Office of Inspector General

Audit Report

LONG TERM SUCCESS OF ATSAP WILL 

REQUIRE IMPROVEMENTS IN OVERSIGHT, 

ACCOUNTABILITY, AND TRANSPARENCY

Federal Aviation Administration

Report Number: AV-2012-152

Date Issued: July 19, 2012
U.S. Department of

Memorandum

Transportation

Office of the Secretary

of Transportation

Office of Inspector General

Subject: ACTION: Long Term Success of ATSAP Will 

Require Improvements in Oversight, 

Accountability, and Transparency

Report No. AV-2012-152

Date: July 19, 2012

From: Jeffrey B. Guzzetti

Assistant Inspector General 

 for Aviation and Special Program Audits

Reply to 

Attn. of: JA-10

To: Federal Aviation Administrator

The United States has one of the best air safety records in the world, thanks in part 

to the actions of the nation’s air traffic controllers. However, operational errors, 

which occur when an air traffic controller fails to ensure the required separation 

distance between aircraft, remain a significant safety concern. Federal Aviation 

Administration (FAA) statistics show that the number of reported operational 

errors increased from 1,234 in fiscal year 2009 to 1,887 in fiscal year 2010. 

According to FAA, this increase was mostly due to increased reporting, such as 

through the Air Traffic Safety Action Program (ATSAP), rather than other factors 

that could contribute to an increase in the actual number of errors. FAA initiated 

ATSAP in July 2008 as a voluntary non-punitive reporting program to encourage 

FAA air traffic employees to report safety events and safety concerns, with the 

intent of capturing all events that might lead to a breakdown in safety. The 

program is governed by, among other things, a Memorandum of Understanding 

(MOU) established between FAA and the National Air Traffic Controllers 

Association (NATCA).

In 2011, the Chairmen and Ranking Members of the Senate Committee on 

Commerce, Science, and Transportation and its Subcommittee on Aviation 

Operations, Safety, and Security as well as the Chairman of the House Committee 

on Transportation and Infrastructure and the Chairman and the Ranking Member

of the House Transportation and Infrastructure Subcommittee on Aviation 

requested that we review ATSAP. Accordingly, our objectives were to 1) evaluate 

FAA’s progress with implementing ATSAP and 2) assess FAA’s oversight of 

ATSAP.
2

We conducted this audit in accordance with generally accepted Government 

auditing standards. Exhibit A details our scope and methodology.

BACKGROUND

FAA modeled ATSAP after another voluntary safety reporting system used by 

selected air carriers known as the Aviation Safety Action Program (ASAP). 

Similar to ASAP, employees are promised that no punitive or disciplinary actions 

will be taken as a result of reporting errors that could impact safety, provided 

those errors are not the result of gross negligence or illegal activity.

Following an event, or identification of a safety problem, employees can file a 

report online through the ATSAP Web site. The reports are reviewed by ATSAP 

analysts1 who remove personally identifiable information from the reports, link 

multiple reports on the same event, and attach other available information 

regarding the event. Then, Event Review Committees (ERCs) consisting of a 

member of FAA’s Air Traffic Organization (ATO) management, a NATCA 

representative, and a member of FAA’s Air Traffic Safety Oversight Service 

(AOV) evaluate each report submitted to the program to determine whether it 

meets the requirements set forth in the MOU between FAA and NATCA. If so, the 

ERC accepts the report into ATSAP.2

Once an ERC has accepted a report, FAA cannot take disciplinary action against 

the involved employee.

3 However, the ERCs can recommend skill enhancement 

training (SET)4

Accepted ATSAP reports are categorized as either “Safety Problem” or “Event” 

reports. Safety Problem reports address policies, procedures, equipment, or 

publications used to provide air traffic control services. Event reports identify 

actual or potential losses of separation, including operational errors, or other 

situations that may degrade air traffic safety. Prior to FAA’s implementation of a 

revised ATO Order regarding ATSAP in January 30, 2012, event reports were

further categorized

to employees. ERC decisions are made by consensus, meaning 

that all three members of the ERC must agree that the resolution of the event falls 

within their range of acceptable solutions.

5

 1 ATSAP analysts can be contract personnel, FAA bargaining unit employees, or FAA managers.

as follows: 

2 If the reported event is found to potentially involve criminal activity, substance abuse, controlled substances, alcohol, 

or intentional falsification, the MOU stipulates that it must be referred to an appropriate office within FAA for 

further action. If upon completion of subsequent investigation it is determined that the event did not involve any of 

the aforementioned activities, then the report will be referred back to the ERC for a determination of acceptability 

under ATSAP. 3 If information becomes available later which indicates that the report should have been rejected, the ERC can reopen 

the case. 4 SET is individually focused training that is designed to address specific controller performance issues. 5 These categories are not included in the ATSAP MOU, which uses the terms “sole source” and “non-sole source.” 
3

• Known Events—events included in FAA’s Air Traffic Quality Assurance 

system (ATQA)6

• Unknown Events—events that are not reported in ATQA; or 

at the time an ERC reviews the ATSAP report; 

• Other Events—events that the ERC believes may not result in a reportable 

event.

7

RESULTS IN BRIEF

FAA completed ATSAP implementation at all air traffic control facilities in 

October 2010; however, the Agency will need to make significant improvements 

before ATSAP will be able to effectively identify and address the root causes of 

safety risks. As of December 31, 2011, FAA has collected more than 41,000 

reports, and the program shows promise as a tool to promote increased safety 

reporting. Yet, FAA has only recently developed processes to analyze ATSAP 

data to identify safety trends and to share valuable safety data with individual air 

traffic facilities. In addition, due to ATSAP provisions designed to protect 

controller confidentiality, much of the ATSAP data that FAA collects are not 

validated. In particular, unknown events, approximately 50 percent of all ATSAP 

event reports, are not verified for accuracy before being accepted. Furthermore, 

FAA has not yet finalized the process to effectively share ATSAP data so that 

safety improvements can be made at the facility level. Finally, FAA has not 

effectively communicated and implemented changes to performance management 

under ATSAP, including assigning skill enhancement training to controllers.

