 

reached the final stage of SMS implementation.14

 

13Part 135 operators also hold air carrier certificates, but according to FAA officials, a 

smaller proportion of these operators are participating in the AFS pilot project. 

However, most small air 

carriers have not yet begun implementing SMS. In contrast to AFS, AIR is 

at an earlier stage in its efforts to require SMS for the approximately 

14FAA does not certify SMS implementation by commercial air carriers participating in the 

pilot project as complete. However, FAA has laid out four phases of SMS implementation 

for pilot project participants, and FAA officials meet with participants to verify whether or 

not they have completed the steps included in each phase. 
 

Page 14 GAO-12-898 Safety Management Systems

3,000 design and manufacturing firms it oversees. AIR began a voluntary 

pilot project for SMS implementation by design and manufacturing firms in 

2011 and has 11 pilot project participants. AIR officials stated that they 

are in the process of launching a second aviation rulemaking committee 

to continue to explore options to require SMS for design and 

manufacturing firms. Officials also noted that AFS and AIR are working 

together to share lessons learned and assist one another in their 

implementation efforts.

ARP is in the early stages of working to integrate SMS principles into its 

oversight of airports, and recently took steps to reduce the scope of that 

oversight. ARP initially planned to apply SMS-based oversight to all 

certificated airports. Officials stated that ARP is currently limiting its SMSbased oversight to large hub airports because of budget constraints and 

will reassess its capacity to expand oversight to smaller airports in 2013. 

ARP began its SMS implementation in 2010 and issued an internal order 

to provide a basis for the integration of SMS into its operations later that 

year. The office finalized its SMS implementation plan in September 2011 

and has begun to make changes to its oversight. For instance, In June 

2011, ARP began to apply SMS-based oversight to construction projects 

at the 29 large hub airports in the United States.15 Under this new 

oversight framework, ARP staff assess proposed airport construction 

projects using risk-based SMS principles, and airports need to 

incorporate strategies to mitigate identified risks into their construction 

plans prior to receiving ARP’s approval for the project. Like AVS, ARP is 

also in the midst of a rulemaking to require SMS for all certificated 

airports and has completed three voluntary SMS pilot projects for airports 

from 2008 to 2011.16

 

15Large hub airports are those which enplane at least 1 percent of U.S. passenger 

enplanements system-wide. See 49 U.S.C. § 47102 (10).

Thirty-one airports participated in at least one of 

ARP’s SMS pilot projects. ARP is using information gathered through the 

pilot projects to inform a planned advisory circular that will provide 

additional guidance to airports on SMS implementation. The pilot projects 

also allowed airports to share their SMS implementation practices with 

other airports. The final rule to require SMS for Part 139 certificated 

16The first pilot project focused on airport creation of SMS implementation plans; the 

second pilot project focused on SMS implementation for smaller airports, and the third 

pilot project focused on SMS implementation at airports that participated in at least one of 

the first two pilot projects. 

Office of Airports
 

Page 15 GAO-12-898 Safety Management Systems

airports is expected to be issued in April 2013 and, if implemented as 

proposed, would require over 500 airports to implement SMS.17

Other FAA business lines are in varying stages of implementation. AST is 

not currently required to implement SMS; however, AST is taking initial 

steps toward integrating SMS into an existing set of safety management 

processes. ANG is farther along in its implementation of SMS because of

its previous status as a part of ATO.18 According to officials, ANG is 

basing its implementation of SMS on policies and processes established 

during ATO’s implementation of SMS. The officials stated that since ANG 

will provide the systems and components that will be used by ATO to 

manage air traffic, it made sense for ANG to develop its SMS based on 

policies, processes, and systems established by ATO. Officials stated that 

ANG completed its implementation plan in June 2012 and estimated that 

ANG’s SMS implementation is about 70 percent complete.

There are a number of key practices and implementation steps that can 

help agencies successfully plan for and implement new projects, including 

large scale transformative ones, such as FAA’s implementation of SMS. 

As we have previously reported, addressing these key practices can help 

an agency improve its efficiency, effectiveness, and accountability.19

 

17While ARP has limited its SMS-based oversight efforts to large hub airports, the 

proposed rulemaking would require Part 139 certificated airports of all sizes to integrate 

SMS into their operations.

 FAA 

currently has many of these key factors in place, such as established 

support from top leadership and a clear project mission; however, it has 

only partially addressed other key practices, such as providing needed 

expertise and technology, and has yet to establish SMS performance 

measures (see fig. 6).

18In 2011, FAA reorganized some of its offices and, as part of the reorganization, 

separated NextGen efforts from ATO.

19GAO-03-669 and GAO-08-242R. 

Offices of Commercial Space 

Transportation and NextGen

FAA’s SMS Approach 

Is Consistent with 

Many but Not All Key 

Practices for 

Successful Project 

Implementation
 

Page 16 GAO-12-898 Safety Management Systems

Figure 6: Alignment of FAA’s SMS Implementation with GAO-Identified Key Practices for Successful Organizational 

Transformations

FAA has instituted many key practices that will help it prepare for and 

implement SMS across its business lines and offices.

• Top leadership: Top leaders from each FAA business line provide 

support for and actively participate in SMS implementation. As 

previously mentioned, FAA established the SMS Executive Council, a 

group of high-ranking FAA officials that provides executive-level 

guidance and conflict resolution for SMS-related issues across the 

Many Key Practices Are in 

Place
 

Page 17 GAO-12-898 Safety Management Systems

agency. In accordance with our key practices, the SMS Executive 

Council has the authority to make resource allocation decisions, but 

also confers decision-making authority where appropriate to the FAA 

SMS Committee.

For instance, FAA officials told us that the SMS Executive Council 

retains the authority to make final decisions about changes to FAA’s 

implementation plan that affect policies or procedures for multiple 

business lines; the FAA SMS Committee has the authority to make 

decisions that relate to daily concerns that fall within the purview of its 

members. For example, committee members settled a disagreement 

between ATO and airport officials over whether an airport should 

conduct certain components of a safety risk management panel. At 

the time, FAA had not yet issued its safety risk management policy 

clarifying terms and requirements, so the airport and ATO each had 

its own distinct safety risk management definitions and processes. 

