Testimony 

Before the Subcommittee on Aviation, 

Committee on Commerce, Science, and 

Transportation, U.S. Senate 

United States Government Accountability Office

GAO 

Not to Be Released 

Before10:00 a.m. EST 

Thursday, November 17, 2005 AVIATION SAFETY

FAA’s Safety Oversight 

System Is Effective but 

Could Benefit from Better 

Evaluation of Its Programs’ 

Performance 

Statement for the Record by 

Gerald L. Dillingham, Ph.D., Director 

Physical Infrastructure Issues 

GAO-06-266T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

www.gao.gov/cgi-bin/getrpt?GAO-06-266T.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Dr. Gerald 

Dillingham at (202) 512-2834 or 

dillinghamg@gao.gov. 

Highlights of GAO-06-266T, a testimony to 

the Subcommittee on Aviation, Committee 

on Commerce, Science, and 

Transportation, U.S. Senate 

Thursday, November 17, 2005

AVIATION SAFETY

FAA's Safety Oversight System Is 

Effective but Could Benefit from Better 

Evaluation of Its Programs' Performance 

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

identification and mitigation through a risk-based system safety approach, 

leveraging of resources through designee and partnership relationships, and 

enforcement of safety regulations, but the benefits of these programs are not 

being fully realized. For example, FAA’s system safety approach includes 

the addition of a program that emphasizes risk identification to its traditional 

inspection program for overseeing some airlines, which is not based on risk. 

However, it is likely that the benefits of this approach could be enhanced if 

the inspection workload was not as heavily oriented to the traditional 

inspection program’s non-risk based activities. FAA leverages its resources 

through its designee programs, in which designated individuals and 

organizations perform about 90 percent of certification-related activities, and 

through its industry partnership programs, which are designed to assist the 

agency in receiving safety information. An outgrowth of FAA’s inspection 

process is its enforcement program, which is intended to ensure industry 

compliance with safety regulations. However, GAO has expressed concerns 

that this program may not be as effective as it could be in deterring 

violations. 

FAA has made training an integral part of its safety oversight system, but 

several actions could improve the results of its training efforts, including 

ensuring that inspectors are well-trained in FAA’s system safety approach 

and have sufficient knowledge of increasingly complex aircraft and systems 

to effectively identify safety risks. FAA has established mandatory training 

requirements for its workforce and designees. We have reported that FAA 

has generally followed effective management practices for planning, 

developing, delivering, and assessing the impact of its technical training for 

safety inspectors. 

GAO has found inadequate evaluative processes and limitations with data for 

FAA’s inspection programs, designee programs, industry partnership 

programs, and enforcement program. For example, FAA lacked 

requirements or criteria for evaluating its designee programs. In another 

example, FAA’s nationwide enforcement database is not as useful as it could 

be because of missing or incomplete historical information about 

enforcement cases. 

FAA’s Safety Oversight System Includes Inspections, Training, and Other Activities 

The U.S. commercial aviation 

industry has an extraordinary 

safety record. However, when 

passenger airlines have accidents 

or serious incidents, regardless of 

their rarity, the consequences can 

be tragic. The Federal Aviation 

Administration (FAA) works to 

maintain a high level of safety 

through an effective safety 

oversight system. Keys to this 

system are to: (1) establish 

programs that focus resources on 

areas of highest safety risk and on 

mitigating risks; (2) provide 

training and communication to 

ensure that inspectors can 

consistently carry out the agency’s 

oversight programs; and (3) have 

processes and data to continuously 

monitor, evaluate, and improve the 

numerous oversight programs that 

make up the safety oversight 

system. This statement focuses on 

these three key areas and is based 

on recent GAO reports on FAA’s 

inspection oversight programs, 

industry partnership programs, 

enforcement program, and training 

program. 

What GAO Recommends

In order to help FAA fully realize 

the benefits of its safety oversight 

system, GAO has made a number of 

recommendations to address 

weaknesses identified in previous 

reviews, such as improving 

program evaluation and data. 

These recommendations have not 

been fully implemented, although 

in some cases FAA has taken steps 

towards addressing them. 
Page 1 GAO-06-266T 

Mr. Chairman and Members of the Subcommittee: 

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

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

record. This record is a result of the efforts of the Federal Aviation 

Administration (FAA), airlines, manufacturers, and others in the aviation 

industry to maintain one of the safest aviation systems in the world. 

However, when passenger airlines have accidents or serious incidents, 

regardless of their rarity, the consequences can be tragic, as a single 

accident can result in hundreds of deaths. In order to maintain a high level 

of safety, it is critical to have a safety oversight system that is 

comprehensive, efficient, and effective and can provide an early warning 

of hazards that can lead to accidents. It is equally important to have a 

skilled, well-trained workforce to implement and monitor this safety 

oversight system. FAA’s workforce of about 3,200 inspectors stationed at 

more than 100 field offices throughout the world is responsible for 

carrying out the agency’s processes to certify, inspect, and enforce safety 

regulations for all aspects of the aviation industry, including the aircraft 

and its component parts, over 100 commercial airlines, about 5,000 aircraft 

repair stations, and hundreds of thousands of pilots and mechanics. FAA 

augments its inspector workforce with nearly 13,600 designated 

organizations and individuals (designees) that conduct the more routine 

aspects of industry oversight, such as administering tests to pilots and 

mechanics as part of their certification requirements, and augments the 

safety information that it obtains from inspections with industry 

partnership programs. Keys to making this safety oversight system work 

are to: (1) establish programs that focus resources on areas of highest 

safety risk and on mitigating risks; (2) provide training and other 

communication to ensure that inspectors maintain the skills and 

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

(3) have processes and data to continuously monitor, evaluate, and 

improve the numerous oversight programs that make up the safety 

oversight system. This statement focuses on these three key areas of 

FAA’s “early warning system” and is based on our recent reports on FAA’s 

inspection oversight programs, industry partnership programs, 

enforcement program, and training program. We will also discuss our 

recommendations that FAA has not fully addressed in these areas. 