FAA’s oversight of ATSAP lacks effective program management controls. For 

example, FAA does not have a formal process to review the effectiveness of

decisions made by the program’s review committees. ERCs do not always adhere

to ATSAP report acceptance criteria established in the MOU. In addition, reports 

were accepted into ATSAP that dealt with the conduct of controllers, rather than 

specific safety issues. For example, a report was accepted into ATSAP concerning 

a controller who was watching a video player while on duty. We consider this a 

conduct issue that requires management attention rather than a safety issue 

appropriate for a confidential safety program. While FAA has recently 

implemented a process for dealing with reports that include controller conduct 

issues, this process lacks management oversight. ATSAP ERCs can refer reports

that may include conduct issues to FAA’s Professional Standards Program (PSP)8

 6 ATQA is a FAA database used to capture and store the official investigation reports for air traffic incidents, 

including operational errors. 

for review, but the PSP does not require that actions be documented for 

7

 Reportable events include operational errors and operational deviations. 8 The Professional Standards Program is defined in Article 52 of FAA’s 2009 Collective Bargaining Agreement with 

NATCA. It is designed to allow bargaining unit employees to address conduct and/or performance issues of their 

peers before such issues rise to a level requiring corrective action by the Agency. 
4

accountability, transparency, and resolution. Though most final decisions 

regarding matters referred to the PSP are intended to be made by bargaining unit 

employees at the facility level, if the PSP does not accept the referral, the issue 

may be excluded from the program and handled through more traditional methods. 

Failure to address these issues may lead to the perception that ATSAP is an 

amnesty program in which reports are automatically accepted, regardless of 

whether they qualify under the program’s guidelines.

We are making a series of recommendations intended to improve on the 

implementation of ATSAP and to strengthen FAA’s internal controls, use of data, 

and performance management within the program.

FAA IMPLEMENTED ATSAP, BUT SIGNIFICANT CHALLENGES

WITH IDENTIFYING AND ADDRESSING SAFETY RISKS REMAIN

FAA completed ATSAP implementation nationwide in October 2010 and has 

received over 41,000 reports since the start of the program. ATSAP continues to 

evolve in several key areas that impact FAA’s ability to use ATSAP data for 

identification and mitigation of safety risks. FAA has only recently started to 

develop effective processes to analyze ATSAP data to identify safety trends and is 

still developing processes to communicate valuable safety data to individual 

facilities. In addition, FAA has recently adjusted ATSAP policies and procedures 

to comport with new air traffic orders implemented in January 2012 that change 

how ATSAP reports are processed. The impact of these changes on improving 

FAA’s use of ATSAP is still uncertain. Finally, FAA has not yet resolved issues 

regarding performance management and accountability of controllers brought 

about by the introduction of ATSAP, including the assignment of skill 

enhancement training to controllers.

Deficiencies With ATSAP Data Analysis Limit FAA Efforts To Identify 

and Mitigate Safety Risks 

FAA has begun effectively using ATSAP reports to resolve specific safety issues 

that the ERCs have identified. For example, FAA has developed a formal process 

to ensure that recommendations made by ERCs are implemented. ATSAP can also

be used to elevate previously identified problems to ERCs, who then hold facilities 

or lines of business accountable for corrective action through FAA’s formal 

Corrective Action Request (CAR) process.9

 9 A CAR is a formal request to a FAA line of business requesting corrective action for an identified safety issue. The 

objective of this process is to ensure that important safety issues receive high level visibility.

In one instance, ATSAP was used at a 

Chicago air traffic facility to identify problems with communicating that a runway 

had been shortened due to construction. Through the CAR process, FAA corrected

the issue throughout the National Airspace System (NAS) by issuing an air traffic 
5

order. In another case, FAA used ATSAP data through the CAR process to 

address a long-standing issue involving improper altitude readings during cold 

weather.

While ATSAP has resolved numerous issues, the program’s full potential is not 

being realized because of ineffective data analysis. Although FAA can identify 

high-level trends at the national level, they are not always specific enough for the 

Agency to identify root causes. For example, causal factors are reported quarterly 

under ATSAP using terms such as “actions or plans poorly executed” or “training 

in progress during event,” which are too broad to identify specific mitigating 

actions. 

In addition, the data that FAA relies on for identifying safety trends are often not 

verified for accuracy by the ERCs. As a result, any safety trend FAA develops 

using data from unknown events may not be reliable. Approximately 50 percent of 

all ATSAP event reports are classified as “unknown,” which means that the event 

captured in the ATSAP report was not captured in FAA’s ATQA System10

ERCs are also missing opportunities to validate reports that were classified as 

“unknown.” Some of the events we reviewed that were classified as “unknown,”

and therefore not verified by the ERCs, were known to local management. For 

example, we reviewed a statistical sample of 70 “unknown” reports, and found 

4 reports that specifically referenced conversations with supervisors about the 

event. Based on the results of our sample we estimate that in FY 2011, 302 or 5.7 

percent out of 5,279 “unknown” event reports were incorrectly labeled as 

“unknown.”

before 

it was reviewed by an ERC. When ATSAP reports involve events already in 

ATQA, ERC members are able to confirm the reports’ accuracy by gathering 

information from facilities. However, ATSAP reports for unknown events are not

regularly cross-checked the same way because ERCs do not collect additional 

information on unknown reports in order to protect controller confidentiality. 