Working with ARP and ATO officials, committee members identified a 

compromise in which ATO protocols were followed, but any 

disagreements on terms or procedures were documented. ARP 

officials told us that FAA’s safety risk management policy, issued in

April 2012, should help prevent this type of disagreement from 

occurring.

• Clear project mission: FAA’s internal order requiring SMS 

implementation for ARP, ATO, and AVS clearly describes that FAA’s 

mission is to improve aviation safety and that implementing SMS and 

its components supports that mission. Each business line also has its 

own internal order requiring SMS implementation that mirrors this 

mission and goals.

• Implementation team: AVP’s safety management division and the 

FAA SMS Committee, function jointly as FAA’s dedicated SMS 

implementation team. The team’s structure and actions align with our 

criteria for a strong and stable team20

 

20

because it is composed of 

senior-level program managers from each business line, all of whom 

GA0-03-669. 
 

Page 18 GAO-12-898 Safety Management Systems

had received SMS training according to FAA officials. Despite some 

recent departures, its membership has been largely stable.21

• Leading practices: FAA shares information across business lines to 

identify lessons learned related to SMS implementation. For example, 

ATO assembled lessons learned from its SMS implementation into a 

presentation for the other business lines, and included tips such as 

encouraging others to implement a training program and monitor 

mitigations. According to FAA’s implementation plan, the agency 

plans to systematize the sharing of lessons learned by creating a 

central repository to collect and communicate safety lessons learned 

among its business lines and offices by September 30, 2013.

• Troubleshooting: FAA has processes in place to manage SMS 

implementation across FAA, including troubleshooting unexpected 

problems. For example, the FAA SMS Committee meets monthly and 

manages agency-wide SMS implementation and any challenges that 

arise, and regularly briefs the SMS Executive Council, a briefing that

includes a discussion of any issues or unexpected problems that 

could not be resolved at the committee level. For instance, when the 

Air Traffic Manager at an airport disagreed with airport officials 

regarding how to handle a potential safety issue with planes that were 

taking off on runways that were temporarily closed, the FAA SMS 

Committee elevated the issue to the SMS Executive Council, which 

resolved it. As we have previously reported, instituting practices like 

these can help an agency become more results-oriented, customerfocused, and collaborative.

Although FAA is still in the process of finalizing new requirements for 

airports and air carriers to implement SMS, it has already taken some 

steps to institute key practices for those efforts. For example, FAA 

officials stated that the agency has taken steps to identify leading 

practices during pilot projects by soliciting information from participating 

 

21Our review of implementation practices focused on FAA’s internal implementation 

efforts; however, FAA does not currently have a dedicated implementation team to 

coordinate efforts to require industry SMS across FAA business lines. FAA officials stated 

that the FAA SMS Committee is the appropriate group to handle industry SMS 

implementation issues that cross FAA organizations, but committee officials told us that 

SMS implementation in industry is implemented separately by AFS and ARP. In addition, 

FAA reported that several FAA offices, including the Rulemaking Management Council 

and the Office of Rulemaking, manage all of FAA’s rulemaking efforts. 
 

Page 19 GAO-12-898 Safety Management Systems

airports and air carriers, and FAA officials told us they plan to incorporate 

these lessons learned into rulemaking and guidance. ARP officials 

reported that they encouraged pilot project participants to share lessons 

learned directly with one another through studies and roundtable 

discussions, and incorporated some of the lessons learned into FAA 

advisory circulars. FAA has also made efforts to troubleshoot and 

manage unexpected problems with pilot participants through meetings, 

calls, and conferences with airport and air carrier officials to understand 

their experiences. For example, AFS officials reported that they helped 

officials from air carriers to understand when certain safety risk

management documentation and processes are necessary, and how they 

could be adapted for a variety of changes made to carrier operations, 

including smaller day-to-day changes. However, despite this assistance, 

officials from some airports that participated in pilot projects reported that 

they could have benefited from additional assistance from ARP, such as 

clarification on the safety risk management component of SMS. In 

addition, an official at one airport told us that he would have liked FAA to 

facilitate conversations between airports of similar size to help them share 

lessons learned.

Other steps FAA has taken in its SMS implementation efforts partially 

align with key practices for implementing a new program.

• Project plan: Currently, the agency-wide project plan for SMS 

implementation is a single page of high-level milestones, which AVP 

officials monitor and report on to the SMS Executive Council. Also, 

AVS has a detailed project plan for its own SMS implementation and 

elements of agency-wide implementation for which AVP, as the 

agency SMS lead, has responsibility. Officials stated that they have 

plans to develop a system to monitor and track the progress of 

activities needed to implement SMS, but FAA does not currently have 

a system for tracking agency-wide SMS implementation, a key 

practice particularly important during the initial planning phase of 

project implementation.22

 

22Our review of implementation practices focused on FAA’s internal SMS implementation 

efforts. However, FAA also does not currently have an agency-wide project plan to track 

its efforts to oversee industry implementation.

However, given the scope and complexity of 

SMS, a detailed, agency-wide project plan could help FAA track and 

monitor the interim steps of SMS implementation across the agency. 

FAA Efforts to Create a 

Project Plan and Consult 

and Assist Stakeholders 

Partially Align with Key 

Practices
 

Page 20 GAO-12-898 Safety Management Systems

Without such a plan, it may be more difficult for FAA to identify 

problems or deviations from planned activities, putting both the 

timeliness and effectiveness of SMS implementation at risk.

• Consulting with stakeholders: FAA has made efforts to consult with 

employees and stakeholders regarding its SMS implementation, but it 

has not yet developed a communications plan. Agencies should 

involve employees in planning, and incorporate employee feedback 

into new policies and procedures.23

FAA has been working to implement SMS for the last 4 years, but the 

agency does not have a communications plan or strategy for ensuring 

that the SMS messages communicated to staff are consistent across the 

agency. Instead, FAA relies on a more informal communications structure 

in which each program manager staffed to the implementation team 

communicates relevant information back to their respective business line. 