In summary: 

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

risk identification and mitigation through a system safety approach, the 

leveraging of resources, and enforcement of safety regulations, but the 
Page 2 GAO-06-266T 

benefits of these programs are not being fully realized. FAA’s system 

safety approach has many strengths, including the addition of a program 

that emphasizes risk identification to its traditional inspection program for 

overseeing non-legacy airlines,1 which is not based on risk. However, it is 

likely that the benefits of this approach could be enhanced if the 

inspection workload for non-legacy airlines was not still heavily oriented 

to the traditional inspection program’s non-risk based activities. FAA 

leverages resources through its designee programs, in which designees 

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

FAA to better concentrate its limited staff resources on the most safetycritical functions. However, concerns about the consistency and adequacy 

of designee oversight that FAA field offices provide have been raised by 

experts and other individuals we interviewed. FAA also leverages its 

resources through industry partnership programs, which are designed to 

assist the agency in receiving safety information. For example, FAA 

encourages voluntary reports of safety violations by responding to them 

by issuing a warning letter rather than a fine or other legal sanction. FAA’s 

enforcement program, which is an outgrowth of its inspection process, is 

intended to ensure industry compliance with safety regulations and is 

another important element of its safety oversight system. FAA’s policy for 

assessing legal sanctions against entities or individuals that do not comply 

with aviation safety regulations is intended to deter future violations. 

However, we found that recommendations for sanctions are sometimes 

reduced on the basis of factors that are not associated with the merits of 

the case, and the economic literature on deterrence suggests that the goal 

of preventing future violations is weakened when the penalties for 

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

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

several actions could improve the results of its training efforts. FAA’s use 

of a risk-based system safety approach to inspections requires inspectors 

to apply data analysis and auditing skills to identify and control potential 

risks. Therefore, it is important that inspectors are well-trained in this 

approach and have sufficient knowledge of increasingly complex aircraft 

and systems to effectively identify safety risks. FAA has established 

mandatory training requirements for its workforce as well as designees. 

 1

We refer to all passenger airlines that are not in FAA’s Air Transportation Oversight 

System (ATOS) as non-legacy airlines. The seven “legacy” airlines and eight other airlines 

are overseen through ATOS. The air carriers in the ATOS program are Alaska; American; 

Continental; Delta; Northwest; United; American Eagle; Champion; ExpressJet; SkyWest; 

Southwest; Trans States; FedEx; United Parcel Service; and US Airways, which recently 

merged with America West. 
Page 3 GAO-06-266T 

We have reported that FAA has generally followed effective management 

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

its technical training for safety inspectors, although some practices have 

yet to be fully implemented. For example, in developing its training 

curriculum for inspectors, FAA followed effective management practices, 

such as developing courses that support changes in inspection procedures 

resulting from regulatory changes or agency initiatives. On the other hand, 

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

an overall curriculum for each type of inspector, such as inspectors of 

operations or cabin safety, because the agency has not systematically 

identified the technical skills and competencies each type of inspector 

needs to effectively perform inspections. FAA has recognized the need for 

improvements to its training program in this and other areas. 

• It is important for FAA to have effective evaluative processes and accurate 

nationwide data for its numerous safety oversight programs so that 

program managers and other officials have assurance that the safety 

programs are having their intended effect. Such processes and data are 

especially important because FAA’s workforce is so dispersed throughout 

the world—with thousands of staff working out of more than 100 offices 

worldwide—and because FAA’s use of a system safety approach 

represents a cultural shift from its traditional inspection program. 

Evaluation is important for understanding if the cultural shift has 

effectively occurred. Our most recent work has shown the lack of 

evaluative processes and limitations with data for FAA’s inspection 

program for non-legacy airlines, designee programs, industry partnership 

programs, and enforcement program. For example, we found that FAA 

lacked requirements or criteria for evaluating its designee programs. In 

another example, FAA’s enforcement policy calls for the assessment of 

sanctions that would potentially deter future violations. However, FAA 

lacks an evaluative process, so it is not known whether the agency’s 

enforcement practices, such as at times reducing sanctions, may weaken 

any deterrent effect that would be expected from such sanctions. 

Furthermore, FAA’s ability to evaluate its programs is hindered by the lack 

of useful nationwide data. For example, FAA’s nationwide enforcement 

database is not as useful as it could be because of missing or incomplete 

historical information about enforcement cases. 

• In order to help FAA fully realize the benefits of its safety oversight 

system, we have made a number of recommendations to address the 

weaknesses that we identified in our reviews. These recommendations 

have not been fully implemented, although in some cases FAA has taken 

steps towards addressing them. Evaluative processes and relevant data are 

particularly important as FAA works to change its culture by incorporating 
Page 4 GAO-06-266T 

a system safety approach into its oversight, and we have recommended 

that FAA develop continuous evaluative processes for its oversight of nonlegacy airlines, its designee programs, and its enforcement program, and 

systematically assess inspectors’ technical training needs. In addition, 

FAA’s nationwide databases are in need of improvements in their 

comprehensiveness and ease of use. We have recommended that FAA 

improve the consistency and completeness of its designee and 

enforcement databases. Continuous improvements in these areas are 

critical to FAA’s ability to have a robust “early warning system” in order to 

maintain one of the safest aviation systems in the world. 

FAA’s safety oversight system is made up of a number of programs for 

airlines and other entities. Safety oversight programs for airlines provide 

for their initial certification, periodic surveillance, and inspection. Since 

1985, FAA has used National Work Program Guidelines (NPG), its 

traditional inspection program for airlines, as a primary means of ensuring 

that airlines comply with safety regulations. In NPG, an FAA committee of 

program managers identifies an annual minimum set of required 

inspections that are to be undertaken to ensure that airlines are in 

compliance with their operating certificates. In 1998, the agency 

implemented the Air Transportation Oversight System (ATOS), which 

currently oversees the nation’s largest 15 commercial airlines and cargo 

carriers, with the goal of eventually including all commercial passenger 

and cargo airlines in it. ATOS emphasizes a system safety approach that 

extends beyond periodically checking airlines for compliance with 

regulations to the use of technical and managerial skills to identify, 

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

inspectors develop surveillance plans for each airline, based on data 

analysis and assessment of risks, and adjust the plans periodically based 

on inspection results. However, the agency has been delayed in placing a 

significant number of other passenger airlines in ATOS, resulting in 99 

passenger airlines, which we refer to as non-legacy airlines, continuing to 

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

oriented. In 2002, FAA added the Surveillance and Evaluation Program 

(SEP) to the NPG inspection program to incorporate principles of ATOS 

into its oversight of non-legacy passenger airlines. The two programs are 

used together to establish the number of annual inspections for non-legacy 

airlines. (Appendix 1 describes each inspection program.) Figure 1 

illustrates some typical activities covered during inspections. 

Background 
Page 5 GAO-06-266T 

Figure 1: FAA’s Safety Inspections Cover a Wide Range of Activities 

Note: As a workforce, FAA inspectors conduct a wide variety of inspections, including ensuring that 

pilots are qualified to operate aircraft, inspecting aircraft for safety, and overseeing FAA-certified 

mechanics. 

