Office of Inspector General

Audit Report

FAA’S EFFORTS TO TRACK AND 

MITIGATE AIR TRAFFIC LOSSES 

OF SEPARATION ARE LIMITED BY 

DATA COLLECTION AND 

IMPLEMENTATION CHALLENGES

Federal Aviation Administration

Report Number: AV-2013-046

Date Issued: February 27, 2013
U.S. Department of

Memorandum

Transportation

Office of the Secretary

of Transportation

Office of Inspector General

Subject: ACTION: FAA’s Efforts To Track and Mitigate

Air Traffic Losses of Separation Are Limited by 

Data Collection and Implementation Challenges

Report No. AV-2013-046

Date: February 27, 2013

From: Jeffrey B. Guzzetti

Assistant Inspector General 

 for Aviation and Special Program Audits

Reply to 

Attn. of: JA-10

To: Federal Aviation Administrator

The Nation’s air traffic controllers play an important role in maintaining the 

world’s safest air transportation system. Yet, losses of standard separation—when 

aircraft do not maintain the minimum distance apart—remain a significant safety 

concern. In January 2011, an operational error—a loss of standard separation

caused by air traffic controllers1

Concerned with this increase, the Senate Committee on Commerce, Science, and 

Transportation and the Subcommittee on Aviation Operations, Safety, and 

Security requested that we review FAA’s ongoing efforts to assess operational 

errors and mitigate their risks. We also received a similar request from the House 

Committee on Transportation and Infrastructure. Accordingly, we 

(1) identified the reasons for the increase in losses of separation—specifically

operational errors—from fiscal years 2009 to 2010; (2) assessed the effectiveness 

of FAA’s policies and processes to collect, investigate, and report separation 

losses; and (3) evaluated the effectiveness of FAA’s policies and processes to 

mitigate the risk of separation losses.

—led to a near mid-air collision between a 

commercial airliner and two military aircraft near New York City. According to 

the National Transportation Safety Board (NTSB), who investigated the incident, 

at their closest point, the aircraft came within a mile of each other. According to 

Federal Aviation Administration (FAA) statistics, the number of reported 

operational errors increased by more than 50 percent between fiscal years 2009 

and 2010.

 1 Most losses of separation are classified as either an operational error (if the controller’s actions caused the loss) or a 

pilot deviation (if the pilot’s actions caused the loss).
2

We conducted this audit in accordance with generally accepted Government 

auditing standards. Exhibit A details our scope and methodology. Exhibit B lists 

the organizations we visited or contacted.

RESULTS IN BRIEF

According to FAA, the dramatic increase in reported operational errors between 

fiscal years 2009 and 2010 was mostly due to increased reporting through 

programs such as the Air Traffic Safety Action Program (ATSAP)2 and the Traffic 

Analysis and Review Program (TARP), an automated system to detect losses of 

separation at air traffic terminal facilities.

3 However, we found that the increase in 

reported errors was linked, in part, to a rise in actual errors rather than increased 

reporting. For example, FAA’s air route traffic control centers (ARTCC)4

—which 

have had an automated system in place for years to detect and investigate reported 

errors—had a 39 percent increase in operational errors during the same period. In 

addition, we identified other contributing factors to the rise in the number of 

operational errors. For example, almost one-quarter of the increase is due to the 

revocation of a separation waiver at the Southern California Terminal Radar 

Approach Control (TRACON) that led to the reclassification of many routine 

approach and landings as operational errors.

5

FAA’s new policies and procedures for collecting, investigating, and reporting 

separation losses have the potential to reduce losses and improve reporting, but 

their effectiveness is limited by incomplete data and implementation challenges.

Under FAA’s new policies, FAA uses TARP to detect losses, then examines the 

risk of these losses, and identifies corrective actions. FAA’s Air Traffic 

Organization (ATO) has three regional air traffic Service Areas that review TARP 

alerts to determine whether a valid loss of separation occurred. However, FAA 

currently reviews only a portion of all TARP alerts. In addition, ATSAP data 

indicate that more operational errors might be occurring than those that FAA

reports. As we reported last year,6 approximately 50 percent of all ATSAP event 

reports7

 2 ATSAP is a voluntary, non-punitive program in which controllers can self-report safety instances and concerns. In 

July 2012, we issued a separate report on FAA’s implementation of ATSAP (OIG Report Number 2012-152, “LongTerm Success of ATSAP Will Require Improvements in Oversight, Accountability, and Transparency” July 19, 2012). 

OIG reports are available on our Web site at 

are classified as “unknown,” which means that the event captured in the 

http://www.oig.dot.gov/. 3 Terminal facilities include airport traffic control towers and Terminal Radar Approach Control (TRACON) facilities. 

Air traffic control towers separate aircraft on the airport surface and guide aircraft as they take off and land. TRACONs 

guide aircraft as they approach or leave airspace surrounding airports to about 40 miles away. 

4 ARTCC guide aircraft flying at high altitudes, generally above 17,000 feet. 5 The waiver allowed aircraft landing simultaneously to be closer than normally allowed. Air Traffic Safety Oversight 

Service revoked the waiver because it considered it unsafe, and subsequently, reclassified aircraft landings that 

occurred under the waiver as operational errors. 6 OIG Report Number 2012-152, “Long-Term Success of ATSAP Will Require Improvements in Oversight, 

Accountability, and Transparency,” July 19, 2012. 7 Event reports identify actual or potential losses of separation, including operational errors, or other situations that may 

degrade air traffic safety.
3

confidential ATSAP report was not captured in FAA’s Air Traffic Quality 

Assurance (ATQA) database,8 and therefore, unknown to the air traffic facility 

management. Any losses of separation included in these unknown reports may not 

be in FAA’s official count. At the same time, FAA’s training for controllers and 

managers on the new policies and procedures has been limited. Facility officials 

said that while FAA training on new procedures was helpful for explaining the 

reasons for the changes to the procedures, it failed to explain the technical aspects 

of how errors should be reported. For example, facility officials said they received 

limited training on how to use a new database to store data on losses of separation.

Managers at 15 of 25 of the air traffic facilities we visited9

Recently, FAA developed corrective action plans to mitigate high-risk separation 

loss events—such as an aircraft executing an unexpected go-around

also raised concerns 

that the three ATO Service Areas may not have enough staff or knowledge of local 

flight procedures and airspace to effectively investigate operational errors.