According to ERC members, they do not follow up on unknown events because 

doing so would expose controller mistakes to managers at air traffic facilities,

which would then discourage reporting through ATSAP.

11

FAA’s ability to conduct trend analyses has also been adversely impacted by the 

still-evolving nature of ATSAP. The categorical system that FAA uses to identify 

the causes of events in ATSAP has been revised twice since the Agency started its 

pilot program, making it more difficult to perform trend analyses with the older 

data in the system. FAA officials stated that they desire to transition away from 

Since local management was already aware of the event, the data 

could have been verified before the report was accepted.

 10 FAA replaced ATQA with the Comprehensive Electronic Data Analysis and Reporting (CEDAR) system on January 

30, 2012. 11 Our estimate has a margin of error of +/- 241 or 4.6 percentage points at 90% confidence.
6

categorical analysis, and focus more on “text mining,” or reviewing the text in 

reports to identify causal patterns.

FAA Does Not Effectively Communicate Safety Data to Facilities

ATSAP’s current program structure makes it difficult for facilities to access 

information. Direct access to the ATSAP database is restricted to contractor 

employees, and data cannot be released without the consent of all three 

organizations that are involved in ATSAP (i.e., ATO Management, AOV, and 

NATCA). FAA has established a data request process to allow facility managers

to request information collected through ATSAP. However, many facility 

managers that we interviewed stated that the process is time consuming and that 

they were not satisfied with the information that was provided. For example, one 

manager told us that when he requested information regarding his facility’s 

operational errors, the information that he received was so heavily redacted, with 

times and operational positions removed, that he was unable to use it for any 

significant analysis. 

To its credit, the Agency does publish summarized information about incidents 

reported through ATSAP. However, this information is high level, scrubbed of 

personal information, and does not contain details necessary to improve safety at 

individual facilities. For example, information disseminated to facilities is based 

on NAS-wide data, rather than detailing specific, local facility-level issues.

Facility managers that we spoke with stated that information routinely distributed 

by the ATSAP Office in the form of briefing sheets and monthly/quarterly reports 

is not detailed enough to be useful to them.

FAA recognizes that it does not have the resources to respond to all facility data 

requests. To address this concern, FAA plans to develop a method to provide 

facilities with access to additional safety data, through a pilot program that began

at five facilities in January 2012. Pending the results of the pilot, facility managers

and personnel will be able to use a new data portal to access information (both 

qualitative and quantitative) that is specific to their facilities. FAA expects the 

rollout of the new program to be completed by the end of FY 2012.

New Air Traffic Orders That Affect ATSAP Report Classification May 

Not Improve the Program

FAA implemented new air traffic orders on January 30, 2012, that change how 

FAA organizes, categorizes, and stores ATSAP data.

12

 12 FAA Order JO 7200.20. Voluntary Safety Reporting Programs (VSRP). January 30, 2012.

Under these orders, several 

adjustments to ATSAP reports have been made. For example:
7

• Due to difficulties in coming to consensus when ERCs apply the term “gross 

negligence,” FAA and NATCA agreed to supplement the ATSAP MOU by 

adding “knowingly introduced an unacceptable level of risk” to the 

program’s report acceptance criteria. However, this change in acceptance

criteria may not lead to a clear and consistent resolution of the problems 

faced by the ERCs, due to the subjective definition of what constitutes 

“knowingly introducing an unacceptable level of risk.”

• The categories of “unknown,” “known,” and “other” reports are eliminated

under the new orders. Instead, FAA is transitioning ATSAP to a sole 

source/non-sole source system similar to airline ASAP agreements. However, 

the ATSAP MOU is much more generous than ASAP MOUs in regard to 

what qualifies as “sole-source.” ASAP considers a sole-source report to be 

any report where all evidence of the event available to FAA or the air carrier 

is predicated on the ASAP disclosure. The MOU between FAA and NATCA 

expands the sole-source category to include allowing an ATSAP report to be 

filed any time a controller has had an operational error or deviation. Solesource reports are exempt from the MOU requirement that all ATSAP reports 

must be submitted within 24 hours of learning of the event, and in order to 

protect reporter confidentiality, the ERCs will not contact facilities if they 

believe an event is unknown to management. While this system could bolster 

confidence in ATSAP’s confidentiality, it also prevents facility management 

from becoming aware of potential safety problems.

While FAA’s new orders are an attempt to address several issues with ATSAP, it 

is unclear whether these changes will result in needed improvements to the 

program. They also may lead to new challenges depending on how they are 

implemented and interpreted by FAA and the ERCs. 

Facility Managers Do Not Always Understand Their Rights and 

Obligations Under ATSAP

For ATSAP to work effectively, it is important for management at individual 

facilities to understand their role in the program. FAA has not effectively

communicated management rights and responsibilities under ATSAP to facility 

managers. For example, while FAA is not allowed to take punitive action against 

controllers, such as decertification, for events that are accepted into ATSAP,

managers are allowed to conduct a post-event review, and “coach” a controller on 

reported incidents. However, ERC members, facility managers, union 

representatives, and other officials indicated that there are still significant issues at 

the facility level with managers understanding what actions they were permitted to 

take under ATSAP. 
8

During ATSAP implementation, FAA provided training to facility managers and 

bargaining unit employees prior to program initiation at individual air traffic 

control facilities. However, both facility and ATSAP officials stated that the 

training did not adequately address ATSAP performance management 

expectations. Possibly as a result of ineffective management training, we found 

examples of local facility managers under the erroneous impression that once an 

ATSAP report had been filed, they could no longer discuss the event with 

employees. Because of this misconception, it was very difficult to improve the 

controller’s performance or address specific issues. FAA has attempted to address 

these issues by holding workshops for front-line managers, and providing 

additional training to air traffic management.