FAA’s safety oversight programs for other aspects of the aviation 

industry—including manufacturers of aircraft and aircraft parts, repair 

stations, flight schools, aviation maintenance technician schools, pilots, 

Source: FAA.
Page 6 GAO-06-266T 

and mechanics—involve certification, surveillance, and inspection by 

FAA’s safety inspectors, engineers, flight surgeons, and designated 

representatives. FAA authorizes about 13,400 private individuals and about 

180 organizations (called “designees”) to act as its representatives to 

conduct many safety certification activities, such as administering flight 

tests to pilots, inspecting repair work by maintenance facilities, 

conducting medical examinations of pilots, and approving designs for 

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

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

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

Office of Aviation Safety (see fig. 2). 
Page 7 GAO-06-266T 

Figure 2: FAA Offices That Manage the Different Designee Programs and Numbers of Designees (as of May 2004) 

Since 1990, FAA has emphasized gaining compliance from the aviation 

industry through cooperative means by establishing industry partnership 

programs with the aviation community that allow participants, such as 

airlines and pilots, to self-report violations of safety regulations and help 

identify safety deficiencies, and potentially mitigate or avoid fines or other 

legal action. For example, the Voluntary Disclosure Program encourages 

the self-reporting of manufacturing problems and safety incidents by 
Page 8 GAO-06-266T 

participants that can include air carriers and repair stations. Appendix II 

describes the industry partnership programs. 

When violations of statutory and regulatory requirements are identified 

through inspections, through the partnership programs in certain cases, or 

through other methods, FAA has a variety of enforcement tools that it may 

use to respond to them, including administrative actions (such as issuing a 

warning notice or a letter of correction that includes the corrective actions 

the violator will take) and legal sanctions (such as levying a fine or 

suspending or revoking a pilot or other FAA-issued certificate). 

In recent reports, we found that FAA’s safety oversight system has 

programs that focus on risk identification and mitigation through a system 

safety approach, the leveraging of resources, and enforcement of safety 

regulations, but that the benefits of these programs are not being fully 

realized. In our recent report on FAA’s oversight of non-legacy airlines, we 

found that the focus on risk identification through the addition of SEP has 

many strengths and allows for enhancing the efficiency of FAA’s oversight 

activities.2

 Rather than relying on NPG’s customary method of conducting 

a set number of inspections of an airline’s operations, SEP emphasizes a 

system safety approach of using risk analysis techniques. SEP allows for 

the efficient use of inspection staff and resources by prioritizing workload 

based on areas of highest risk, and it includes a requirement that 

inspectors verify that corrective actions have occurred. For example, FAA 

has developed risk assessment worksheets for SEP that are aligned with 

key airline systems that guide inspectors through identifying and 

prioritizing risks. The worksheets guide inspectors to organize the results 

of their previous inspections and surveillance into a number of areas such 

as flight operations and personnel training in order to identify specific 

risks in each area and target the office’s resources to mitigating those 

risks. The development of a system safety approach addresses a longstanding concern by us that FAA did not have a methodology for assessing 

airline safety risks so that it could target limited inspection resources to 

high-risk conditions.3

 Another strength of SEP, consistent with findings in 

 2

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

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

3

GAO, Aviation Safety: Weaknesses in Inspection and Enforcement Limit FAA in 

Identifying and Responding to Risks, GAO/RCED-98-6 (Washington, D.C.: Feb. 27, 1998); 

GAO, Aviation Safety: FAA Needs to More Aggressively Manage Its Inspection Program, 

GAO/T-RCED-92-25 (Washington, D.C.: Feb. 6, 1992). 

FAA’s Safety 

Oversight System 

Focuses on Risk 

Identification and 

Mitigation Through 

System Safety, 

Leveraging of 

Resources, and 

Enforcement of 

Safety Regulations, 

but Benefits Are Not 

Being Fully Realized 
Page 9 GAO-06-266T 

our past reports, is that SEP relies on teams of inspectors, which are 

generally more effective than individual inspectors in their ability to 

collectively identify concerns.4

However, the benefits of FAA’s system safety approach for the inspection 

of non-legacy airlines could be enhanced by a more complete 

implementation of SEP and addressing other challenges. The inspection 

workload for non-legacy airlines is still heavily oriented to the NPG’s nonrisk based activities. For example, as shown in table 1, from fiscal years 

2002 through 2004, 77 percent of inspection activities required for the top 

25 non-legacy airlines in terms of the number of enplanements were 

identified through NPG, and the remaining percentage of inspection 

activities were identified based on risk through SEP. Although inspectors 

can replace NPG-identified activities with SEP-identified activities that 

they deem constitute a greater safety risk, we found that FAA inspectors 

interpret agency emphasis on NPG as discouraging this practice. In order 

to ensure that all inspectors who oversee non-legacy airlines have a 

complete and timely understanding of the agency’s policies relating to the 

inspection process, we recommended in September 2005 that FAA 

improve communication with and training of inspectors in this area. 

Table 1: SEP-and NPG-Initiated Required Inspections for the Top 25 Non-legacy 

Airlines, Fiscal Years 2002-2004 

Type of inspection 2002 2003 2004 Total

SEP-initiated 1,261 1,567 927 3,755 (23%)

NPG-initiated 5,470 3,623 3,338 12,431 (77%)

Total 6,731 5,190 4,265 16,186 (100%)

Source: GAO analysis of FAA information. 

Another way that FAA attempts to enhance the efficiency of its oversight 

activities is through its designee programs. We reported that FAA 

maximizes its resources by allowing designees to perform about 90 

percent of certification-related activities, thus allowing FAA to better 

concentrate its limited staff resources on the most safety-critical 

functions.5

 For example, while designees conduct routine certification 

functions, such as approvals of aircraft technologies that the agency and 

 4

GAO/RCED-98-6; GAO/T-RCED-92-25. 

5

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

Programs, GAO-05-40 (Washington, D.C.: Oct. 8, 2004). 
Page 10 GAO-06-266T 

designees have had previous experience with, FAA focuses on new and 

complex aircraft designs or design changes. In addition, the use of 

designees expands FAA’s access to technical expertise within the aviation 

community. For the aviation industry, the designee programs enable 

individuals and organizations to obtain required FAA certifications—such 

as approvals of the design, production, and airworthiness of aircraft—in a 

timely manner, thus reducing delays and costs to the industry that might 

result from scheduling direct reviews by FAA staff. For example, officials 

from an aircraft manufacturer told us that the use of designees has added 

significantly to the company’s ability to enhance and improve daily 

operations by decreasing certification delivery time and increasing the 

flexibility and utilization of company resources. In addition, designees are 

convenient to the aviation industry due to their wide dispersal throughout 

the United States. 