10 and aircraft 

arriving at the same altitude on parallel runways. However, because the Agency

has not completed implementation of the action plans, it is too early to determine 

whether the plans will reduce the number of separation losses. In addition, FAA’s 

corrective action plans do not include all safety risks identified by FAA and will 

not address all losses of separation that air traffic facility officials consider to be 

high risk. For example, FAA’s process may not consider an instance of converging 

aircraft prevented from collision by Traffic Collision Avoidance Systems 

(TCAS)11

We are making recommendations to improve FAA’s policies and processes for 

identifying and mitigating separation losses.

to be a high-risk event if over 66 percent of the required separation was 

maintained. However, facility officials stated this type of event should be 

considered high risk regardless of the amount of separation loss because the 

controller introduced the risk of collision. 

BACKGROUND

At any given time, there are roughly 7,000 aircraft occupying U.S. airspace. To 

help maintain safe distances between aircraft, while under the control of air traffic 

controllers, FAA established minimum separation standards based on the aircraft’s 

phase of flight and size. Controllers are responsible for providing instructions to 

pilots. 

 8 Prior to January 30, 2012, ATQA contained reports of losses of separation. After this date, FAA began to replace 

ATQA with the Comprehensive Electronic Data Analysis and Reporting (CEDAR) database.

9 These 25 facilities include: 9 ARTCCs, 11 TRACONs, 2 air traffic control towers, and 3 ATO Service Areas. 

Nationwide, there are a total of 21 ARTCCs (within the continental U.S), 28 TRACONS, 513 air traffic control towers, 

and 3 ATO Service Areas. Our selection criteria for facilities we visited are in Exhibit A. A listing of the facilities 

visited is in Exhibit B.

10 A go around is an aborted landing of an aircraft on final approach to the runway. 11 An onboard TCAS issues advisories for pilots to take evasive actions when the system detects a potential collision 

with another aircraft.
4

We have been reporting on separation losses for over a decade. Historically, 

FAA’s oversight of operational error self-reporting has been problematic. Our 

previous work (see exhibit C) on operational errors has repeatedly raised concerns 

that nearly 300 FAA terminal facilities relied solely on controllers to self-report 

errors. In some cases, we found that the self-reporting process was subject to 

intentional manipulation.12

In response to our reports, FAA has undertaken a number of efforts to provide 

better oversight of and minimize separation losses, including the following:

More recently, in 2009, we found that inadequate 

guidance and insufficient staff contributed in part to control and oversight 

weaknesses in FAA’s process for reporting and investigating losses. 

• FAA implemented the Risk Analysis Process (RAP), a new risk-based 

approach to address losses of separation. RAP consists of a panel of at least 

two controllers and a pilot. Three panels, one in each ATO Service Area, 

review separation losses for events in which pilots maintain less than 

66 percent of required separation. For example, if aircraft are required to be 

separated by 3 miles, a separation of less than 2 miles (66 percent of 3 miles) 

would be reviewed under RAP. FAA reviews various risk factors, including 

the severity and repeatability of the event, and identifies the highest risk 

events13

• FAA revised its process for tracking high-risk errors. Previously, FAA 

tracked operational errors using a severity rating of A, B, or C—with A being 

the highest or most severe risk and C the lowest. The rating was based on the 

proximity of the aircraft to one another.

to develop a list of the top five highest risk types of separation losses, 

along with corrective actions to address such hazards.

14

 12 For example, in both 2005 and again in 2008, our investigations at the Dallas/Fort Worth TRACON found that air 

traffic managers intentionally misclassified operational errors as either pilot deviations or “non-events” to reduce the 

number of operational errors reported at that location. Further, FAA’s oversight processes failed to uncover this 

practice despite FAA’s prior assurances that it would not allow operational errors to go unreported.

As a performance measure, prior to 

fiscal year 2011, FAA reported the rate of A and B errors per every thousand 

operations. However, in fiscal year 2011, FAA developed a new metric, the 

System Risk Event Rate (SRER), based on the high-risk events identified in 

RAP. This metric identifies the ratio between separation losses identified as

high risk to all losses of separation. FAA’s goal is to limit the rate of high risk 

of standard separation losses to 20 or fewer for every 1,000 standard separation

losses.

13 Based on a risk assessment model used by the Eurocontrol, the European Organization for the Safety of Air 

Navigation.

14 An “A” rating (high/severe risk) meant that less than 34 percent of separation standards were met; a “B” rating 

(moderate risk) at least 34 and less than 75 percent of separation standards were met; and a “C” rating (low risk)

75 percent or more of separation standards were met, but the horizontal and vertical separation is less than 90 percent. 

Proximity events are minor losses of separation between two aircraft where 90 percent or greater of the required 

separation is maintained.
5

• FAA issued orders changing its process for identifying, investigating, and 

reporting losses of separation on January 30, 2012. One of the fundamental 

differences under the new orders is FAA’s decision to move the responsibility 

for investigating losses of separation from specific air traffic facilities (where 

the losses in question occurred) to three ATO Service Areas.15

VARIOUS FACTORS CONTRIBUTED TO THE DRAMATIC

INCREASE IN REPORTED OPERATIONAL ERRORS

In the years leading up to fiscal year 2009, reported operational errors remained 

relatively stable (see figure 1). However, between fiscal years 2009 and 2010, 

reported operational errors increased 53 percent, from 1,234 to 1,887. FAA’s 

recent numbers show a rise in the most serious Category A errors—from 37 in 

fiscal year 2009 to 43 in fiscal year 2010, and again to 55 in fiscal year 2011.

Also, for fiscal years 2008, 2009, and 2010, FAA exceeded its target limits for the 

number of category A and B operational errors per million operations.16

Figure 1. Operational Errors for Fiscal Years 2006 Through 2011 

In 

addition, FAA did not meet its fiscal year 2011 goal of reducing high-risk events 

to no more than 20 per 1,000 separation losses; instead, the rate was 24.5 per 

1,000, or 23 percent higher than its goal.

Source: OIG analysis of FAA data.

 15 FAA was prompted in part by our April 2008 recommendation to remove the quality assurance function at all Air 

Traffic Control facilities from the supervision of facility management. We made this recommendation because we 

reported in 2005 and 2008 that Dallas/Ft. Worth TRACON intentionally misclassified operational errors. See OIG 

Report No. CC-2007-083, “OIG Investigation-Alleged Cover-up of Operational Errors at DFW TRACON,” April 18, 

2008.