The implementation team does not communicate any information directly 

to employees, which could hinder the team’s ability to ensure consistency 

in its message across FAA. ATO officials reported experiencing this

challenge at the beginning of ATO’s SMS implementation, when a lack of 

clear requirements for communicating SMS information resulted in 

variation in staff’s understanding of guidance. We have previously 

reported that a communication plan or strategy can ensure consistency of 

message, provide information to meet the specific needs of employees, 

encourage two-way communication, and build trust. FAA plans to begin 

working on a communications plan in September 2012, and is scheduled 

to issue the plan at the end of February 2013. FAA officials also said they 

are in the process of developing an internal SMS website for employees 

to share information and ideas, which could enhance SMS 

communications. However, until the communications plan is developed 

FAA involved its business line 

program managers and some of the managers’ staff by assigning 

them responsibility for the day-to-day tasks related to implementing 

SMS across the agency. FAA has involved other employees by 

soliciting questions and comments on SMS in town hall meetings and 

the online DOT site called “IdeaHub,” and by offering SMS training 

through each business line. ATO, ARP, and AVS all offer introductory 

SMS courses for their staff as well as additional related courses, such 

as an SMS course specifically for managers and ATO’s safety risk 

management course.

 

23GAO-03-669. 
 

Page 21 GAO-12-898 Safety Management Systems

and implemented, FAA’s employees may not receive timely or consistent 

information on SMS or be as invested in its implementation as they might 

otherwise be. 

FAA’s approach to overseeing industry SMS implementation allowed for 

additional two-way communication.24

• Providing technology and expertise: FAA has provided some SMS 

training and tools to its employees; however, it has not yet provided 

other tools important for SMS implementation. FAA officials reported 

that each business line has provided SMS training to staff. In addition, 

FAA recently developed a standardized Safety Risk Management 

(SRM) policy, which will assist employees across FAA by 

standardizing SRM terminology and clarifying confusion on the 

conduct of SRM across the agency. FAA plans to create a simple 

version of an agency-wide hazard-tracking system in the next 3 to 6 

months, but does not have plans to create a more complex system 

until August 2015, according to FAA’s SMS implementation plan. The 

simple version will draw from hazard-tracking systems already in 

place in some business lines, and summarize information from them 

to highlight broader hazards such as those that would affect multiple 

business lines. For instance, FAA officials stated that if ATO wanted 

to make a change to its operations at a particular airport, then ATO 

would be responsible for identifying associated hazards, risks, and 

risk mitigations and would also be responsible for assuming 

responsibility for the risk. However, if ATO determined that the airport 

was better equipped to mitigate the identified risks, then the airport 

and ARP would become more involved in designing risk mitigations 

and overseeing their implementation. FAA’s efforts to provide tools to 

help in SMS implementation are affected by differences in how data 

are collected and assessed across the agency. For example, these 

differences have held back agency efforts to model how changes to 

the national airspace system, such as increases to air travel, can 

For example, FAA solicited views on 

SMS implementation from airport and air carrier officials through voluntary 

pilot projects described previously, and learned more about industry 

perspectives through the formal rulemaking process—whereby an agency 

issues a Notice of Proposed Rulemaking and is required to notify the 

public and give them an opportunity to submit comments.

 

24Our review of implementation practices focused on FAA’s internal SMS implementation 

efforts, so we do not comment on FAA’s overall communication strategy. 
 

Page 22 GAO-12-898 Safety Management Systems

affect safety. We have previously reported on and made 

recommendations related to FAA’s data challenges,25 and also 

discuss them later in this report. These data challenges mean that 

FAA is not always able to perform comparisons across databases, a 

challenge that that limits the usefulness of the data in identifying 

possibly dangerous hazards. Identifying, monitoring, and mitigating 

hazards is a key tenet of SMS, and without the proper technologies 

and tools, FAA may not be able to do this as effectively.

FAA’s efforts do not align with two key practices for implementing a new 

program.

• Integrating SMS into employee performance plans: FAA does not 

consistently evaluate employees’ performance on SMS-related tasks. 

We have previously reported that effective performance management 

systems create a clear linkage between individual performance and 

organizational success, and include aligning individual performance 

expectations with organizational goals.26

 

25GAO, Aviation Safety: Improved Data Quality and Analysis Capabilities Are Needed as 

FAA Plans a Risk-Based Approach to Safety Oversight, 

 FAA’s organizational mission 

and goal, and that of SMS, is to improve safety, yet FAA officials told 

us that the agency does not require employee performance plans to 

include SMS-related tasks. Although officials reported that some 

employees’ performance plans explicitly include SMS items, such as 

providing SMS training or developing SMS policy, it is left to the 

discretion of each business line whether SMS items are included. FAA 

officials told us that SMS principles and methodologies will be 

included in the performance plans of employees involved in writing 

SMS policy and revising SMS processes, and will be incorporated into 

the tasks of others once SMS implementation reaches those 

individuals. However, currently, none of the business lines require 

this. As such, FAA does not have a system for assessing the extent to 

which staff are effectively supporting SMS, and FAA may not be able 

to determine if staff are completing tasks and responsibilities 

necessary for the successful implementation of SMS.

GAO-10-414 (Washington D.C.: 

May 6, 2010).

26GAO, Results-Oriented Culture: Creating a Clear Linkage Between Individual 

Performance and Organizational Success, GAO-03-488 (Washington D.C.: 

Mar. 14, 2003).