However, concerns about the consistency and adequacy of designee 

oversight that FAA field offices provide have been raised by experts and 

other individuals we interviewed. For example, designees and industry 

officials that we spoke with indicated that FAA’s level of oversight and 

interpretation of rules differ among regions and among offices within a 

region, which limits FAA’s assurance that designees’ work is performed 

uniformly in accordance with FAA’s standards and policy. Experts also 

ranked this issue as a top weakness.6

 Table 2 shows the top five 

weaknesses identified by our experts. Experts also made a number of 

suggestions to strengthen the designee program, including clearly defining 

and following agency criteria for selecting designees and increasing 

penalties for designees found to violate standards or who do not exercise 

proper judgment. To improve management control of the designee 

programs, and thus increase assurance that designees meet FAA’s 

performance standards, we recommended that FAA develop mechanisms 

to improve the compliance of FAA program and field offices with existing 

policies and incorporate, as appropriate, suggestions from our expert 

panel. In response to our recommendations, FAA is planning, among other 

 6

We identified 62 aviation experts with knowledge and expertise in FAA’s designee 

programs, who participated on a Web-based panel that provided the group’s views on the 

strengths and weaknesses of the designee programs and ways to improve the programs. 

The experts included designees, FAA inspectors and engineers, independent experts and 

university academics, and private sector and aviation industry associations. We obtained 

the experts’ views by employing an iterative and controlled feedback process for obtaining 

individual views and then allowing each participant to respond to the entire panel’s 

comments. 
Page 11 GAO-06-266T 

things, to form a team to identify and share best practices for overseeing 

designee programs. 

Table 2: Experts’ Ranking of Top 5 Oversight Weaknesses 

Ranking Weakness 

1 FAA offices level of oversight and interpretation of rules are inconsistent. 

2 Inactive, unqualified, or poor performing designees are not identified and 

removed expeditiously. 

3 It is difficult to terminate poor performing designees. 

4 Inadequate surveillance and oversight of designees. 

5 FAA has not made oversight of designees a high enough priority. 

Source: GAO analysis of expert panel information. 

Note: Rankings based on responses from 62 experts and the frequency of responses indicating a 

“great” or “very great” weakness. 

FAA also leverages its resources through its industry partnership 

programs. These partnership programs are designed to assist the agency in 

receiving safety information, including reports of safety violations. 

According to FAA officials, the Aviation Safety Action Program, Aviation 

Safety Reporting Program, and Voluntary Disclosure Reporting Program 

augment FAA’s enforcement activities and allow FAA to be aware of many 

more safety incidents than are discovered during inspections and 

surveillance. In addition, the Flight Operational Quality Assurance 

Program provides safety information in the form of recorded flight data 

from participating airlines. FAA has established some management 

controls over its partnership programs, such as procedures to track 

actions taken to correct safety incidents reported under the programs, but 

the agency lacks management controls to measure and evaluate the 

performance of these programs, an issue that we will discuss later in the 

testimony. 

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

compliance with safety regulations, is another important element of its 

safety oversight system. FAA’s policy for assessing legal sanctions against 

entities or individuals that do not comply with aviation safety regulations 

is intended to deter future violations. FAA has established some 

management controls over its enforcement efforts, with procedures that 

provide guidance on identifying regulated entities and individuals that are 

subject to inspections or surveillance actions, determining workload 

priorities on the basis of the timing and type of inspection to be 

performed, detecting violations of safety regulations, tracking the actions 
Page 12 GAO-06-266T 

that are taken by the entities and individuals to correct the violations and 

achieve compliance with regulations, and imposing punitive sanctions or 

remedial conditions on the violators. These procedures provide FAA 

inspectors, managers, and attorneys with a process to handle violations of 

safety regulations that are found during routine inspections. 

However, we found that the effect of FAA’s legal sanctions on deterrence 

is unclear, and that recommendations for sanctions are sometimes 

changed on the basis of factors that are not associated with the merits of 

the case. We found that from fiscal years 1993 through 2003, attorneys in 

FAA’s Office of the Chief Counsel authorized a 52 percent reduction in the 

civil monetary penalties assessed from a total of $334 million to $162 

million. FAA officials told us that the agency sometimes reduces sanctions 

in order to prioritize attorneys’ caseloads by closing the cases more 

quickly through negotiating a lower fine. Economic literature on 

deterrence suggests that although negative sanctions (such as fines and 

certificate suspensions) can deter violations, if the violator expects 

sanctions to be reduced, he or she may have less incentive to comply with 

regulations. In effect, the goal of preventing future violations is weakened 

when the penalties for present violations are lowered for reasons not 

related to the merits of the case. In addition, FAA lacks management 

controls to measure and evaluate its enforcement process, which we 

discuss later in this testimony. 

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

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

assess, and control potential hazards and risks. Therefore, it is important 

that inspectors are well-trained in this approach and have sufficient 

knowledge of increasingly complex aircraft, aircraft parts, and systems to 

effectively identify safety risks. It is also important that FAA’s large cadre 

of designees is well-trained in federal aviation regulations and FAA 

policies. FAA has made training an integral part of its safety inspection 

system and has established mandatory training requirements for its 

workforce as well as designees. FAA provides inspectors with extensive 

training in federal aviation regulations; inspection and investigative 

techniques; and technical skills, such as flight training for operations 

inspectors. The agency provides its designees with an initial indoctrination 

that covers federal regulations and agency policies, and refresher training 

every 2 to 3 years. 

We have reported that FAA has generally followed effective management 

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

FAA Has Made 

Training an Integral 

Part of Its Safety 

Oversight System but 

Several Actions Could 

Improve Results 
Page 13 GAO-06-266T 

its technical training7 for safety inspectors, although some practices have 

yet to be fully implemented.8

 In its planning activities for training, FAA has 

linked technical training efforts to its goal of safer air travel and has 

identified technical proficiencies needed to improve safety inspectors’ 

performance in meeting this goal. For example, FAA’s Offices of Flight 

Standards and Aircraft Certification have identified gaps in several of the 

competencies required to conduct system safety inspections, including 

risk assessment, data analysis, systems thinking, and designee oversight. 

According to FAA, it is working to correct these gaps. We have also 

identified gaps in the training provided to inspectors in the Office of Flight 

Standards who oversee non-legacy airlines, and have recommended that 

FAA improve inspectors’ training in areas such as system safety and risk 

management to ensure that these inspectors have a complete and timely 

understanding of FAA’s inspection policies. We have identified similar 

competency gaps related to designee oversight. For example, FAA does 

not require refresher training concerning designee oversight, which 

increases the risk that staff do not retain the information, skills, and 

competencies required to perform their oversight responsibilities. We 

recommended that FAA provide additional training for staff who directly 

oversee designees.9

 We did not identify any specific gaps in the 

competencies of designees.10 In prioritizing funding for course 

development activities, FAA does not explicitly consider which projects 

are most critical. Figure 3 describes the extent to which FAA follows 

effective management practices in planning training. 