16 In fiscal year 2008, FAA goal was 2.15 A and B operational errors per million operations and the reported number 

was 2.25. In fiscal year 2009, the goal was 2.10 and the reported number was 2.44. In fiscal year 2010, the goal was 

2.05 and the reported number was 3.32.

1,338 1,391 1,349 

1,234 

1,887 1,895 

1,000 

1,100 

1,200 

1,300 

1,400 

1,500 

1,600 

1,700 

1,800 

1,900 

2,000 

FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011

Total Operational Errors
6

A large percentage of the increases in operational errors reported between fiscal 

years 2009 and 2010 occurred at the same 10 facilities—60 percent of the total 

increase of 653 errors (see table 1). TRACONs had the largest increase in reported 

errors—86 percent.

Table 1. Ten Air Traffic Facilities With the Largest Increase in 

Operational Errors From Fiscal Year 2009 to Fiscal Year 2010

Facility FY 2009 FY 2010 Percent 

Increase

Southern California TRACON 33 189 473%

Central Florida TRACON 5 24 380%

Houston TRACON 11 44 300%

Miami ARTCC 15 30 100%

Potomac TRACON 21 41 95%

Dallas/Fort Worth TRACON 84 143 70%

Charlotte Douglas International Airport Air Traffic Control Tower 20 34 70%

New York TRACON 74 119 61%

New York ARTCC 25 40 60%

Atlanta ARTCC 35 50 43%

Total 323 714 121%

Source: OIG analysis of FAA data.

According to FAA, increased ATSAP reporting contributed to the 53 percent 

increase in reported operational errors between fiscal years 2009 and 2010. While 

non-punitive reporting may encourage more controllers to report errors, we 

identified other factors that contributed to the increase. Additionally, managers 

and controllers we spoke with at 7 of the 10 facilities attributed the increases to 

other factors. These factors include the following:

• ARTCC automated reporting indicates an increase in actual errors. The 

number of errors reported at FAA’s ARTCCs—which have had a full-time 

detection tool in use for many years—also increased from fiscal year 2009 to 

2010 (from 353 to 489, an increase of 39 percent). This suggests that a portion 

of the overall increase is due to more errors actually occurring, rather than 

being attributable entirely to improved reporting.

• FAA reclassified 147 aircraft landings guided by the Southern California 

TRACON as operational errors. Originally, the landings were not classified 

as errors because the TRACON was operating under a waiver that allowed 

aircraft landing simultaneously to be closer than normally allowed. In 2010, 

the Air Traffic Safety Oversight Service revoked the waiver, citing safety 
7

concerns, and subsequently reclassified aircraft landings that occurred under 

the waiver. This accounted for 23 percent of the increase.

• Improved radar and voice replay tools have facilitated incident reviews, 

allowing them to more readily determine whether an operational error 

occurred. Fewer errors may have been discovered under prior incident reviews 

because of the difficulty obtaining data.

• FAA has placed additional emphasis on ensuring correct phrasing when 

pilots read back controllers' instructions. For example, FAA officials stated 

that greater emphasis has been placed on ensuring correct readbacks for visual 

separation procedures. If the controller fails to catch and correct inadequate 

readbacks, the event is reported as an operational error. Previously, these types 

of events were not reported as rigorously. 

EFFECTIVENESS OF FAA’S POLICIES AND PROCEDURES TO 

COLLECT, INVESTIGATE, AND REPORT SEPARATION LOSSES

IS LIMITED

FAA’s policies and procedures to identify and report on losses of separation are 

limited by incomplete data and implementation challenges. For example, FAA 

lacks an accurate baseline of the actual total number of separation losses that 

occur. In addition, facility managers expressed concerns that FAA’s training is not 

comprehensive in explaining how to use the new operational error reports database 

under the new procedures. Facility staff are also concerned about FAA’s decision 

to move the responsibility for investigating errors to ATO Service Areas, which 

may not have adequate staffing levels and familiarity of each facility's operations.

Data Collection Deficiencies and Reporting Inconsistencies Limit 

FAA’s Efforts To Track Separation Losses

FAA does not have an accurate baseline of separation losses due to gaps in TARP 

and ATSAP reporting and inconsistent classifications of losses. A complete 

picture of losses that occur is critical for FAA to track, fully address, and mitigate 

the risk of separation losses in the National Airspace System.

In 2009, we recommended that FAA fully implement TARP at its air traffic 

facilities.17 Although TARP has been installed and running at air traffic terminal 

facilities,

18

 17 OIG Report No. AV-2009-045, “FAA’s Process for Reporting and Investigating Operational Errors”, March 24, 

2009.

FAA does not analyze and report all separation losses that are 

automatically flagged by TARP. TARP provides alerts when a potential loss of 

separation occurs. Then, FAA must investigate the TARP alerts to determine 

18 Terminal facilities are TRACONs and airport control towers.
8

whether an actual loss of separation happened. FAA Service Area staff only 

investigate losses of separation of less than 70 percent.

19

In addition, ATSAP data indicate that more losses of separation might be 

occurring than those that are known to facility management. As we reported in 

2012,

20 approximately 50 percent of all ATSAP event reports21 are classified as 

“unknown,” which means that the event captured in the confidential ATSAP 

report was not captured in FAA’s Air Traffic Quality Assurance (ATQA)

database,

22

Inconsistencies in FAA’s classification of separation losses further reduce the 

reliability of the Agency’s count of operational errors and runway incursions. For 

example, in fiscal year 2011, there were a total of 1,895 reported operational 

errors, a negligible increase from the 1,887 reported in fiscal year 2010. However, 

the fiscal year 2011 count does not include 157 events classified as runway 

incursions

and therefore, unknown to the air traffic facility management. Any 

losses of separation included in these unknown reports may not be in FAA’s 

official count.

23 that occurred in August 2011 at Charlotte-Douglas International 

Airport. FAA reclassified the incursions as non-events due to its interpretation of 

the definition of a runway incursion and the judgment by senior Agency officials 

that safety was not compromised.24

Staffing Challenges Undermine FAA’s Efforts To Investigate

Separation Losses 

Runway incursions are considered to be 

operational errors when an air traffic controller is the cause. Therefore, had the 

classification to non-events not occurred, the fiscal year 2011 operational error

count would have increased by 9 percent of the number of reported errors the 

previous year.