FAA Has Not Yet Resolved Issues Regarding Post-Event Skill 

Enhancement Training

As FAA works to implement further improvements to the ATSAP program, the

Agency will be challenged with addressing issues related to the assignment of skill 

enhancement training (SET) following significant safety events. Under the current 

program, facility managers can recommend training for controllers who submit an 

ATSAP report. However, ERCs can accept, modify, or reject these management 

recommendations, or the ERCs can assign the training on their own. ERCs 

typically concur with training recommendations that specifically address identified 

skill deficiencies in controllers who have a demonstrated “performance history”—

i.e., controllers who were involved in multiple losses of separation events or had 

other documented performance issues. Our review, however, found that ERCs 

rarely assign SET. For example, in FY 2011, ERCs assigned this training in only 

about 1.3 percent of the 8,500 known and unknown reports,13

Moreover, facility managers interviewed during this audit consistently expressed 

concern about the rejection or reduction of their training suggestions by the ERCs.

For example, one ERC rejected a training recommendation for a developmental 

controller

or 108 of those 

cases.

14

 13 This represents the population of known reports (approximately 3,200) and unknown reports (approximately 5,300) 

for FY 2011.

who was responsible for a serious loss of separation between a general 

aviation airplane and a Boeing 737 airliner. Although facility management clearly 

expressed that the controller needed the training, the ERC rejected the request due 

to “a lack of performance history.” However, this was the first control position on 

which the controller had been certified, and the controller had only been certified 

on the position for 8 days—making it unlikely that he/she would have had a 

14 Controller trainees assigned to an air traffic control facility are considered “developmental” controllers until they 

have fully qualified as Certified Professional Controllers (CPCs). Developmental controllers that have certified on a 

given sector can independently work that sector, as they continue training to certify on the rest of their area sectors. 

However, developmental controllers do not become fully qualified as CPCs until they certify on all sectors within 

their assigned facility areas.
9

documented performance history. Although the facility manager clearly expressed 

concern about this controller’s skills to the ERC, the requested training was 

denied.

In addition, ERCs rarely assign SET for unknown events due to concerns about 

reporter confidentiality. According to ERC members, if a controller was assigned 

training in response to reporting an unknown event, managers at the controller’s 

facility may become aware that an ATSAP report was submitted and reprimand 

the controller. Even though the reason for the assignment would remain unknown 

to management,

15

FAA’S OVERSIGHT OF ATSAP LACKS MANAGEMENT 

CONTROLS IN KEY AREAS

the controller could view reporting through ATSAP as nonconfidential. Our review revealed that many controllers perceive SET as punitive,

and ERC members expressed concerns that assigning training for “unknown” 

events would discourage personnel from reporting through ATSAP. However, as 

SET is designed to address the performance deficiencies of air traffic personnel 

that are identified by the ERCs, FAA may be missing opportunities to correct 

issues that affect safety.

FAA has not instituted sufficient management controls in key areas to effectively 

oversee ATSAP. For example, FAA does not have a formal process for reviewing 

or analyzing the decisions made by the ERCs. In addition, FAA and ATSAP 

officials do not always comply with the criteria in the MOU that determines when 

reports should be accepted. ATSAP guidance also does not disqualify reports that 

involve aircraft accidents. Lastly, FAA’s process for handling ATSAP reports 

involving potential misconduct lacks oversight.

FAA Does Not Review the Effectiveness of ERC Decisions

FAA does not have a formal process for reviewing the decisions made by ERCs.

As a result, FAA may have difficulty identifying whether ERC decisions regarding 

reports, CARs, and SET are actually improving the safety of the NAS. For 

example, FAA does not track how often an ERC rejects or modifies a SET request 

from a facility and therefore cannot oversee whether ERCs are making these 

decisions in the best interest of improving safety.

In addition, ERCs are making decisions on ATSAP reports without important 

information about the report submitters. In particular, the ATSAP system does not 

have an automatic flag to alert ERCs of controllers who have submitted multiple 

reports on the same issue. Currently, ATSAP does not automatically link a current 

 15 The fact that SET is assigned to a particular employee is documented; however, the NATCA ERC member will 

contact and work directly with only the submitters and their facility NATCA representatives.
10

report with past reports submitted by the same person. While ATSAP analysts 

have access to this information and can provide it to ERCs upon request, analysts 

we interviewed stated that producing that information can be very time 

consuming. One analyst stated that an ERC discovered by chance that one

submitter had already submitted 49 previous ATSAP reports.16

FAA has also not yet developed a formal process for evaluating the effectiveness 

of SET or for identifying best practices that might result from ATSAP reports.

ERC members stated that they want to change how SET was assigned prior to 

ATSAP, because managers would assign ineffective training in a cookie cutter 

approach to dealing with operational errors or controller weaknesses rather than 

addressing the causes of errors. However, the lack of a formal process has 

hindered FAA’s ability to assess the effectiveness of the training, or identify best 

practices to improve the training that is assigned by the ERCs. While the new 

orders that were implemented in January 2012 require that the ATSAP program 

manager conduct periodic reviews in order to assess the effectiveness of SET 

assignments, this process has not yet been completed. 

Our review found 

that as of July 2011, there were 6 employees who had each submitted over 100 

reports. While many of these reports may represent safety problems identified by 

controllers, rather than operational errors, repeat submitters warrant additional 

scrutiny by ERCs to ensure they are not overlooking potential safety concerns.

Provisions of the ATSAP MOU Have Not Been Enforced

We found instances where FAA is not enforcing key provisions of the MOU

between FAA and NATCA that establishes the guidelines and requirements for the 

program. These include issues with timeliness of ATSAP reports, lack of clarity 

on key terms in the ATSAP MOU, inappropriate voting on reports that ERC 

members personally submitted, and acceptance of ATSAP reports that involve 

controller conduct or behavior issues. 