 7

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

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

skills, data analysis, and training in software packages. 

8

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

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

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

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

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

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

9

GAO-05-40. 

10However, many experts on our panel indicated it was of high or highest importance to 

ensure standard training of designees within specific specialties to improve the consistency 

of their work, and to increase the number of subject-matter workshops for designees. 
Page 14 GAO-06-266T 

Figure 3: Extent that FAA Follows Effective Management Practices in Planning 

Technical Training 

In developing its training curriculum for inspectors, FAA also for the most 

part follows effective management practices, such as developing courses 

that support changes in inspection procedures resulting from regulatory 

changes or agency initiatives. On the other hand, FAA develops technical 

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

each inspector specialty—such as air carrier operations, maintenance, and 

cabin safety—because the agency has not systematically identified the 

technical skills and competencies each type of inspector needs to 

effectively perform inspections. Figure 4 describes the extent to which 

FAA follows effective management practices in developing training. 
Page 15 GAO-06-266T 

Figure 4: Extent that FAA Follows Effective Management Practices in Developing 

Technical Training 

a

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

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

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

organizational needs. 

In delivering training, FAA has also generally followed effective 

management practices. (See fig. 5.) For example, FAA has established 

clear accountability for ensuring that inspectors have access to technical 

training, developed a way for inspectors to choose courses that meet job 

needs and further professional development, and offers a wide array of 

technical and other courses. However, both FAA and its inspectors 

recognize the need for more timely selection of inspectors for technical 

training. In addition, FAA acknowledges the need to increase 

communication between inspectors and management with respect to the 

training program, especially to ensure that inspectors have bought into the 

system safety approach to inspections. 
Page 16 GAO-06-266T 

Figure 5: Extent that FAA Follows Effective Management Practices in Delivering 

Technical Training 

FAA offers numerous technical courses from which inspectors can select 

to meet job needs. However, from our survey of FAA’s inspectors, we 

estimate that only about half think that they have the technical knowledge 

needed for their jobs.11 FAA officials told us that inspectors’ negative views 

stem from their wanting to acquire proficiencies that are not as crucial in a 

system safety environment. We also found a disparity between inspectors 

and FAA concerning the receipt of requested training. We estimated that 

28 percent of inspectors believe that they get the technical training that 

they request. However, FAA’s records show that FAA approves about 90 

percent of these requests, and inspectors are making good progress in 

receiving training. Over half of the inspectors have completed at least 75 

percent of technical training that FAA considers essential. FAA officials 

told us that inspectors’ negative views on their technical knowledge and 

the training they have received stem from their not accepting FAA’s move 

 11Because of the statistical survey techniques we employed in surveying FAA’s inspectors, 

we are 95 percent confident that the results we present are within 4.6 percentage points of 

the results that we would have obtained if we had surveyed all 3,000 inspectors. That is, we 

are 95 percent confident that had we surveyed all inspectors, between 48 and 57 percent of 

them would have told us that, to a great or very great extent, they have the technical 

knowledge to do their jobs. All percentage estimates from the survey have a margin of 

error of plus or minus 4.6 percentage points or less, unless otherwise noted. 
Page 17 GAO-06-266T 

to a system safety approach. That is, the inspectors are concerned about 

acquiring individual technical proficiency that is not as crucial in a system 

safety environment. Given that it has not completed assessing whether 

training for each inspector specialty meets performance requirements, 

FAA is not in a position to make definitive conclusions concerning the 

adequacy of inspector technical training. 

FAA also generally followed effective management practices in evaluating 

training. The agency requires that each training course receive a 

systematic evaluation every 3 years to determine if the course is up to date 

and relevant to inspectors’ jobs, although training officials noted that 

many courses have yet to undergo such an evaluation. However, FAA 

collects limited information on the effectiveness of training, and its 

evaluations have not measured the impact of training on FAA’s mission 

goals, such as reducing accidents. Training experts acknowledge that 

isolating performance improvements resulting from training programs is 

difficult for any organization. (See fig. 6.) 

Figure 6: Extent that FAA Follows Effective Management Practices in Evaluating Its 

Training Program 
Page 18 GAO-06-266T 

While FAA follows many effective management practices in its training 

program, the agency also recognizes the need for improvements, including 

(1) systematically assessing inspectors’ needs for technical and other 

training, (2) better timing of technical training so that inspectors receive it 

when it is needed to perform their jobs, and (3) better linking the training 

provided to achieving agency goals of improving aviation safety. FAA has 

begun to act in these areas, and we believe that if effectively implemented, 

the actions should improve the delivery of training and ultimately improve 

aviation safety. Therefore, it is important for FAA to follow through with 

its efforts. As a result, we recommended in September 2005, among other 

things, that in order to ensure that inspector technical training needs are 

identified and met in a timely manner, FAA systematically assess 

inspectors’ technical training needs, better align the timeliness of training 

to when inspectors need the training to do their jobs, and gain inspectors’ 

acceptance for changes made or planned to their training. 

It is important that both FAA’s inspection workforce and FAA-certified 

aviation mechanics are knowledgeable about increasingly complex 

aircraft, aircraft parts, and systems. While we did not attempt to assess the 

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

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

amount of technical training courses because inspectors are hired with a 

high degree of technical knowledge of aircraft and aircraft systems. They 

further indicated that inspectors can sufficiently keep abreast of many of 

the changes in aviation technology through FAA and industry training 

courses and on-the-job training. However, in its certification program for 

aviation mechanics, we found that FAA standards for minimum 

requirements for aviation courses at FAA-approved aviation maintenance 

technician schools and its requirements for FAA-issued mechanics 

certificates do not keep abreast with the latest technologies. In 2003, we 

reported that those standards had not been updated in more than 50 

years.12 We recommended that FAA review the curriculum and 

certification requirements and update both. FAA plans to make changes in 

the curriculum for FAA approved aviation maintenance technicians that 

reflect up-to-date aviation technologies and finalize and distribute a 

revised Advisory Circular in March 2006 that describes the curriculum 

changes. FAA then plans to allow the aviation industry time to implement 

 12GAO, Aviation Safety: FAA Needs to Update the Curriculum and Certification 

Requirements for Aviation Mechanics, GAO-03-317 (Washington, D.C.: Mar. 6, 2003). 
Page 19 GAO-06-266T 

the recommended curriculum changes before changing the requirements 

for FAA-issued mechanics certificates. 