FAA faces significant staffing challenges with implementing its new procedures 

for investigating separation losses. Prior to January 30, 2012—when FAA 

implemented the new procedures—investigations were conducted at the Nation’s 

more than 300 air traffic facilities. Therefore, conservatively, at least 300 staff 

conducted investigations on at least a part-time basis. With the implementation of 

 19 Losses of separation in which less than 70 percent of the separation was maintained. 20 OIG Report Number 2012-152, “Long-Term Success of ATSAP Will Require Improvements in Oversight, 

Accountability, and Transparency,” July 19, 2012.

21 Event reports include identify actual or potential losses of separation, including operational errors, or other situations 

that may degrade air traffic safety. 22 Prior to January 30, 2012, ATQA contained reports of losses of separation. After this date, FAA began to replace 

ATQA with the Comprehensive Electronic Data Analysis and Reporting (CEDAR) database.

23 The definition of a runway incursion is any occurrence at an airport involving “the incorrect presence of an aircraft, 

vehicle, or person on the protected area of a surface designated for the landing or take-off of aircraft.” 24 The errors involved the continued clearance of 157 take-offs and landings on a runway that was in close proximity to 

a disabled commercial airplane that had previously aborted a takeoff and was cleared off the runway onto an adjacent 

taxiway for maintenance. A portion of the disabled airplane intruded upon the protected area of the active runway 

environment. 
9

FAA’s new procedures, the number of personnel investigating losses of separation

has been substantially reduced. Currently, FAA has a total of 16 staff in the three 

Service Areas to investigate the high numbers of separation losses that occur. 

However, the Agency plans to hire additional staff.

FAA faces substantial staffing challenges in several areas, including:

• Increased workload: Once TARP data from all facilities with TARP are 

reviewed by Service Areas, FAA estimates that an additional 600 to 900 

reports of separation losses will need to be reviewed each day.

• Available tools: FAA has not fully implemented the Digital Audio Legal 

Recorder, which allow staff in the Service Areas to obtain air traffic audio data 

remotely and review audio replays of incidents. Without this automated tool, 

staff must request the facility to send the audio data for each incident to their 

Service Area, which could delay investigations of separation losses. FAA is 

aware of this issue and plans to address it as implementation continues.

• Training: Some facility officials stated that the FAA training on new 

procedures was helpful for explaining the reasons for the changes to the 

procedures, but failed to explain the technical aspects of how things should be 

done. For example, as part of its new procedures, FAA replaced its previous 

ATQA reporting database with a new database called Comprehensive 

Electronic Data Analysis and Reporting (CEDAR) for completing loss of 

separation reports. Yet facilities received limited training on how to use the 

new database. Additionally, FAA acknowledged that a lack of facility training 

on how to properly complete operational error reports contributed to

incomplete or inadequate causal data in its ATQA database. In ATQA, 

descriptions in the causal section of these reports often provided limited 

information about the cause of the errors. For example, according to FAA, the 

causal factor called “inappropriate use of displayed data [on aircraft]” was 

identified as the cause in 50 percent of all ATQA reports. This description of 

cause did not always identify the cause of the incident such as a training 

deficiency, fatigue, or a lack of experience.

• Knowledge of local facility operations: Air Traffic facility officials

questioned whether the Service Center staff have knowledge of each facility’s 

local procedures and operations such as the expertise and technical knowledge 

related to aircraft routing and altitudes covered by a facility, particularly in 

complex areas in large cities.
10

FAA’S NEW CORRECTIVE ACTION PLANS DO NOT ADDRESS ALL 

SAFETY CONCERNS RELATED TO SEPARATION LOSSES

FAA has developed a new strategy to mitigate separation losses—including 

implementing corrective action plans to reduce the five highest risk events. 

However, FAA does not examine all losses of separation that air traffic officials 

considered to be high risk. Facility officials also question the effectiveness of 

FAA’s mitigation efforts. 

FAA’s Corrective Action Plans Do Not Include Safety Risks and 

Causal Factors Identified in Previous FAA Analyses

In fiscal year 2011, FAA developed new corrective action plans to reduce the five 

highest risk separation loss events identified through RAP. For example, two of 

the top five risk categories involve loss of separation when an aircraft overshoots 

the turn to final approach on parallel runways and conflicts with another aircraft. 

FAA’s plans to mitigate these risks include the following:

• limit the turn to final angle of no more than 30 degrees (see figure 2);

• require altitude separation of at least 1,000 feet prior to application of visual 

separation; and

• develop airport-specific speed restrictions for final approach courses.
11

Figure 2. Example of a Corrective Action Plan Initiative

Source: FAA.

FAA also identified factors contributing to the top five high-risk events (see 

table 2). 
12

Table 2. Overview of Top Five Risk Categories and Corrective 

Action Plans

Top Five Event 

Category

Causal Factors Key Corrective Action Plan 

Initiatives

1. Arrival aircraft 

executes an 

unexpected go around 

Lack of adequate go around 

procedures

Each facility must define local 

procedures for go arounds.

2. Arriving aircraft at 

the same altitude on 

parallel runways.

Aircraft overshoot the turn to final 

and conflict with parallel traffic 

same altitude.

Proposal to require aircraft on flight

paths at right angles to the landing 

runway to be assigned altitudes at 

least 1,000 feet apart until visual 

separation is established.

3. Aircraft at an 

altitude other than 

expected.

(a) Breakdown of communications

(b) Incorrect data block altitudes 

prevent conflict alert activation

Investigate the feasibility of using 

"Mode S" technology to allow 

controllers to view the altitudes 

pilots have entered into aircraft 

systems.

4. Aircraft in 

unexpected position 

resulting in a loss of 

separation.

Controller Coordination: Aircraft 

transferred to another controller on 

route or at different altitude than 

expected.

Develop training to address 

coordination.

5. Aircraft vectored at 

speed and/or angle of 

intercept, leading to 

loss of separation.

Current air traffic procedures 

(7110.65) allow aircraft to turn to 

final approach at excessive speed 

and excessive intercept angle.

Proposed procedure changes to: 

(1) require headings that allow an 

intercept angle to final approach of 

no greater than 30 degrees, and (2) 

require development of local speed 

restrictions for facilities that vector to 

final approach on parallel runways.

Source: FAA.