FAA Has Yet to Integrate 

SMS into Employee 

Performance Plans and 

Establish Performance 

Measures
 

Page 23 GAO-12-898 Safety Management Systems

• Measuring performance: FAA does not have performance measures 

in place to assess whether the SMS goals of improving safety are 

being achieved. FAA has broader safety-related performance 

measures, such as tracking rates of runway incursions and losses of 

separation,27 but SMS-related performance measures could address 

intermediate safety issues, such as precursors to incursions or 

incidents. Such measures could help FAA track progress toward its 

broader safety measures.28 FAA officials told us that AVS is a 

member of the Safety Management International Collaboration Group, 

a group formed in 2009 to address safety management-related topics, 

including performance measures. Most recently, FAA formed an 

agency-wide working group to study performance metrics for SMS 

implementation, and FAA’s implementation plan states that such 

metrics will be finalized in October 2014. However, FAA officials we 

spoke with acknowledged that they are at the very beginning phase of 

this process and, although already in the process of implementing 

SMS, have not yet identified metrics to measure safety results under 

an SMS system.29 We have previously reported that performance 

information is critical for achieving results and maximizing the return 

on federal funds.30

 

27Runway incursions are the unauthorized presence of an airplane, vehicle, or person on 

the runway. Losses of separation involve a loss of the minimum required distance 

between aircraft or as individual aircraft fly too close to terrain or obstructions.

Performance measures should help FAA identify 

the extent to which SMS implementation will contribute to increased 

aviation safety—FAA’s stated overall goal for SMS—as well as help 

identify what changes could be made to improve SMS performance 

over time.

28We previously reported that such measures could help the Transportation Security 

Administration track its progress in securing transit and passenger rail systems. For more 

information, see GAO, Surface Transportation Security: TSA Has Taken Actions to 

Manage Risk, Improve Coordination, and Measure Performance, but Additional Actions 

Would Enhance its Efforts, GAO-10-650T (Washington, D.C.: Apr. 21, 2010).

29We will discuss the challenges of developing SMS performance measures later in this 

report. 

30The Government Performance and Results Act of 1993 instituted a government-wide 

requirement that agencies set goals and report annually on performance, and encouraged 

federal agencies to conduct in-depth program evaluations to assess their program’s 

impact or learn how to improve results. Pub. L. No. 103-62. Congress subsequently 

passed the GPRA Modernization Act of 2010 (GPRAMA) which establishes a new 

framework aimed at taking a more crosscutting and integrated approach to focusing on 

results and improving government performance. Pub. L. No. 111-352, 124 Stat. 3866 

(2011).
 

Page 24 GAO-12-898 Safety Management Systems

As previously mentioned, FAA has taken steps to address many of the 

practices associated with planning and implementing a new program. 

However, we identified six challenges that could negatively affect FAA’s 

efforts to implement SMS in a timely and efficient manner: 

1) the large scope and complexity of SMS implementation, 

2) resource and capacity constraints, 

3) standardization of policies and processes, 

4) data sharing and protection, 

5) data quality and usefulness, and 

6) development of performance measures to evaluate SMS 

effectiveness.

Implementing SMS is one of several major initiatives FAA has under way, 

and its sheer scope and complexity could affect, or be affected by, 

concurrent FAA efforts such as NextGen or Unmanned Aircraft 

Systems.31

 

31Unmanned Aircraft Systems are remotely operated aircraft and vehicles that come in a 

variety of shapes and sizes, and serve diverse purposes. GAO is currently conducting a 

study on Unmanned Aircraft Systems. 

SMS requires changes in many of FAA’s operations: from the 

way the agency tracks hazards to the way it oversees industry. SMS will 

also require a transformation of FAA’s and the aviation industry’s safety 

culture to one in which information and safety data are shared openly, 

and errors are addressed through whatever action is necessary to 

prevent them from happening in the future. FAA is making efforts to move 

toward this new approach to safety, for instance by using data-sharing 

systems that are protected from public disclosure to encourage voluntary 

reporting of safety issues and enable more robust analysis of safety data 

among FAA and air carriers. Moreover, as previously stated, each of 

FAA’s business lines has its own role in implementing SMS that must be 

coordinated across the agency. This is particularly challenging because 

the business lines are at different stages of implementation and, 

according to FAA officials, have historically operated independently.

Addressing Key 

Implementation 

Practices and Other 

Challenges Could 

Enhance SMS 

Effectiveness

Large Scope and 

Complexity of SMS
 

Page 25 GAO-12-898 Safety Management Systems

The scope and complexity of SMS implementation may also be a 

challenge for the aviation industry, and some stakeholders expressed 

concerns both in interviews and in official comments on FAA’s Notices of 

Proposed Rulemaking that eventual FAA requirements to implement SMS 

need to allow for variation in airport and air carrier operations. For 

example, officials from some smaller airlines and airports noted that SMS 

implementation could require additional resources, such as staff and 

software, which may not be readily available. In addition, officials from 

some airports and air carriers were concerned that FAA’s final 

requirements would be too prescriptive to allow entities to implement an 

SMS program that best fit their organizational type, management 

practices, and resources. Most stakeholders and experts we interviewed 

stated that FAA could design SMS requirements for airports and airlines 

that are scalable and flexible to accommodate this variation, which would 

address these concerns. For instance, airport officials from smaller 

airports told us that staff size limits their ability to assign a dedicated SMS 

employee or safety director, while some officials at larger airports said 

they were able to hire a SMS safety director or already had an 

established safety director in place. Also, FAA’s SMS implementation pilot 

project for airports found that 35 percent of participants planned to hire 

additional staff to support SMS and 15 percent were not sure. FAA 

officials have noted that they understand these scalability concerns, and 

are taking them into consideration as they develop final SMS rules for 

industry.