It is important for FAA to have effective evaluative processes and accurate 

nationwide data on its numerous safety oversight programs so that 

program managers and other officials have assurance that the safety 

programs are having their intended effect. Such processes and data are 

especially important because FAA’s workforce is so dispersed 

worldwide—with thousands of staff working out of more than 100 local 

offices—and because FAA’s use of a risk-based system safety approach 

represents a cultural shift from its traditional inspection program. 

Evaluation is important to understanding if the cultural shift has 

effectively occurred. Our most recent work has shown the lack of such 

processes and limitations with data for FAA’s inspection programs for 

non-legacy airlines, designee programs, industry partnership programs, 

and enforcement program. In response to recommendations that we have 

made regarding these programs, some improvements are being made. On 

the positive side, as we mentioned earlier, our most recent work found 

that FAA generally follows effective management practices in evaluating 

individual technical training courses. 

FAA has not evaluated its inspection oversight programs for non-legacy 

airlines—which include SEP and NPG—to determine how the programs 

contribute to the agency’s mission and overall safety goals, and its 

nationwide inspection database lacks important information that could 

help it perform such evaluations—such as whether risks identified through 

SEP have been mitigated. In addition, the agency does not have a process 

to examine the nationwide implications of or trends in the risks that 

inspectors have identified through their risk assessments—information it 

would need to proactively determine risk trends at the national level on a 

continuous basis. FAA’s evaluation office instead conducts analyses of the 

types of inspections generated under SEP by airline and FAA region, 

according to FAA. We recommended that FAA develop a continuous 

evaluative process for activities under SEP and link SEP to the 

performance-related goals and measures developed by the agency, track 

performance toward these goals, and determine appropriate program 

changes. FAA is considering our recommendation, but its plan to place the 

remaining non-legacy airlines in the ATOS program by the end of fiscal 

year 2007 might make this recommendation unnecessary, according to the 

agency. Since FAA’s past efforts to move airlines to ATOS have 

experienced delays, we believe that this recommendation is still valid. 

FAA Has Evaluated 

Some Safety 

Programs, but the 

Lack of Evaluative 

Systems and 

Nationwide Data 

Impedes FAA’s Ability 

to Continuously 

Monitor Its Safety 

Programs 
Page 20 GAO-06-266T 

We also found that FAA lacked requirements or criteria for periodically 

evaluating its designee programs. In 2004, we reported that the agency had 

evaluated 6 of its 18 designee programs over the previous 7 years and had 

plans to evaluate 2 more, although it had no plans to evaluate the 

remaining 10 programs because of limited resources.13 FAA conducted 

these evaluations on an ad hoc basis usually at the request of headquarters 

directors or regional office managers. In addition, we found that FAA’s 

oversight of designees is hampered, in part, by the limited information on 

designees’ performance contained in the various designee databases.14

These databases contain descriptive information on designees, such as 

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

complete information would allow the agency to gain a comprehensive 

picture of whether staff are carrying out their responsibilities to oversee 

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

thus increase assurance that designees meet the agency’s performance 

standards, we recommended that FAA establish a process to evaluate all 

designee programs and strengthen the effectiveness of its designee 

databases by improving the consistency and completeness of information 

in them. To address our recommendations, FAA expects to develop a plan 

to evaluate all designee programs on a recurring basis and intends to 

establish a team that will examine ways to improve automated information 

related to designees. 

In addition, we found that FAA does not evaluate the effects of its industry 

partnership and enforcement programs to determine if stated program 

goals, such as deterrence of future violations, are being achieved. For 

example, little is known about nationwide trends in the types of violations 

reported under the partnership programs or whether systemic, nationwide 

causes of those violations are identified and addressed. Furthermore, 

FAA’s enforcement policy calls for inspectors and legal counsel staff to 

recommend or assess enforcement sanctions that would potentially deter 

future violations. However, without an evaluative process, it is not known 

whether the agency’s practice of generally closing cases with 

 13GAO-05-40. 

14These databases are Flight Standards Service’s Program Tracking and Reporting 

Subsystem and National Vital Information Subsystem, Aircraft Certification Service’s 

Designee Information Network, and Office of Aerospace Medicine’s Airmen Medical 

Certification Information Subsystem. 
Page 21 GAO-06-266T 

administrative actions rather than legal sanctions15 and at times reducing 

the amount of the fines, as mentioned earlier in this testimony, may 

weaken any deterrent effect that would be expected from sanctions. 

FAA’s ability to evaluate the impact of its enforcement efforts is also 

hindered by the lack of useful nationwide data. FAA inspection offices 

maintain independent, site-specific databases because they do not find the 

nationwide enforcement database—the Enforcement Information System 

(EIS)—as useful as it could be because of missing or incomplete historical 

information about enforcement cases. As a result of incomplete data on 

individual cases, FAA inspectors lack the complete compliance history of 

violators when assessing sanctions. We recommended that FAA develop 

evaluative processes for its enforcement activities and partnership 

programs and use them to create performance goals, track performance 

towards those goals, and determine appropriate program changes. We also 

recommended that FAA take steps to improve the usefulness of the EIS 

database by enhancing the completeness of enforcement information. FAA 

expects to address some of these issues as it revises its enforcement 

policy, which is expected to be issued later in fiscal year 2006. In addition, 

FAA has established a database workgroup that is developing long- and 

short- term solutions to address the problems with EIS. 

In order to help FAA fully realize the benefits from its safety oversight 

system, we have made a number of recommendations to address 

weaknesses that we identified in our reviews. These recommendations 

have not been fully implemented, although in some cases FAA has taken 

steps towards addressing them. Evaluative processes and relevant data are 

particularly important as FAA works to change its culture by incorporating 

a system safety approach into its oversight, and we have recommended 

that FAA develop continuous evaluative processes for its oversight 

programs for non-legacy airlines, its designee programs, and its industry 

partnership and enforcement programs, and systematically assess 

inspectors’ technical training needs. In addition, FAA’s nationwide 

databases are in need of improvements in their comprehensiveness and 

ease of use. Without comprehensive nationwide data, FAA does not have 

the information needed to evaluate its safety programs and have assurance 

 15We found that during fiscal years 1993 through 2003, FAA closed about 53 percent of the 

nearly 200,000 enforcement actions with administrative actions (such as warning notices). 

About 28 percent of the actions were closed with legal sanctions (such as fines) and about 

18 percent were closed with no enforcement action. 

Recommendations We 

Have Made to 

Improve FAA’s Safety 

Oversight System 
Page 22 GAO-06-266T 

that they are having the intended results. We have recommended that FAA 

improve the completeness of its designee and enforcement databases. 