However, FAA’s corrective action plans, which were finalized in July 2011, do 

not address previously identified causal factors, trends based on the factors, or 

follow-up actions to address them. In particular, in June 2011, RAP identified 

perception, memory, training, and experience as the top causal factors for highrisk events. Also, the RAP panel identified training and on-the job training as key 

corrective action areas and recommended FAA:

• Develop specific training requirements and curriculum to address poor 

recovery. Of all events analyzed through RAP, 41 percent involved poor 

recovery from a loss of separation. The RAP panel also found over half of the 

recovery efforts worsened the situation, causing the aircraft to be in closer 

proximity. Furthermore, RAP determined that of the 87 most severe risk 

analysis events, 76 (or 87 percent) involved poor air traffic control recovery.
13

• Conduct root cause analyses and determine the best way to address 

incidents that occur during on-the-job training. These incidents accounted 

for 10 percent of all analyzed events.

FAA chose to exclude these causal factors (perception, memory, training, and 

experience) and trends (poor recovery and on-the-job training) from the corrective 

action plans because it considered them to be “contextual.” However, a 2005 study 

published by FAA25

Facility Officials Question the Effectiveness of Mitigation Efforts 

found that the majority (86 percent) of operational errors 

reviewed were “skill-based errors,” which tend to be “the result of habitual actions 

associated with an individual’s attention, memory, and/or execution technique.” 

The study’s finding is similar to causal factors identified by FAA in its 2011 RAP 

document. Also, the trend of poor recovery was present in the majority of the most 

severe risk analysis events reviewed.

Facility officials questioned the overall effectiveness of FAA’s corrective action 

plans. While the new air traffic procedures proposed in the plans are reviewed for 

risk through the Safety Management System26

Table 3. FAA Proposals To Mitigate Losses of Separation and Facility 

Officials’ Concerns With Them

(SMS) process, facility officials had 

concerns with the proposed procedures, as shown in table 3 below.

FAA Proposals for Facilities Facility Officials’ Concerns

Determine facility-specific speed requirements 

to reduce the potential of an aircraft 

overshooting a runway

Controllers should let aircraft fly the most 

efficient approach, unless speed control for 

separation is required.

Determine the feasibility of the potential benefits 

from automatically relaying additional altitude 

information from the aircraft’s autopilot to 

controllers

FAA must consider the impact of this 

information on controller workload.

Define procedures for go-arounds and missed 

approaches

Controllers must assess the situation and make 

the best decision based on established 

procedures and other traffic. Facilities cannot 

plan for every scenario, because varying traffic 

flows can affect the best option for controllers.

Source: FAA and OIG analysis. 

Finally, air traffic facility officials are concerned that FAA’s RAP, SRER, and 

corrective action plans do not include events they consider to be high-risk, such as 

those for which the loss of separation was more than 66 percent. For example, 

converging aircraft prevented from colliding by the Traffic Collision and 

 25 “Examining ATC Operational Errors Using the Human Factors Analysis and Classification System,”

DOT/FAA/AM-05/25, FAA Office of Aerospace Medicine, December 2005. 26 FAA defines the Safety Management System as an integrated collection of processes, procedures, policies, and 

programs that are used to assess, define, and manage the safety risk in providing ATC and navigation services.
14

Avoidance System (TCAS) could be a high-risk event regardless of the degree of 

separation loss. TCAS, an automated cockpit avoidance system, operates 

independently from the ground-based Air Traffic Control system and serves as a 

last line of defense for preventing mid-air collisions. In other words, use of the 

TCAS system could indicate a high-risk event because it is an event in which the 

controller failed to separate aircraft and introduced the risk of collision. Yet 

FAA’s mitigation plans do not include all of these events. 

CONCLUSION

Reported losses of separation continue to be a major air safety concern, 

particularly in light of dramatic increases in their occurrence. While FAA recently 

issued new policies and processes for investigating and mitigating separation 

losses, a lack of a reliable baseline creates substantial challenges for FAA to 

ensure these new policies and processes are effective. Until FAA takes action to 

determine the true magnitude of operational errors, assess their potential safety 

impacts, identify their root causes, and align adequate staffing for oversight, the 

risk of separation losses will remain a safety concern.

RECOMMENDATIONS

To improve its policies and processes for collecting, investigating, and reporting 

separation losses, and mitigating their risks, we recommend that FAA:

1. Include all losses of separation that are reported under ATSAP, but unknown 

to air traffic facilities, in its official count of such events.

2. Determine the level of staff and expertise needed at the ATO Service Areas to 

effectively implement ATO’s new Orders on investigating losses of separation, 

audit all TARP data, and initiate actions to fill those requirements.

3. Determine the extent to which ATO has successfully implemented its new 

orders (effective January 2012). This determination should include reviews of 

the quality of separation loss investigation reports, effectiveness of training, 

and additional actions or resources needed.

4. Include high-risk TCAS warning events in its Risk Analysis Process and 

System Risk Event Rate when the separation between two converging aircraft 

is maintained at 66 percent or more.

5. Develop actions to mitigate the following situations identified in the Risk 

Analysis Process: (1) poor recovery from loss of separation and (2) losses of 

separation involving on-the-job training.
15

6. Utilize analysis of the causal and contributory factors derived in the Risk 

Analysis Process—including perception, memory, and training—to identify the 

underlying reasons for separation losses and develop mitigation strategies to 

address those causes.

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

We provided FAA with a draft copy of this report on December 14, 2012, and 

received FAA’s response on January 25, 2013. FAA’s response is included in its 

entirety in the appendix to this report. In its response, FAA fully concurred with 

recommendations 2, 3, 5, and 6, and partially concurred with recommendations 1 

and 4. FAA’s planned actions for recommendations 2, 3, 4, and 5 met the intent of 

our recommendations and included reasonable timeframes for implementation. 

However, we are requesting that FAA reconsider its response or provide additional 

information for recommendations 1 and 6, as detailed below.