SMS implementation across FAA will require some skills that agency 

employees currently do not have, yet FAA has not formally assessed the 

skills of its workforce to identify any gaps in the expertise required to 

implement SMS or determined how to fill those gaps. In addition, FAA 

officials stated that existing staff may not be able to be trained to fill SMS 

implementation needs in all cases. For instance, FAA officials noted that 

SMS implementation will require some engineers and other technical 

employees to understand certain terminologies and have certain 

knowledge, skills, and abilities, such as an enhanced ability to perform 

complex modeling and analysis of aviation safety data to identify potential 

safety hazards. AVS officials stated that to implement SMS, additional 

employees with skills in analyzing data for hazards and associated risks 

would be needed, along with additional training for existing staff. ARP 

officials stated that the office might need program analysts with specific 

Resources and Capacity
 

Page 26 GAO-12-898 Safety Management Systems

data analysis skills to implement SMS.32

Despite these concerns, FAA has not yet conducted a strategic workforce 

assessment to accurately determine the skills and staffing levels it needs 

to manage SMS. Although FAA’s SMS implementation plan recommends 

that business lines create such staffing analyses, none have done so. Nor 

has FAA conducted an agency-wide workforce assessment for SMS. Our 

internal control standards state that agencies should ensure that skill 

needs are continually assessed to ensure workforces have the skills 

necessary to help the agency meet its goals.

ARP officials stated that they do 

not expect to receive significantly more resources and, as previously 

mentioned, have already had to reduce the scope of the office’s SMSbased oversight because of insufficient staff. Stakeholders and experts 

also questioned whether FAA currently has the resources and capacity 

needed to fully implement SMS. For example, experts noted that FAA 

may not have the requisite engineers and other staff to participate in 

safety risk management efforts, or FAA inspectors to oversee individual 

airport and air carrier SMS programs.

33 We have reported that 

strategic workforce planning is an integral part of human capital 

management and helps an agency, among other things, determine the 

critical skills and competencies that will be needed to achieve current and 

future programmatic results, and then develop strategies tailored to 

address any gaps identified.34

A workforce analysis could help FAA determine how to best address its 

most critical needs in ways that account for budget limitations, such as 

through retraining or shifting staff, rather than hiring additional employees.

Without conducting an agency-wide SMS workforce analysis, FAA cannot 

be sure that it has sufficient staff, skills, or competencies to implement 

SMS, thus putting its SMS implementation efforts at risk.

 

32FAA officials stated that ARP received approval to hire 26 additional staff in fiscal year

2012. However, most hiring is on hold until enactment of the fiscal year 2013 budget, 

when ARP officials will be able to assess the office’s ability to continue to fund the 

positions.

33GAO, Internal Control: Standards for Internal Control in the Federal Government,

GAO/AIMD-00-21.3.1 (Washington D.C.: Nov. 1999).

34GAO, Human Capital: Key Principles for Effective Strategic Workforce Planning, 

GAO-04-39 (Washington D.C.: Dec. 11, 2003) and GAO/AIMD-00-21.3.1. 
 

Page 27 GAO-12-898 Safety Management Systems

SMS standardization across FAA business lines and offices is central to 

implementation success, yet developing common systems for distinct 

FAA business lines and offices has proved challenging. For example, 

FAA realizes that the agency needs a common hazard-tracking system in 

order to maximize SMS effectiveness, yet FAA officials and stakeholders 

stated that it is difficult to develop such a system because each of FAA’s 

business lines uses different hazard-related terms and definitions, and 

often different data systems. These differences, in turn, prevent the 

agency from performing simple comparisons across databases and have 

delayed advances in using data analysis to proactively identify potential 

safety hazards. FAA officials stated that the agency has recently taken 

steps to make its databases interoperable, and also recently issued a 

standardized policy for the safety risk management component of SMS. 

Both of these steps may enhance FAA’s hazard-tracking and analysis 

capabilities. The agency is also working with ICAO to address issues 

related to standardization, such as adopting a collaborative approach to 

increase the sharing of safety information internationally.

Industry officials are also concerned that FAA inspectors and certificate 

management offices35 may have different interpretations of SMS and 

other regulations. We and others have previously reported that variation 

in FAA’s interpretation of standards for certification and approval 

decisions is a long-standing issue.36

 

35FAA Certificate Management Offices are located throughout the U.S. and employ staff 

who specialize in the certification, surveillance, and inspection of major air carriers and 

Flight Safety Training Centers.

Industry stakeholders we interviewed 

expressed concerns that a similar result could occur once final rules are 

issued requiring airports and air carriers to implement SMS, and could 

lead to airports or air carriers of similar size being held to different 

standards of SMS implementation. FAA officials acknowledged that this is 

a challenge for the agency and noted that the agency plans to provide 

additional training to inspectors related to oversight of SMS. Additionally, 

based on our 2010 recommendation, recent legislation directs FAA to 

36GAO, Aviation Safety: Certification and Approval Processes Are Generally Viewed as 

Working Well, but Better Evaluative Information Needed to Improve Efficiency, GAO-11-14 

(Washington, D.C.: Oct. 7, 2010); Congressional Research Service, U.S. Airline Industry 

Issues and Role of Congress, 7-5700, RL34467 (July 29, 2008).

Standardization of SMS 

Policies and Processes
 

Page 28 GAO-12-898 Safety Management Systems

establish an advisory body of government and industry representatives to 

address the issue of inconsistent interpretation of regulations.37

FAA’s organizational structure for SMS implementation may pose 

challenges to standardization as well. For example, as previously 

mentioned, AVP’s safety management division is the lead for SMS, and 

AVP and the FAA SMS Committee share responsibility for implementing 

SMS across the agency. Despite AVP’s role as lead for SMS 

implementation, it does not have any additional authority compared to the 

other business lines’ committee representatives, something that AVP 

officials noted can make SMS implementation difficult. This could slow 

decision-making, particularly around issues that require business lines to 

come to a single decision, such as how to standardize policies. 

Nevertheless, FAA officials acknowledged that having to collaborate to 

implement an agency-wide SMS has improved communication among the 

business lines. FAA will likely continue to face challenges standardizing 

its policies and processes as standardization of this scale is not 

something the agency has previously undertaken, and the need to 

negotiate solutions across FAA business lines could take time.