Continuous improvements in these areas are critical to FAA’s ability to 

have a robust “early warning system” and maintain one of the safest 

aviation systems in the world. 

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

Dillingham at (202) 512-2834 or by email at dillinghamg@gao.gov. 

Individuals making key contributions to this testimony include Brad 

Dubbs, Phillis Riley, Teresa Spisak, and Alwynne Wilbur. 

Contacts and 

Acknowledgments 
Page 23 GAO-06-266T 

Table 3 describes the Federal Aviation Administration’s (FAA) three 

inspection processes for overseeing airlines: Air Transportation Oversight 

System (ATOS), National Work Program Guidelines (NPG), and 

Surveillance and Evaluation Program (SEP). Many of the elements of 

ATOS, such as the use of data to identify risks and the development of 

surveillance plans by inspectors, are incorporated in the SEP process. The 

NPG process, in contrast, is not focused on the use of data and relies on an 

established set of inspections that are not risk based. 

Table 3: Various Elements of ATOS, NPG, and SEP 

 ATOS NPG SEP 

Description of 

program 

• Focuses on safety vulnerabilities 

rather than regulatory compliance 

• Analysts and inspectors review airline 

data to identify areas of safety risk 

• Inspectors develop surveillance plans 

for each airline, based on data 

analysis and assessment of risks, 

and adjust the plans periodically 

based on inspection results 

• Focuses on inspectors 

completing a prescribed 

number of inspection activities 

• Primarily based on checking 

airline compliance with 

regulations 

• Relies on inspectors’ expertise 

to identify trends and risks 

• Focuses on inspectors 

conducting a risk assessment 

of various areas 

• Inspectors review data to 

identify areas of safety risk and 

use Flight Standards Safety 

Analysis Information Center 

and the Safety Performance 

Analysis System as analytical 

tools 

• Inspectors develop surveillance 

plans for each airline, based on 

data analysis and assessment 

of risks, and adjust plans 

periodically based on 

inspection results 

• Inspectors can also verify that 

planned NPG activities meet 

the surveillance needs for a 

particular year 

Type of commercial 

passenger airline 

inspected 

Legacy commercial airlines Non-legacy commercial airlines Non-legacy commercial airlines 

Frequency of 

inspections 

Continuous safety oversight Periodic; regular inspections are 

established annually by an FAA 

headquarters committee 

Periodic; inspections are 

established during meetings held 

at least twice a year using riskbased criteria 

Approximate number 

of aviation safety 

inspectors 

conducting 

inspectionsa

585 1,100b

 1,100b

Number of 

commercial 

passenger airlines 

under the programb

13c

 99 99 

Source: GAO and FAA 

Appendix I: Description of FAA’s Inspection 

Programs 
Page 24 GAO-06-266T 

a

As of July 2005. 

b

There are a total of about 1,100 inspectors for both the NPG and SEP inspections. 

c

FedEx and United Parcel Service, two cargo air carriers, are also in the ATOS program. This number 

reflects the recent merger of US Airways and America West, which were both in ATOS prior to the 

merger. 
Page 25 GAO-06-266T 

Year Established: 1997

Participation: Participants include employees of air carriers and repair 

stations that have entered into a memorandum of understanding with the 

Federal Aviation Administration (FAA). The memoranda can cover 

employee groups, such as pilots, maintenance employees, dispatchers, or 

flight attendants. Each employee group is covered by a separate 

memorandum of understanding. As of June 2004, FAA had accepted 54 

memoranda of understanding and received over 80,000 ASAP reports, 

which may or may not include safety violations, according to FAA 

officials. 

Purpose: ASAP seeks to improve aviation safety through the voluntary 

self-reporting of safety incidents under the procedures set forth in the 

memorandum of understanding. Under the program, FAA does not take 

enforcement action against employees who voluntarily self-reported safety 

violations for reports that are sole-source (the report is the only way FAA 

would have learned about the incident) and will pursue administrative 

action only for reports that are not sole-source. Incidents that involve 

alcohol, drugs, criminal activity, or an intentional disregard for safety are 

not eligible for self-reporting under ASAP. 

Process: Each memorandum of understanding is a voluntary partnership 

between FAA, the airline, and an employee group. Although employee 

groups are not always included, FAA encourages their participation. The 

memorandum of understanding ensures that employees who voluntarily 

disclose FAA safety violations in accordance with the procedures and 

guidelines of ASAP will receive administrative action or no action in lieu 

of legal enforcement action. 

Once a memorandum of understanding is approved, employees can begin 

reporting violations that fall under the agreement. When a violation 

occurs, an employee notifies the Event Review Committee, which includes 

representatives from FAA and the airline or the repair station and 

generally includes the appropriate employee association. The committee 

must be notified in writing within the time limit specified in the 

memorandum of understanding. The committee then determines whether 

to accept the report under the ASAP program. If the report is accepted (it 

meets the acceptance criteria in the memorandum and does not involve 

criminal activity, substance abuse, controlled substances, or alcohol), then 

the committee determines the action to take. That action may include 

remedial training or administrative action, but it will not include a legal 

sanction. 

Appendix II: Description of FAA’s Partnership 

Programs 

Aviation Safety Action 

Program (ASAP) 
Page 26 GAO-06-266T 

Results: FAA does not know the overall program results because it does 

not have a national, systematic process in place to evaluate the overall 

success of ASAP. However, FAA cites examples that describe ASAP’s 

contribution to enhanced aviation safety. These examples include 

identifying deficiencies in aircraft operations manuals, airport equipment, 

and runways. In July 2003, FAA’s Compliance and Enforcement Review 

recommended that FAA evaluate the use and effectiveness of this 

program. 

Year Established: 1975

Participation: Participants are all users of the national airspace system, 

including air traffic controllers and employees of air carriers and repair 

stations. 

Purpose: The program is designed to improve aviation safety by offering 

limited immunity for individuals who voluntarily report safety incidents. 

ASRP was founded after TWA Flight 514 crashed on approach to landing 

in December 1974 after the crew misinterpreted information on the 

approach chart. This accident occurred only 6 weeks after another plane 

experienced the same error. 

Process: The National Aeronautics and Space Administration (NASA) 

administers this program. When a safety incident occurs, a person may 

submit a form and incident report to NASA. There are four types of forms 

that can be submitted to NASA: (1) Air Traffic Control, (2) General 

Reports (includes Pilots), (3) Flight Attendants, and (4) Maintenance 

Personnel. 