Per the MOU, controllers are required to submit non-sole source reports within 24 

hours of the event, or of learning of the event. Sole-source reports, which include 

all losses of required separation submitted through ATSAP, are exempt from this 

requirement. However, in some cases, at management instruction, ERCs have been 

ignoring report submission deadlines in order to increase workforce acceptance of 

the program. This non-compliance allows a controller who is involved in an event

to postpone submitting a report until it becomes apparent that the event will be 

discovered, thus providing an incentive to not report all events.

In addition, the program does not provide sufficient guidance for the definition of 

“gross negligence.” We found that ERCs have rejected very few ATSAP reports 

 16 ATSAP guidance states that the number of reports that an employee has submitted should not be central to ERC 

decisions. However, a history of repeated non-compliance would be considered by the ERC when making a decision. 
11

for gross negligence on the part of the controller. As of December 2011, only 8 of 

over 28,000 safety event reports had been rejected for violation of paragraph 

10a(2) of the ATSAP MOU, which includes gross negligence. ERC members 

stated that gross negligence is one of the most difficult terms on which they have 

to come to consensus due to the lack of a clear guidance on how to distinguish 

between simple and “gross” negligence. As we discussed earlier in this report, 

FAA has recently introduced new language through the new air traffic orders that 

may help further define the criteria that ERCs use to determine whether to accept a 

report. However, it remains to be seen whether this will be the case. 

We also found that FAA lacks formal controls to prevent ERC members from 

reviewing reports that they confidentially submitted. According to ERC and 

program officials, NATCA representatives assigned to ERCs have participated in 

discussions and voted on reports that they personally submitted on safety 

problems. While FAA and NATCA have informed ERC members that they may 

not participate in discussions or vote on reports that they submitted, the MOU, 

Order, and other program guidance do not explicitly prohibit it. In addition, 

personally identifiable information is removed from reports before they are 

reviewed by the ERC, preventing the other ERC members from becoming aware 

of a potential conflict.

Finally, reports have been accepted in ATSAP that suggest air traffic controller 

conduct issues, rather than performance deficiencies. These include controllers 

falling asleep, viewing a personal video player while on position, and refusing to 

take handoffs

17

Aircraft Accidents Involving Potential Controller Error Are Eligible for 

ATSAP Processing, Thus Limiting Accountability and Safety 

Investigations 

in a timely manner. Although the ATSAP MOU, Order, and

program guidance do not specifically exclude these types of reports, we question 

whether they are appropriate for a confidential reporting program such as ATSAP. 

Because these reports were accepted into ATSAP, the controllers involved were 

immune from potential disciplinary actions for their conduct. While these 

represent a very small number of reports in the context of the 41,000 that have 

been accepted as of December 2011, accepting reports of this nature may lead to 

the incorrect perception that ATSAP is an amnesty program where reports are 

automatically accepted.

ATSAP currently allows reports involving accidents (including fatal accidents) to 

be accepted into the program, similar to ASAP. In our May 2009 report on 

 17 Handoff - An action taken by air traffic controllers to transfer the radar identification of an aircraft from one 

controller to another if the aircraft will enter the receiving controller's airspace and radio communications with the 

aircraft will be transferred.
12

airlines’ ASAPs,

18

The ATSAP MOU contains similar language in regard to its stated purpose, and 

does not exclude reports that involve accidents from the program. FAA believes 

that allowing reports that are involved in accidents into the program will 

encourage controllers to be open and honest following an accident, which will 

result in more information being gathered immediately following an accident. 

However, since all accidents are reported to FAA and investigated thoroughly by 

both FAA and the NTSB, it is unlikely that any significant unknown information 

would be gleaned through acceptance of any accident into ATSAP. In addition, 

given the potential severity of an accident, we question whether it is appropriate to 

accept reports into a program that eliminates that possibility of disciplinary action 

against an employee who may have contributed to an accident. 

we recommended that FAA exclude reports involving accidents 

from ASAP eligibility. We stated that they undermined ASAP’s fundamental 

purpose—to gain access to safety information that might otherwise remain 

unknown—by allowing employees to report safety violations that contributed to 

an accident without fear of reprisal through legal or disciplinary actions. FAA did 

not agree with our recommendation, stating that accepting accident reports into 

ASAP may result in a faster analysis, due to the extended time it takes to formally 

investigate an accident. FAA added that it would consult with the National 

Transportation Safety Board (NTSB) on this matter. However, this 

recommendation is still open.

ATSAP Processing of Controller Misconduct Reports Lacks 

Transparency and Accountability

FAA has recently implemented a separate process for handling accepted ATSAP 

reports that involve controller misconduct that does not rise to the level of gross 

negligence. ERCs refer reports that involve potential controller misconduct to the 

Professional Standards Program (PSP). The PSP is designed to allow bargaining 

unit employees to address conduct or performance issues of their peers before such 

issues rise to a level requiring corrective action by the Agency.

However, FAA’s management oversight of the PSP is limited, and there is 

minimal transparency behind the PSP’s decisions. For example, final resolution of 

misconduct issues is conducted at the facility level by a committee that is solely 

composed of bargaining unit employees.

19

 18 OIG Report No. AV-2009-057. May 14, 2009. OIG reports are available on our Web site at 

In addition, the agreement between 

FAA and NATCA that established the PSP does not allow records to be kept on 

individual PSP decisions. As a result, the referring ERC does not receive specific 

information on the disposition of any issue referred to the PSP, only notification 

that the issue has been “resolved.” As a result of this lack of oversight and 

http://www.oig.dot.gov/. 19 Not all facilities have their own committees. In those cases, a labor representative of the National PSP workgroup is 

assigned. 
13

transparency, FAA cannot evaluate whether PSP decisions fairly and appropriately 

resolve any potential misconduct issues reported through ATSAP, which also 

limits FAA’s ability to hold the PSP accountable for any actions taken.