For recommendation 1, FAA stated that there would be legal and data 

compatibility concerns with integrating ATSAP-reported losses of separation into

its baseline of total separation losses. Further, the Agency stated that TARP 

captures the vast majority of separation losses and has proven to be the best 

solution for establishing a new baseline. We agree that the process of fully 

implementing TARP has generated significantly more data than FAA previously

had available. However, FAA is assuming that there is a virtually 100 percent 

overlap between ATSAP-reported losses and TARP-detected losses,

27

 27 FAA does not analyze and report all separation losses that are flagged by TARP. FAA Service Area staff investigate 

losses of separation identified by TARP of less than 70 percent (i.e., when less than 70 percent of the separation 

between aircraft was maintained).

which we 

question as we are not aware of any effort by FAA to reconcile ATSAP and TARP 

data. Without this reconciliation, FAA cannot be assured that ATSAP data are 

being captured in the Agency’s counts of losses of separation. FAA also did not

provide a rationale for its exclusion of these data, nor has it clarified the legal 

impediments to integrating ATSAP-reported losses of separation into its total 

count of separation losses. Furthermore, there are several air traffic facilities with 

equipment that is not compatible with TARP, including in Honolulu, HI; San Juan, 

PR; Twin Falls, ID; and Helena, MT. To determine losses of separation at these 

locations, FAA may rely on manual reporting by controllers, which is less 

effective, as we have pointed out in our prior work. Therefore, in our opinion, 

FAA is missing an opportunity to establish a complete and accurate baseline of 

separation losses by not including ATSAP-reported losses in its count, and we 

request it reconsider its position on this recommendation.
16

For recommendation 6, FAA stated that it believes it has met the intent of our 

recommendation because its Risk Analysis Process (RAP) and yearly 

identification of the Top 5 hazards in the NAS use both causal and contributory 

factors to develop corrective actions and mitigation strategies. However, FAA did 

not specify how its processes have used the specific causal and contributory 

factors we included in our recommendation—perception, memory, and training. 

As we noted in our report, FAA chose to exclude these factors from its corrective 

action plans because it considered them to be “contextual.” Therefore, to ensure 

that FAA’s response meets the full intent of our recommendation, we request that 

FAA provide us with more information on how RAP uses these factors in its 

mitigation strategies.

ACTIONS REQUIRED 

We consider recommendations 2, 3, 4, and 5 resolved but open pending the 

completion of the planned actions. We also consider recommendations 6 resolved 

but open pending receipt of supporting documentation of FAA’s actions taken. For 

recommendation 1, we request that FAA reconsider its position. In accordance 

with Department of Transportation Order 8000.1C, we request that FAA provide 

us this additional information within 30 days.

We appreciate the courtesies and cooperation of FAA representatives during this 

audit. If you have any questions concerning this report, please call me at 

(202) 366-0500 or Scott Macey, Program Director, at (415) 744-0434.

#

cc: DOT Audit Liaison, M-1

FAA Audit Liaison, AAE-100
17

Exhibit A. Scope and Methodology

EXHIBIT A. SCOPE AND METHODOLOGY 

We conducted this audit in accordance with generally accepted Government 

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

obtain sufficient, appropriate evidence to provide a reasonable basis for our 

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

evidence obtained provides a reasonable basis for our findings and conclusions 

based on our audit objectives. We conducted this performance audit from June 

2011 through December 2012, which included site visits to FAA Headquarters and 

air traffic facilities nationwide (see exhibit B).

To evaluate the effectiveness of FAA’s policies and procedures to collect, 

investigate, and report separation losses, we interviewed FAA Headquarters 

officials and analyzed FAA orders, data, and reports on losses of separation. In 

addition, we interviewed officials and analyzed information at the 30 facilities we 

contacted to evaluate these issues. We visited or contacted 9 of 21 nationwide Air 

Route Traffic Control Centers (ARTCC) within the continental United States, 

11 of 28 stand-alone Terminal Radar Approach Control (TRACON) facilities, 2 of 

513 Air Traffic Control Towers, 4 of 81 Flight Standards District Offices 

(FSDO),

28 3 of 3 ATO Service Areas, and 1 of 20 Certificate Management Offices 

(CMO).

29 Specifically, the OIG statistician selected a stratified random sample of 

11 (6 TRACON and 5 ARTCC) out of 41 TRACON and ARTCC facilities that 

had increases in operational errors from fiscal years 2009 to 2010. We focused on 

ARTCCs and TRACONs in our sample because these facilities had the largest 

increases in operational errors between fiscal years 2009 and 2010. Over this time 

period, errors at TRACONs increased 86 percent while errors at ARTCCs 

increased 39 percent. We visited 10 of these facilities and had a teleconference 

with the remaining facility.30 We also visited 19 other facilities to obtain a broader 

range of information about operations nationwide including facilities located near 

our sample sites. A list of the sample sites and additional sites we visited in is 

exhibit B.

To determine various factors that contribute to increases in reported losses of 

separation, we interviewed FAA Headquarters officials as to why operational 

errors increased from fiscal year 2009 to 2010. We also interviewed officials and 

analyzed information at the 30 facilities we contacted to identify any other 

contributing factors.

To assess the effectiveness of FAA’s efforts to mitigate operational errors, we 

analyzed mitigations and corrective action plans from FAA Headquarters. 

 28 FSDOs are part of FAA’s Flight Standards Service, which promotes safe air transportation by setting the standards 

for certification and oversight of airmen, air operators, and air agencies.

29 CMOs specialize in areas such as the certification, surveillance, and inspection of major air carriers. 30 We teleconferenced with Anchorage Air Route Traffic Control Center.
18

Exhibit A. Scope and Methodology

Furthermore, we obtained and reviewed mitigation strategies at the 30 facilities we 

contacted. At both FAA headquarters and the 30 contacted facilities, we 

interviewed officials for their perspective on operational error mitigation 

strategies.
19

Exhibit B. Organizations Visited or Contacted

EXHIBIT B. ORGANIZATIONS VISITED OR CONTACTED

Washington Air Route Traffic Control Center (ZDC)

Seattle Air Route Traffic Control Center (ZSE)

Fort Worth Air Route Traffic Control Center (ZFW)

Atlanta Air Route Traffic Control Center (ZTL)*

New York Air Route Traffic Control Center (ZNY)*

Chicago Air Route Traffic Control Center (ZAU)

Cleveland Air Route Traffic Control Center (ZOB)*

Boston Air Route Traffic Control Center (ZBW)*

Anchorage Air Route Traffic Control Center (ZAN)*

Potomac Consolidated Terminal Radar Approach Control (PCT)

Seattle Terminal Radar Approach Control (S46) *

Northern California Terminal Radar Approach Control (NCT)

Southern California Terminal Radar Approach Control (SCT)*

Houston Terminal Radar Approach Control (190)*

Dallas/Fort Worth Terminal Radar Approach Control (DIO)*

Las Vegas Terminal Radar Approach Control (L30)*

New York Terminal Radar Approach Control (N90)*

Chicago Terminal Radar Approach Control (C90)

Cleveland Terminal Radar Approach Control (CLE)

Boston Consolidated Terminal Radar Approach (A90)