Airport officials’ concerns about sharing and protecting their safety data 

may reduce SMS effectiveness by limiting the ability of airports and FAA 

to analyze safety data and identify trends. Although FAA has some data 

protections in place, such as those established by the FAA Modernization 

and Reform Act of 2012, which protects data that airports and air carriers 

submit to FAA for SMS from federal Freedom of Information Act (FOIA) 

requests,38

 

37Pub. L. No. 112-95, §313, 126 Stat. 11, 67 (2012).

any data airports collect and any data air carriers share with 

airports could be subject to state-specific FOIA laws. Most certificated 

U.S. airports are either owned by a state, a subdivision of a state, or a 

local government body, and thus are subject to state laws, including state 

FOIA laws. This means that data airports collect and submit to FAA for 

SMS—such as information on hazards or other safety data—is protected 

from federal FOIA public disclosure requests, but, according to officials 

and experts, may be subject to public disclosure under state FOIA laws. 

Air carriers are not directly subject to state FOIA laws because they are 

privately owned. Nevertheless, officials and experts stated that these laws 

38Pub. L. No. 112-95, §310, 126 Stat. 11, 64 (2012).

Data Sharing and 

Protection
 

Page 29 GAO-12-898 Safety Management Systems

could affect air carriers because any data they choose to share with 

airports could then be subject to state FOIA laws. As a result, air carrier 

officials told us they may be less likely to share safety information with 

airports. Airport and airline officials’ primary concern is that the public 

disclosure of such information could result in negative publicity or expose 

them to legal liability in the event of an incident or accident. FAA officials 

said that data protection and legal liability are two of the major concerns 

throughout the aviation industry that could hinder the implementation of 

SMS. 

FAA officials told us that they intend to continue to promote and expand 

safety information sharing efforts, but that airports could find ways to 

structure their SMS implementation so that they realized safety benefits 

while limiting the public release of air carrier safety information. In FAA’s 

official response to comments on two Notices of Proposed Rulemaking, 

FAA stated that airport officials are best situated to understand how to 

comply with state laws. Nonetheless, we found consensus among NTSB 

and many aviation stakeholders that FAA should seek congressional 

action regarding the protection of airport data from state FOIA laws.

Data sharing can also be challenging within FAA. In 2011, we 

recommended that FAA improve information sharing among its programs 

because not doing so could limit the ability of FAA and others to analyze 

safety data and understand safety trends.39 The Department of 

Transportation agreed that it must continue to promote and expand safety 

information sharing efforts and safety practices in order to maximize the 

effectiveness of safety data mining40 to analyze trends and prioritize 

safety efforts to address hazards before they lead to incidents or 

accidents. However, our recommendation remains open. According to 

officials, ICAO has also formed the Safety Information Exchange Study 

Group to help enhance data protection and identify potential international 

solutions.

 

39GAO, Aviation Safety: Enhanced Oversight and Improved Availability of Risk-Based 

Data Could Further Improve Safety, GAO-12-24 (Washington, D.C: Oct. 5, 2011).

40Safety data mining involves the use of data based applications to look for hidden 

patterns in groups of data that can be used to predict future behavior or occurrences that

may lead to an incident or accident.
 

Page 30 GAO-12-898 Safety Management Systems

Long-standing issues with data quality and usefulness could negatively 

affect FAA’s understanding of aspects of the safety of the aviation 

industry and, consequently, affect SMS’s effectiveness. Obtaining 

relevant data and understanding how to analyze those data to identify 

potential hazards are major challenges that FAA will need to overcome. In 

recent GAO reports, we commented on FAA’s lack of data to effectively 

assess aviation trends for certain types of events and the safety 

performance of certain industry sectors.41 For instance, in April 2012, we 

reported that for such events as runway excursions (when an aircraft 

veers off or overruns a runway) and ramp accidents (incidents or injuries 

that occur off the runway), a shortage of FAA data exists for analysis.42

The Department of Transportation concurred with this and our 

recommendations, and stated that the agency has taken steps to improve 

to its data quality and usefulness. For example, the FAA SMS Committee 

directed a working group to determine what safety data the agency is 

going to collect and track and to recommend what kind of system will be 

needed. However, FAA has not yet fully implemented several of our 

recommendations aimed at improving its capability to use data for 

aviation safety oversight, or several data-related NTSB recommendations 

from recent years. For example, we recommended that FAA extend 

standard quality controls, as appropriate, to the databases that support 

aviation safety oversight to ensure that the data are as reliable and valid 

as possible. By not fully addressing these challenges and 

recommendations, FAA’s ability to comprehensively and accurately 

assess and manage hazards and risk will be compromised, reducing the 

ability of SMS to prevent incidents and accidents.

The aviation community has widely acknowledged that developing SMS 

performance measures is difficult, but without them, FAA will not be able 

to gauge the direct impact of SMS on aviation safety. Some stakeholders 

told us about ways in which SMS improved their organization’s 

operations, and these examples could provide insight into possible SMS 

performance measures. For instance, some airports and air carriers that 

participated in FAA’s SMS pilot projects reported that SMS 

 

41GAO-12-24 and GAO, Aviation Safety: FAA Is Taking Steps to Improve Data, but 

Challenges for Managing Safety Risks Remain, GAO-12-660T (Washington, D.C.: 

Apr. 25, 2012).

42GAO-12-660T. 

Data Quality and 

Usefulness

SMS Performance

Measures
 

Page 31 GAO-12-898 Safety Management Systems

implementation improved communication across their organizations, 

helped them identify organizational gaps—such as those in internal 

auditing and training—and decreased employees’ injuries, aircraft 

damages, and insurance costs. Officials from the Flight Safety 

Foundation43 recommended that the extent to which SMS informs 

management decision making, such as by redirecting resources or 

shifting priorities, may be one way to measure SMS effectiveness. An 

FAA official suggested that performance measures could be directed to 

specific components of SMS, for instance tracking the number of risks 

mitigated as a measure of safety risk management efficacy. We have 

previously reported that agencies need to set quantifiable outcome-based 

performance measures for significant agency activities, such as SMS, to 

demonstrate how they intend to achieve their program goals and measure 

the extent to which they have done so.44 Performance measures allow an 

agency to track its progress in achieving intended results, which can be 

particularly important in the implementation stage of a new program such 

as SMS. In our prior work we recommended that agencies develop 

methods to accurately evaluate and measure the progress of 

implementation, and develop contingency plans if the agency does not 

meet its milestones to complete tasks.45 FAA has established a working 

group to study the issue and participates on two international 

performance measures work groups: the Safety Management 

International Collaboration Group and the aforementioned Safety 

Information Exchange Study Group.