CONCLUSION

With reported numbers of operational errors by controllers on the rise, it is critical 

that FAA determine the root causes of these safety issues and mitigate their risk.

FAA’s ATSAP could provide an opportunity to enhance the collection of safety 

data through voluntary, non-punitive reporting. However, FAA must overcome 

significant implementation and oversight challenges before ATSAP can realize its 

full potential as an effective tool for identifying and addressing safety risks. Until 

FAA provides better enforcement of the terms agreed to in the ATSAP MOU, 

focuses its trend analyses on root causes, enhances communication with facilities, 

and ensures that the decisions made regarding reports are true to the intent of the 

program, FAA’s ability to improve the safety of the National Airspace System 

through ATSAP will be diminished.

RECOMMENDATIONS 

To enhance FAA’s use of ATSAP data and improve internal oversight controls for 

the program, we recommend that FAA:

1. Perform analysis to determine the root causes of incidents reported through 

ATSAP.

2. Expedite the development of a process to provide facility access to ATSAP 

data.

3. Provide recurring training to front line management regarding their rights and 

responsibilities under ATSAP.

4. Create a system to track best practices when assigning skill enhancement 

training, and communicate these best practices to facility management. 

5. Establish a periodic review of ERC actions.

6. Enact a written policy that forbids ERC members from discussing or voting 

on reports that they have submitted and require ERC members to attest that 

they are not personally involved in any reports that will be discussed before 

every ERC meeting.

7. Develop an automated “flag” to easily identify repeat ATSAP report 

submitters.

8. Provide clear guidance to ERCs on what constitutes “knowingly introducing 

an unacceptable level of risk.”
14

9. Develop a process permitting ERCs to validate all reports submitted to 

ATSAP. 

10. Revise ATSAP guidance to exclude accidents from the program. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

We provided FAA with a draft copy of this report on May 17, 2012, and received 

FAA’s response on June 15, 2012. FAA’s response is included in its entirety in the 

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

recommendations 1, 2, 3, 5, and 7 and provided reasonable timeframes for 

completing the planned actions. FAA partially concurred with recommendations 4, 

6, and 8 and has either begun to fully institute our recommendations or has 

provided satisfactory alternative courses of action that meet our intent, also within 

reasonable timeframes. FAA did not concur with recommendations 9 and 10, and 

we are requesting that the Agency reconsider its responses. 

For recommendation 9, FAA did not agree to develop a process permitting ERCs 

to validate all reports submitted to ATSAP, inferring that maintaining strict 

confidentiality supersedes the need for reliable and accurate data. In addition, 

FAA claimed that ATSAP ERCs validate a far higher number of reports than any 

other FAA confidential voluntary reporting program. However, at the time of our 

review, approximately 50 percent of accepted ATSAP reports were categorized as 

“unknown” events and were not captured or investigated through FAA’s quality 

assurance system when they were considered by an ERC. As a result, about half of 

the data collected through ATSAP is not verified for authenticity or accuracy, and 

any trend analyses performed for identifying and mitigating hazards that depend 

on ATSAP data must be considered unreliable at best. While FAA has changed 

how it categorizes ATSAP reports,20

For recommendation 10, FAA did not agree to exclude accidents from ATSAP,

stating that employees may be more accurate and candid in an ATSAP report than 

they might be in interviews with either NTSB or FAA. We disagree with this 

assertion. In our opinion, aviation professionals should understand that it is their 

responsibility to be candid with a Federal investigator after an accident. Further, 

while accident investigations may take several years to complete, NTSB teams

usually arrive on accident scenes within hours, question witnesses immediately, 

the underlying issue of not contacting 

facilities or investigating events to validate reports before accepting them still 

remains. Given the importance of accurate data for meeting FAA’s goals of 

improving safety, we request that the Agency reconsider its position.

 20 As of January 31, 2012, FAA no longer classifies event reports as “known”, “unknown”, or “other”, and has replaced 

those categories with “sole-source” and “non-sole-source.”
15

and have far greater investigative resources and skills than ERC members. 

Therefore, we continue to maintain that accidents should be excluded from 

ATSAP and request that the Agency reconsider its position.

ACTIONS REQUIRED

We consider recommendations 1, 2, 3, 4, 5, 6, 7, and 8 resolved but open pending 

the completion of the actions taken or planned. However, we request that FAA 

reconsider its position regarding recommendations 9 and 10. In accordance with 

DOT Order 8000.1C, please provide your written response regarding 

recommendations 9 and 10 within 30 days of issuance of this report.

We appreciate the courtesies and cooperation of FAA and NATCA representatives 

during this audit. If you have any questions concerning this report, please contact 

me at (202) 366-0500 or Bob Romich, Program Director, at (202) 366-6478.

#

cc: Pierre McLeod, AAE-100

Martin Gertel, M-1
16

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. 

The audit was conducted between June 2011 and May 2012, and included site 

visits to FAA and NATCA Headquarters, nine Terminal Services facilities 

(ATCTs and TRACONs), six ARTCCs, and three ATO Service Centers. In 

addition, we interviewed representatives of the FAA Managers Association, CSSI 

Inc., and NTSB. A full list of the 15 air traffic facilities we visited or contacted 

during this audit—which were selected based on their geographic location and 

facility type—can be found in Exhibit B.