Seattle-Tacoma Air Traffic Control Tower (SEA)

Los Angeles International Air Traffic Control Tower (LAX)

Dallas Fort Worth Flight Standards District Office (DFW FSDO)

Atlanta Flight Standards District Office (ATL FSDO)

New York City Flight Standards District Office (NYC FSDO)

Chicago O'Hare Flight Standards District Office (ORD FSDO)

Delta Certificate Management Office (Delta CMO)

FAA Western Service Area

FAA Central Service Area

FAA Eastern Service Area

*This facility was part of our 11 facility sample.
20

Exhibit C. DOT OIG Reports on Operational Errors Since 2000

EXHIBIT C. DOT OIG REPORTS ON OPERATIONAL ERRORS 

SINCE 2000

Issue Date and Title Key Findings

March 24, 2009

FAA’s Process for 

Reporting and 

Investigating Operational 

Errors (AV-2009-045)

Control and oversight weaknesses in FAA’s process for reporting and 

investigating losses of separation caused by pilots and controllers. 

These weaknesses were due in part to inadequate FAA guidance for 

investigating these events and insufficient staffing in the Air Traffic 

Organization (ATO) Safety Office. Further, FAA’s processes did not 

ensure that all losses of separation were accurately reported across 

terminal and en route facilities or consistently evaluated for severity.

April 18, 2008

OIG InvestigationAlleged Cover-up of 

Operational Errors at 

DFW TRACON 

(CC-2007-083),

Air traffic managers at the TRACON intentionally misclassified 

operational errors as either pilot deviations or “non-events” to reduce 

the number of operational errors reported at that location. FAA’s 

oversight processes failed to uncover this practice despite FAA’s prior 

assurances that it would not allow operational errors to go 

unreported.

February 14, 2005 

Alleged Cover-up of 

Operational Errors at 

DFW TRACON 

(CC-2004-067)

FAA DFW TRACON managers had failed to investigate, and 

therefore, underreported operational errors over a seven-year period. 

In short, management created an atmosphere of self-reporting and 

other incentives that discouraged employees from identifying 

operational errors.

September 20, 2004

Controls Over the 

Reporting of Operational 

Errors (AV-2004-085)

At facilities that handle the most air traffic, FAA relies on supervisors 

and controllers to self-report when errors have occurred and does not 

have a system in place to verify that this reporting process is reliable.

April 3, 2003

Operational Errors and 

Runway Incursions

(AV-2003-040)

Despite FAA progress in reducing operational errors and runway 

incursions, the number of incidents remained high. On average, one 

runway incursion and three operational errors occurred each day in 

fiscal year 2002. High-risk incursions and errors occurred, on 

average, once every 10 days and 8 days, respectively.

December 15, 2000

Actions To Reduce 

Operational Errors and 

Deviations Have Not 

Been Effective

(AV-2001-11)

FAA does not determine the severity of operational errors, and 

controllers and managers have different perceptions of actions taken 

when operational errors occur. According to the National Air Traffic 

Controllers Association, controllers face serious disciplinary actions 

for committing operational errors. Facilities with the most reported 

operational errors over the previous 5 fiscal years lacked adequate 

plans to reduce operational errors. Further FAA has not provided 

provide strong national oversight to effectively reverse the upward 

trend in operational errors.
21

Exhibit D. Major Contributors to This Report 

EXHIBIT D. MAJOR CONTRIBUTORS TO THIS REPORT 

Scott Macey Program Director

Name Title

Stephen Jones Project Manager

Kevin Montgomery Senior Analyst

Judy Nadel Senior Auditor

Susan Crook Analyst

Karen Sloan Communications Officer

Andrea Nossaman Senior Writer

Audre Azuolas Writer-Editor

Petra Swartzlander Senior Statistician

Megha Joshipura Statistician
APPENDIX. AGENCY COMMENTS 22

Appendix. Agency Comments

Federal Aviation

Administration

Memorandum

Date: January 25, 2013

To: Jeffrey B. Guzzetti, Director, Assistant Inspector General for Aviation and

Special Program Audits

From: H. Clayton Foushee, Director, Office of Audit and Evaluation, AAE-1

Subject: Response to Office of the Inspector General (OIG) Review of FAA’s Efforts to 

Track and Mitigate Air Traffic Losses of Separation 

The Federal Aviation Administration (FAA) through its Air Traffic Organization (ATO) is 

committed to conducting safe operations throughout the Nation Airspace System (NAS). 

Tracking data relating to aircraft operations that do not maintain standard separation distances is 

an important component of risk assessment in the NAS and is used to develop appropriate 

corrective actions when significant risks are identified.

In January of 2012, the ATO implemented a significant change in the way safety data, including 

losses of separation, are reported, analyzed, and acted upon. These changes improve utilization 

of the Air Traffic Safety Action Program (ATSAP), which is a non-punitive reporting system, as 

well as the Traffic Analysis and Review Program (TARP), which electronically identifies losses 

of separation. As a result, the ATO has seen a dramatic increase in reporting and now has 

available unprecedented amounts of both qualitative safety data, through ATSAP, and 

quantitative data from TARP. The validation and analysis processes that have been implemented 

have greatly enhanced the agency’s ability to identify and prioritize high risk hazards, which are 

addressed through the ATO’s Top 5 program. This program provides a forum for a coordinated 

and collaborative approach to identify and mitigate risks through the most effective means 

available, including training, procedures, and technological improvements. 

The ATO continues to implement enhancements in training, procedures, and technology based 

on its use of a dramatically improved reporting, with many new initiatives planned throughout 

2013, which offer the potential to further enhance the safety of operations in the NAS. 

RECOMMENDATIONS AND RESPONSES

OIG Recommendation 1: Include all losses of separation that are reported under ATSAP, but 

unknown to air traffic facilities, in its official count of such events.

FAA Response: Partially-concur. The FAA agrees that knowledge of operational incidents is 

crucial to its ability to identify and address safety trends. In order to achieve that goal FAA 
23

Appendix. Agency Comments

successfully developed and is in the process of fully implementing the TARP system that 

captures quantitative data relating to the vast majority of occurrences that involve loss of 

separation. TARP was fully implemented at all terminal radar facilities in September 2012. 