 

43The Flight Safety Foundation is an independent, nonprofit, international organization 

engaged in research, auditing, education, advocacy, and publishing to improve aviation 

safety. 

44See GAO, The Results Act: An Evaluator’s Guide to Assessing Agency Annual 

Performance Plans, GAO/GGD-10.1.20; (Washington, D.C.: April 1998); VA Health Care: 

VA Should Better Monitor Implementation and Impact of Capital Asset Alignment 

Decisions, GAO-07-408 (Washington, D.C.: Mar. 21, 2007); NextGen Air Transportation 

System: FAA’s Metrics Can Be Used to Report on Status of Individual Programs, But Not 

of Overall NextGen Implementation or Outcomes, GAO-10-629 (Washington, D.C. July 

27, 2010); Motor Carrier Safety: More Assessment and Transparency Could Enhance 

Benefits of New Oversight Program, GAO 11-858 (Washington, D.C.; Sept. 29, 2011). 

45GAO, FAA Airspace Redesign: An Analysis of the New York/New Jersey/Philadelphia 

Project, GAO-08-786 (Washington, D.C.: July 31, 2008).
 

Page 32 GAO-12-898 Safety Management Systems

FAA is making progress implementing SMS, both within the agency and 

for the aviation industry. However, SMS implementation represents a 

significant cultural and procedural shift in how the agency will conduct 

business internally and provide oversight to aviation stakeholders such as 

air carriers and airports, and by all estimates, this transformation will take 

many years to complete. Going forward, if FAA is to attain the full benefits 

of SMS, it will be important for the agency to remain committed to fully 

implementing SMS across its business lines. FAA has taken a number of 

steps that align with practices we identified as important to successful 

project planning and implementation, but has not addressed or has only 

partially addressed other key practices. These practices are important for 

large-scale transformative projects such as SMS, which require a 

dramatic shift in FAA’s approach to safety oversight and management. In 

the absence of these key practices, it may be difficult for FAA to prioritize 

projects or monitor SMS implementation and progress toward improving 

safety.

Aviation safety is a shared responsibility among FAA, air carriers, 

airports, and others in the aviation industry, and efforts to improve safety 

will require the agency to overcome several challenges. The magnitude of 

SMS’s potential impact on aviation oversight and the complexity of 

implementation are both a benefit and a drawback for FAA, as SMS 

implementation could help ensure the continued safety of the U.S. 

aviation system, but could also affect implementation time frames for 

other large initiatives as the agency works in a resource-limited 

environment. FAA officials believe that SMS implementation will require 

some skills that employees do not currently have; however, FAA has not 

conducted an agency-wide workforce assessment. With agency 

resources and capacity in great demand, it will be important for the 

agency to maximize the efficiency of SMS implementation, both through 

efficient use of its workforce and creation of policies and systems that 

standardize and streamline implementation. In addition, data protection 

concerns from airport officials and others could prevent aviation 

stakeholders from fully embracing SMS implementation, thus hindering its 

effectiveness. Without assurance of protection from state FOIA laws, 

some aviation stakeholder may choose to collect only the bare minimum 

of safety-related data or may choose to limit the extent to which collected 

information is shared among aviation stakeholders. The agency also 

lacks sufficient data to effectively assess aviation trends for some events 

as well as the safety performance of certain industry sectors. The ability 

of FAA to identify safety risks, develop mitigation strategies, and measure 

outcomes is hindered by limited access to complete and meaningful data.

Conclusions
 

Page 33 GAO-12-898 Safety Management Systems

To enhance the effectiveness of efforts to implement SMS and maximize 

the positive impact of SMS implementation on aviation safety, we 

recommend that the Secretary of Transportation direct the FAA 

Administrator to take the following five actions:

1. To better evaluate the effectiveness of the agency’s efforts to 

implement SMS, develop a system to assess whether SMS meets its 

goals and objectives by identifying and collecting related data on 

performance measures.

2. To align strategic goals with employee efforts, develop a system to 

evaluate employees’ performance as it relates to SMS.

3. To better manage implementation, develop a system to track and 

report on SMS implementation across business lines.

4. To better leverage existing resources and facilitate SMS 

implementation, conduct a workforce analysis to inventory existing 

employee skills and abilities and develop strategies for addressing 

any SMS-related gaps identified.

5. To maximize the positive impact of SMS implementation on aviation 

safety, consider strategies to address airports’ concerns that may 

negatively affect data collection and data sharing, including asking 

Congress to provide additional protections for SMS data collected by 

public entities.

We provided the Department of Transportation and NTSB with a draft of 

this report for review and comment. DOT and NTSB officials provided 

technical comments, which we incorporated as appropriate and DOT 

agreed to consider the recommendations. In addition, DOT officials stated 

there is a need for FAA to have a common hazard-tracking system. FAA 

has taken initial steps towards standardization by publishing FAA Order 

8040.4A, Safety Risk Management Policy, which identifies terms and 

definitions used for safety risk management. DOT also reinforced its 

dedication to the success of SMS and noted its continued efforts to 

improve its implementation plans with a measured, structured approach 

to implementation. 

Recommendations for 

Executive Action

Agency Comments
 

Page 34 GAO-12-898 Safety Management Systems

We are sending copies of this report to the appropriate congressional 

committees, DOT, NTSB, and interested parties, and others. In addition, 

the report will be available at no charge on the GAO Web site at 

http://www.gao.gov. 

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

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

for our Office of Congressional Relations and Public Affairs may be found 

on the last page of this report. Key contributors to this report are listed in 

appendix II.

Gerald L. Dillingham, Ph.D.