At least two aviation safety analysts read these forms and the incident 

reports that accompany them. The analysts at NASA screen the incident 

reports for urgent safety issues, which will be marked for immediate 

action to the appropriate FAA office or aviation authority. NASA analysts 

also edit the report’s narrative to eliminate any identifying information. In 

addition, each report has a tear-off portion, which is separated and 

returned to the individual who reported the incident as a receipt of the 

incident report’s acceptance into the ASRP. When a safety violation that 

has been previously reported under ASRP comes to the attention of FAA, 

the agency issues a legal sanction, which is then waived. Reports that 

would not be eligible to have a legal sanction waived include deliberate 

violations, violations involving a criminal offense, or accident; reports filed 

by participants who have committed a violation of federal aviation 

Aviation Safety 

Reporting Program 

(ASRP) 
Page 27 GAO-06-266T 

regulations or law within the last 5 years and reports filed later than 10 

days following an incident. 

Results: While FAA and NASA do not know the overall program results 

because they do not have a formal national evaluation program to measure 

the overall effectiveness of the program, the agencies widely disseminate 

information generated from the program to aircraft manufacturers and 

others. ASRP reports are compiled into a database known as the Aviation 

Safety Reporting System. When a potentially hazardous condition is 

reported, such as a defect in a navigational aid or a confusing procedure, 

NASA will send a safety alert to aircraft manufacturers, the FAA, airport 

representatives, and other aviation groups. The database is used for a 

monthly safety bulletin that includes excerpts from incident reports with 

supporting commentary by FAA safety experts. NASA officials estimate 

that the bulletin is read by over 150,000 people. In addition, individuals and 

organizations can request a search of the database for information on 

particular aircraft aviation safety subjects, including human performance 

errors and safety deficiencies. Further, NASA has used the database to 

analyze operational safety issues, such as general aviation incidents, pilot 

and controller communications, and runway incursions. 

Year Established: 1995

Participation: Participants include air carriers that equip their airplanes 

to record flight data. As of March 2004, 13 airlines had FAA-approved 

FOQA programs, and approximately 1,400 airplanes were equipped for the 

program. 

Purpose: FOQA is designed to enhance aviation safety through the analysis 

of digital flight data generated during routine flights. 

Process: Air carriers that participate in the program equip their aircraft 

with special acquisition devices or use the airplanes’ flight data recorders 

to collect data and determine if the aircraft are deviating from standard 

procedures. These data include engine temperatures, descent rate, and 

deviations from the flight path. When the aircraft lands, data are 

transmitted from the aircraft to the airline’s FOQA station, where they are 

analyzed for flight trends and possible safety problems. 

Once the data are transmitted to the FOQA ground station, the data are 

extracted and analyzed by software programs. The FOQA data are 

combined with data from maintenance databases, weather conditions, and 

Flight Operational 

Quality Assurance 

(FOQA) 
Page 28 GAO-06-266T 

other safety reporting systems, such as ASAP, in order to identify trends in 

flight operations. The analysis typically focuses on events that fall outside 

normal boundaries specified by the manufacturer’s operational limitations 

and the air carrier’s operational standards. 

FOQA data are collected and analyzed by individual air carriers. The data 

on safety trends are made available to FAA in an aggregated form with no 

identification of individual carriers. According to FAA officials, air carriers 

do not want to release this data to any outside party (including FAA) 

because of concerns that the data could then be publicly released. Air 

carriers pay for the special flight data recorders that can record FOQA 

data, which cost approximately $20,000 each. Although this can be an 

expensive investment for some air carriers, most newer aircraft models 

come with the data recorder built into the airplane. The International Civil 

Aviation Organization (ICAO) has recommended that airlines from 

member countries implement a FOQA program. FAA has notified ICAO 

that the program will remain voluntary in the United States. 

Results: Although FAA has no formal national evaluation program to 

measure the overall results or effectiveness of FOQA programs, FAA cites 

examples that describe FOQA’s contribution to enhanced aviation safety. 

For example, one FOQA program highlighted a high rate of descent when 

airplanes land at a particular airport. On the basis of the information 

provided from FOQA, air traffic controllers at the airport were able to 

develop alternative approach procedures to decrease the rate of descent. 

Year Established: 1990 

Participation: Participants include air carriers, repair stations, and 

production approval holders.1

Purpose: FAA initiated the program to promote aviation safety by 

encouraging the voluntary self-reporting of manufacturing, and quality 

control problems and safety incidents involving FAA requirements for 

maintenance, flight operations, drug and alcohol prevention programs, and 

security functions. 

 1

A production approval holder is an entity that holds a certificate, approval, or 

authorization from FAA to manufacture aircraft, aircraft engines, propellers, and related 

parts and articles. 

Voluntary Disclosure 

Reporting Program 

(VDRP) 
Page 29 GAO-06-266T 

Process: Upon discovering a safety violation, participants can voluntarily 

disclose the violation to FAA within 24 hours. The initial notification 

should include a description of the violation, how and when the violation 

was discovered, and the corrective steps necessary to prevent repeat 

violations. Within 10 days of filing the initial notification to FAA, the entity 

is required to provide a written report that cites the regulations violated, 

describes how the violation was detected, provides an explanation of how 

the violation was inadvertent, and provides a description of the proposed 

comprehensive fix. FAA may pursue legal action if the participant 

discloses violations during, or in anticipation of, an FAA inspection. 

The violation must be reported immediately after being detected, must be 

inadvertent, must not indicate that a certificate holder is unqualified, and 

must include the immediate steps that were taken to terminate the 

apparent violation. If these conditions are met, and the FAA inspector has 

approved the comprehensive fix, then the FAA inspector will prepare a 

letter of correction and the case is considered closed with the possibility 

of being reopened if the comprehensive fix is not completed. 

Results: FAA does not know the overall program results because it does 

not have a process to measure the overall effectiveness of the program 

nationwide. A 2003 internal FAA report recommended that the agency 

evaluate the use and effectiveness of this program. 
Page 30 GAO-06-266T 

Aviation Safety: System Safety Approach Needs Further Integration into 

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

2005. 

Aviation Safety: FAA Management Practices for Technical Training 

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

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

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

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

Aviation Safety: FAA Needs to Strengthen the Management of Its 

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

Aviation Safety: Better Management Controls are Needed to Improve 

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

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

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

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

23, 2003. 

Aviation Safety: FAA Needs to Update the Curriculum and Certification 

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

March 6, 2003. 

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

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

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

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

2000. 

Aviation Safety: FAA’s New Inspection System Offers Promise, but 

Problems Need to Be Addressed. GAO/RCED-99-183. Washington, D.C.: 

June 28, 1999. 

Aviation Safety: Weaknesses in Inspection and Enforcement Limit FAA 

in Identifying and Responding to Risks. GAO/RCED-98-6. Washington, 

D.C.: February 27, 1998. 

Selected GAO Reports on Aviation Safety 

(540113) 
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