FAA is now developing TARP for En Route facilities, and with implementation targeted for May 

2013. TARP has already demonstrated its capability to operate effectively in the terminal 

environment, and is generating ten times the amount of data FAA previously had available 

relating to loss of separation. Further, the system increases the utility of the data captured by 

consolidating the information into a single database available to all facilities. Increased reporting 

is a key strategy to improve air traffic safety and TARP has already proven to be the best 

solution for the FAA to establish a new baseline of reporting losses of separation. Incorporating 

ATSAP data, as recommended would bring about significant legal issues with regard to the use 

of this information and introduce considerable data compatibility problems. As a result, FAA is 

focused on fully implementing and utilizing the vast amount of new data made available by 

TARP, which provides the most accurate available metric for these occurrences. 

OIG Recommendation 2: Determine the level of staff and expertise needed at the ATO Service 

Areas to effectively implement ATO’s new Orders on investigating losses of separation, audit all 

TARP data, and initiate actions to fill those requirements.

FAA Response: Concur. The FAA Air Traffic Organization (ATO) has just completed the 

largest and most significant improvements in the last 30 years to the way air traffic control risk 

and safety performance are managed in the United States. From the implementation of voluntary 

reporting, to electronic detection, the development of standardized risk assessment processes and 

the establishment of a proactive safety management system, the ATO is now able to identify 

precursors to risk rather than just react to single incidents. Our processes and metrics need to 

mature before a proper baseline can be established. We have made commitments to the Office of 

the Secretary and the Office of Management and Budget that at the end of FY14 we will have 

established sound baseline for metrics based upon about two years’ worth of data. With the 

experience developed over that period, FAA will be better able to understand the staffing 

requirements for making full and appropriate use of this newly available data. While FAA will 

continue to evaluate informally resource requirements over the implementation period, it intends 

to conduct a formal staffing study for TARP management and analysis by October 1, 2015. 

OIG Recommendation 3: Determine the extent to which ATO has successfully implemented 

its new orders (effective January 2012). This determination should include reviews of the quality 

of separation loss investigation reports, effectiveness of training, and additional actions or 

resources needed.

FAA Response: Concur. The ATO combined its Safety and Technical Training offices into one 

service unit in 2012 under the leadership of the Vice President, Safety and Technical Training. 

This combination was initiated for the specific purpose of identifying safety issues, evaluating 

the effectiveness of training, and collaboratively identifying necessary resources (e.g. training, 

staffing, procedures, technological improvements) to improve overall safety in the delivery of air 

traffic control services. 
24

Appendix. Agency Comments

The Safety directorate’s QA Group is in the final stage of developing a Standard Operating 

Procedure (SOP) to address the validation and processing of MORs and EORs for each of the 

QA Service Area offices. The QA SOP will be completed in early 2013 and subsequent training 

of these procedures will be conducted throughout 2013. 

The Safety directorate has initiated the development of a revised QA and Quality Control (QC) 

Training Course for ATO personnel to be taught at the FAA Academy. Coordination is currently 

ongoing between the Safety and Technical Training directorates to fully define requirements. 

This course will include lessons on how to utilize Comprehensive Electronic Data Analysis 

Reporting (CEDAR) and provide an overall understanding of the QA and QC processes that have 

been implemented.

Additionally, QA staff has conducted visits to the QC Groups in each of the ATO Service Areas 

to provide clarification and familiarization with the new Orders, CEDAR and TARP. In support 

of these visits, the ATO is in the process of publishing Safety Guidance reflecting best practices 

on how to implement the new orders. This guidance is expected to be published by February 

2013. In addition, the Air Traffic Oversight Service is planning to audit the implementation of 

the new Orders in fiscal year (FY) 2013.

FAA will use the results of these incremental compliance and effectiveness evaluations of the 

individual components of its new approach to continue fine tuning its operation of individual 

elements of its new safety scheme. It intends to conduct an overall evaluation of the overall 

scheme by October 1, 2015, once sufficient data is available to meaningfully evaluate its 

performance. 

OIG Recommendation 4: Include high-risk TCAS warning events in its Risk Analysis Process 

and System Risk Event Rate when the separation between two converging aircraft is maintained 

at 66 percent or more. 

FAA Response: Partially-concur. The ATO has a well-developed risk analysis process that 

reviews events on a prioritized basis in accordance with the risk factors present during an event. 

TCAS is one of several safety countermeasures, and its effectiveness or lack thereof is already 

part of the analysis process used by the ATO. The ATO will clarify and produce written criteria 

for determining which TCAS events represent a high-risk and should be included in the risk 

assessment process. It intends to complete these criteria by December 30, 2013. 

OIG Recommendation 5: Develop actions to mitigate the following situations identified in the 

Risk Analysis Process: (1) poor recovery from loss of separation and (2) losses of separation 

involving on-the-job training. 

FAA Response: Concur. The ATO is already addressing these issues. The number one hazard 

identified in the FY 2013 Top 5 hazards in the NAS was poor recovery after a loss of separation. 

As a result, FAA-wide corrective action and monitoring plans have been developed. Hazard 

Risk Mitigation is a high priority DOT goal that tracks how well the FAA is doing in 

implementing corrective actions on a yearly basis. To meet this goal the FAA has to complete a 
25

Appendix. Agency Comments

minimum of 80% of approved mitigations to address the top five contributing hazards to high 

risk events every year.

The ATO does not have data that directly ties the on-the-job training (OJT) program to a specific 

increase in risk for losses of separation. However, the ATO plans to gather more information 

about such incidents in order to determine whether there is sufficient support provided to OJT 

instructors in the current training methodology. The ATO will be amending CEDAR to require 

identification of OJT in progress when operational incidents occur. ATO intends to implement 

this upgrade by June 2013. 

OIG Recommendation 6: Utilize analysis of the causal and contributory factors derived in the 

Risk Analysis Process—including perception, memory, and training–to identify the underlying 

reasons for separation losses and develop mitigation strategies to address those causes. 

FAA Response: Concur. RAP and the yearly identification of the Top 5 hazards in the NAS 

utilize both causal and contributory factors to develop corrective actions and mitigation strategies 

to address causes for losses of separation in the NAS. Following our Safety Management 

System which requires continuous improvement of our processes, the ATO is making 

improvements to RAP and other safety programs, such as Search and Rescue and QC, as well as 

sharing the ATO’s safety data with Aviation Safety Information Analysis and Sharing for 

analysis of air traffic control and aircraft data. Combining air traffic and aircraft data offers 

numerous opportunities to improve aviation safety. The FAA believes it has met the intent of 

this recommendation and requests that it be closed.