Director

Physical Infrastructure Issues
Appendix I: Objectives, Scope, and 

Methodology

Page 35 GAO-12-898 Safety Management Systems

Our objective was to assess the Federal Aviation Administration’s (FAA) 

implementation of Safety Management Systems (SMS) and provide 

information on potential implementation challenges. To do so, we 

addressed the following questions: 

(1) What is the status of FAA’s implementation of SMS? 

(2) To what extent have FAA’s SMS efforts been consistent with key 

practices for successful planning and implementation of a new 

program? 

(3) What challenges does FAA face in implementing SMS?

To perform our review, we focused primarily on FAA’s implementation of 

SMS for its business lines as well as its preliminary efforts to require and 

oversee SMS implementation by industry. We conducted background 

research to identify literature related to SMS in aviation, and any 

challenges that agencies might face when implementing SMS. We also 

attended parts of a safety risk management panel on runway status lights 

conducted by FAA’s Air Traffic Organization (ATO) at Seattle-Tacoma 

International Airport in March 2012 as a means of learning more about 

SMS and related processes. During the data collection and drafting 

phases of this report, FAA was in the midst of rulemaking efforts to 

require SMS of Part 121 air carriers and Part 139 airports, so we did not 

comment on any draft or proposed regulatory guidance.

To determine the status of FAA’s implementation of SMS, we reviewed 

FAA’s SMS orders and pilot project guidance, implementation plans, and 

Notices of Proposed Rulemaking for Part 121 air carriers and Part 139 

airports. We also reviewed international and FAA guidance on SMS 

issued by the International Civil Aviation Organization (ICAO) and the 

Joint Planning and Development Office (JPDO), respectively, and 

National Transportation Safety Board (NTSB) recommendations to FAA 

related to SMS. Finally, we interviewed FAA SMS program managers 

across FAA business lines and offices; industry experts we identified 

based on their knowledge and experience in industry, recommendations 

from aviation industry officials, and a search of SMS literature; and ICAO 

and NTSB officials.

To assess the extent to which FAA’s efforts have been consistent with 

key practices, we reviewed our reports and other literature on successful 

project planning and implementation, particularly for large-scale 

transformative projects, and condensed the resulting list to eliminate 

Appendix I: Objectives, Scope, and 

Methodology 
Appendix I: Objectives, Scope, and 

Methodology

Page 36 GAO-12-898 Safety Management Systems

duplication and overlap. To do this, we reviewed previous GAO reports 

that highlighted practices associated with successful planning and 

implementation of a new program.1

To identify challenges FAA faces in implementing SMS, we reviewed our 

prior work on long-standing FAA challenges, such as those related to 

training and data, and interviewed aviation industry experts and FAA 

officials mentioned above. We reviewed prior GAO work on performance 

measurement and workforce analysis, Department of Transportation 

Inspector General reports and NTSB recommendations related to SMS. 

To obtain industry views on challenges, we interviewed officials from 

selected airports and air carriers, industry associations representing 

airports, air carriers, and pilots, and individuals with SMS experience 

described above. We also reviewed and analyzed documents, including 

language in the FAA Modernization and Reform Act of 2012 related to 

data protection, and associated scholarly work. To supplement comments 

received from the individuals we interviewed, we also reviewed comments 

made by aviation stakeholders on the two Notices of Proposed 

Rulemaking related to SMS.

We removed or consolidated any 

duplicate items across the reports to create a single list of 10 criteria. We 

then identified FAA’s actions related to these practices by reviewing FAA 

guidance and agency documentation such as its SMS implementation 

plans, conducting interviews with FAA officials across its business lines, 

and using that information to assess the extent to which FAA had 

addressed each practice. We determined whether each key practice was 

addressed, partially addressed, or not addressed by using criteria 

developed for prior GAO reports. As such, we considered a practice

“addressed” if FAA had instituted the practice; “partially addressed” if FAA 

had shown some progress toward instituting, or started but not completed 

the practice; and “not addressed” if FAA had made minimal or no 

progress toward instituting the practice. The team made these coding 

decisions together, with two analysts making initial judgments and team 

management reviewing and confirming them.

 

1

For examples, see GAO, Results-Oriented Cultures: Implementation Steps to Assist 

Mergers and Organizational Transformations, GAO-03-669 (Washington, D.C.: July 2, 

2003) and GAO, Managing for Results: GPRA Modernization Act Provides Important 

Opportunities to Address Government Challenges, GAO-11-617T (Washington, D.C.: 

May 10, 2011). 
Appendix I: Objectives, Scope, and 

Methodology

Page 37 GAO-12-898 Safety Management Systems

To obtain industry views on both SMS implementation practices and 

associated challenges, we interviewed officials from selected airports and 

air carriers, which we selected for diversity in size, location, participation 

in FAA SMS pilot projects, and submission of comments on FAA’s two 

Notices of Proposed Rulemaking related to SMS. (See table 1 for a list of 

selected airports.)

Table 1: Airport Interviews

Airport State 

Concord Regional North Carolina

Dallas/Fort Worth International Texas

King County International Washington

Los Angeles International California

Manchester-Boston Regional New Hampshire

Pittsburgh International Pennsylvania

Sacramento International California

Seattle-Tacoma International Washington

Sloulin Field International North Dakota

South Bend Regional Indiana

Source: GAO.

We also interviewed officials from six air carriers: Delta,

2 GoJet, United,3

Pinnacle, Southwest, and US Airways. Finally, we interviewed officials 

with SMS knowledge and expertise, including experts from the Flight 

Safety Foundation, Embry-Riddle Aeronautical University, John A. Volpe 

National Transportation Systems Center, and MITRE Corporation.

 

2

Northwest Airlines merged with Delta Air Lines in 2008.

3

Continental Airlines merged with United Airlines in 2010.
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 38 GAO-12-898 Safety Management Systems

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

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

Director); Elizabeth Curda; Leia Dickerson; Sarah Farkas; David Hooper; 

Delwen Jones; Brooke Leary; Josh Ormond; Larry Thomas; and Elizabeth 

Wood made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments

(540230)
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