To evaluate FAA’s progress with implementing ATSAP, we compared FAA’s 

stated goals of ATSAP to benefits that were actually being derived from the 

program. This included assessing FAA’s approach to using the data collected 

through ATSAP as a way to improve safety. We also evaluated how ATSAP 

reports are processed and how the program has impacted the operational 

functionality of air traffic facilities. We did this by meeting with air traffic 

managers, ATSAP officials, and ERC members, and then identifying areas where 

ATSAP could be improved. As ATSAP is an agency-wide program, we conducted 

site visits and interviewed FAA air traffic officials at air traffic control facilities to 

determine if a uniform set of procedures were being followed throughout the NAS.

Due to the confidential nature of the program, we selected two statistical samples: 

(1) 70 out of 5,279 “unknown” and (2) 70 out of 3,194 “known” redacted ATSAP 

reports. We analyzed these samples to determine whether ATSAP reports were 

being categorized correctly. We also identified information that FAA could use in 

these reports to improve safety

To assess FAA’s oversight of ATSAP, we reviewed the guidelines and policies 

that FAA created for ATSAP. To determine if they were being adhered to, we met 

with air traffic managers, ATSAP officials, and ERC members, and compared

ATSAP’s policies to what was actually being practiced. We also evaluated the 

controls that FAA has in place to prevent abuse of ATSAP and to ensure that the 

program is used to improve safety.
17

Exhibit B. Organizations Visited or Contacted

EXHIBIT B. ORGANIZATIONS VISITED OR CONTACTED

FAA Headquarters

Air Traffic Organization (ATO)

Air Traffic Safety Oversight Service (AOV) 

Air Traffic Control Facilities

Washington ARTCC

Potomac TRACON

Hartsfield-Jackson Atlanta ATCT

Atlanta ARTCC

Atlanta TRACON

Salt Lake City ATCT/TRACON

Salt Lake City ARTCC

Memphis ARTCC

Memphis ATCT/TRACON

Chicago O’Hare ATCT

Chicago TRACON

Chicago ARTCC

Minneapolis ARTCC

Minneapolis ATCT/ TRACON

Cleveland ATCT/TRACON

ATO Service Areas

ATO Eastern Service Area, Atlanta, GA

ATO Central Service Area, Fort Worth, TX

ATO Western Service Area, Seattle, WA

Other Organizations

National Air Traffic Controllers Association 

FAA Managers Association

National Transportation Safety Board
18

Exhibit C. Major Contributors to This Report

EXHIBIT C. MAJOR CONTRIBUTORS TO THIS REPORT

Name Title

Robert Romich Program Director

Christopher Frank Project Manager

Erik Phillips Senior Analyst

Andrew Olsen Auditor

Audre Azuolas Writer/Editor

Seth Kaufman Senior Counsel

Petra Swartzlander Statistician
APPENDIX. AGENCY COMMENTS 19

Appendix. Agency Comments

Federal Aviation

Administration

Memorandum

Date: June 15, 2012

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: FAA Response to OIG Draft report: Long Term Success of ATSAP Will 

Require Improvements in Oversight, Accountability, and Transparency

Since the beginning of implementation in mid-2008, no other safety program has 

identified and fixed more local and systemic issues than the Air Traffic Safety Action 

Program (ATSAP). Since this time, ATSAP Event Review Committees (ERCs) have 

issued 79 corrective action reports, 59 of these have received responses to which ERCs 

have concurred, and 29 have been fully implemented and closed. In addition, ATSAP 

has begun information sharing with several airlines’ Aviation Safety Action Programs

(ASAP), which has already yielded safety benefits for the airlines and the Air Traffic 

Organization (ATO). While the Federal Aviation Administration (FAA) agrees that 

improvements in oversight and transparency can and will be achieved for the ATSAP, 

guidance regarding accountability has already been improved and ATSAP has made 

numerous contributions to the FAA’s safety mission. The FAA appreciates the 

recommendations in your report and will use them to improve guidance and training for 

ERC members and analysts, as well as in communicating trends to the field. Attached as 

an addendum, is a summary of national issues addressed by ATSAP. 

RECOMMENDATIONS AND RESPONSES

Recommendation 1: Perform analysis to determine the root causes of incidents reported 

through ATSAP.

FAA Response: Concur. The FAA is working with the ATSAP primary contractor, 

CSSI Inc., and also with the MITRE Corporation through the Aviation Safety 

Information and Analysis System (ASIAS) to improve the determination of the root 

causes of incidents reported through ATSAP. This update will be complete by end of 

fiscal year (FY) 2012.
20

Appendix. Agency Comments

In addition, the ATSAP Office undertook a thorough review of the existing ATSAP 

database in 2011 to better identify causal and contributory factors and determine ways to 

improve their identification. The Program Office enlisted the assistance of independent 

research scientists specializing in the discipline of Human Factors (Michael Sawyer, 

PhD, and Katherine Barry, PhD, both now with the Fort Hill Group) to revise and add 

questions from the ATSAP submitter form to better enable the identification of causal 

and contributory factors in accordance with a Human Factors Analysis and Classification 

System taxonomy being developed for use across the Air Traffic Organization (ATO). 

That work resulted in a revised version of the ATSAP submitter form, which allowed the 

submitter to self-identify individual and organizational factors contributing to an incident. 

The form was introduced in May 2011. The same body of work formed the basis of a 

common taxonomy project that will allow similar causal and contributory factors to be 

identified by the Event Review Groups, Risk Analysis panels, Quality Assurance 

Reviews and other types of investigations and audits across the ATO. The FAA will 

have one year of data under the new taxonomy system as of June 1, 2012 and a 

significantly improved ability to analyze that data to determine root causes.

Additionally, two existing programs already provide the ability to use ATSAP and other 

industry ASAP reports in trend analysis; 1) the Aviation Safety Reporting System 

(ASRS) and, 2) ASIAS. The ASRS system is a reporting program through which 

individuals voluntarily and non-punitively provide safety information. The majority of 

ASRS reports received from air traffic employees are, in fact, ATSAP reports. The 

National Aeronautics and Space Administration, who maintains the ASRS database (to 

provide impartiality and ensure submitter confidentiality), routinely, provides “Alerts” to 

the FAA concerning safety issues identified from ASRS submissions. The FAA is also 

committed to the establishment of ASIAS as a centralized system for the acquisition and 

analysis of ASAP (including ATSAP) and other safety-related information at a national 

level. ATSAP data has been shared with ASIAS since early in the program’s inception, 

and it is included in all of the directed studies being conducted at the direction of the 

ASIAS Executive Board. 

Recommendation 2: Expedite the development of a process to provide facility access to 

ATSAP data.

FAA Response: Concur. Work on this effort is ongoing. A web-based Safety Data 

Portal, to be used by facilities with approved local safety councils, has been prototyped 

and is undergoing test and evaluation by representatives from eight air traffic facilities. 

This portal is part of a program being deployed within ATO’s Partnership for Safety 

program. Portal development has been supported by the MITRE Corporation under the 

direction of the FAA and will contain quantitative data such as weather, track and 

National Offload Program data, and Mandatory Occurrence Reports as well as qualitative 

data from ATSAP. Available ATSAP information will include general topics being 

reported by employees at the user’s facility, certain common terms identified through 

semantic text mining, and the primary causal and contributory factors being reported. 

Facility-specific information will be compared to aggregated data. Testing and 

evaluation of the Safety Data Portal system is scheduled to be completed in time for a 
21

Appendix. Agency Comments

national deployment by the end of calendar year (CY) 2012. At that time, portal access 

will be available to all facilities with approved local safety councils.

Recommendation 3: Provide recurring training to front line management regarding their 

rights and responsibilities under ATSAP.

FAA Response: Concur. In conjunction with the introduction of the JO 7200.20 

Voluntary Safety Reporting Programs Order, a computer-based course in the electronic 

Learning Management System ((eLMS), course 60004561, part of Proactive Safety 

Management Training) was introduced in December 2011 and required for all operational 

personnel who maintain familiarity or currency in the Terminal and En Route operational 

environment, including Traffic Management personnel. The required completion date 

was January 30, 2012. The module included an overview of the 7200.20 Order, which 

outlines management responsibility after an event. The Order contains the following 

language:

7200.20 Chapter 3 (ATSAP) section 3-5 c. - Facility Manager must...:

(c) Provide the ERC all relevant information or Skill Enhancement Training (SET) 

recommendations within 3 administrative days of notifying the employee of the event. A 

review of an employee’s performance during an occurrence is not disciplinary in nature. 

Such a review is necessary to consider whether additional action is appropriate. 

Supporting information must accompany any recommended corrective action.

NOTE: The ERC is interested in any additional information that the facility 

management, union representative, and submitter can provide that would help the ERC 

understand not only what happened during a safety event, but also why the event 

happened. If the facility intends to propose SET, they must supply the information relied 

upon to make that recommendation such as: relevant portions of the employee’s 

performance history, involvement in similar types of events, any ongoing training, and 

other performance directly related to this type of event. A joint proposal from facility 

management and the union representative provides the most useable feedback for the 

ERC.

The ATSAP recurrent training eLMS course 68000277 was introduced in February 2012, 

as mandatory training for all operational personnel who maintain familiarity or currency 

in the Terminal and En Route operational environments, including Traffic Management 

personnel. All front line managers and operational managers who maintain currency are 

required to complete the module prior to October 31, 2012.

ATSAP ERC members also participate in the Operational Supervisor’s Workshops 

(OSW) on a monthly basis. This training provides front line managers with recurrent 

training on the ATSAP processes, roles and responsibilities of program participants, etc. 

The OSWs also provide front line managers with the ability to directly ask questions of 

ERC members.
22

Appendix. Agency Comments

Recommendation 4: Create a system to track best practices when assigning skill 

enhancement training, and communicate these best practices to facility management.

FAA Response: Partially concur. The ATSAP Office has already created a repository 

of the types of SET for which positive feedback has been received from either the 

participant or the facility. This tool is available to all ATSAP ERC members and is 

maintained and updated. The FAA agrees that training development personnel in ATO 

Safety and Technical Training should solicit feedback about the training that they 

develop and maintain. Technical Training will request this feedback by the end of CY 

2012. The FAA does not agree that this is an ATSAP ERC responsibility.

The fundamental tenet of voluntary safety reporting is that self-learning and selfcorrection occur as the result of reporting. Thinking through the actions and conditions 

that led to an incident, understanding why it happened, and writing a recommendation 

that details how the individual would act differently to avoid a similar action, mistake, or 

outcome in the future provides a significant learning opportunity. This is a primary 

benefit of any confidential voluntary safety reporting program. Available research on 

human error does not support the concept that controllers and pilots primarily make 

mistakes because they have not been appropriately trained or are not properly qualified 

and that some form of external instruction is the preferred response.

Recommendation 5: Establish a periodic review of ERC actions.

FAA Response: Concur. The ATSAP Office has begun work to adapt an audit form 

used by the Flight Standards Voluntary Reporting Programs Branch (AFS-230) to the 

needs of the air traffic control-specific program and will complete this work by the end of 

FY 2012. Audit responsibilities will be added to the ATSAP Administration Manual by 

the end of FY12.

Recommendation 6: Enact a written policy that forbids ERC members from discussing 

or voting on reports that they have submitted and require ERC members to attest that they 

are not personally involved in any reports that will be discussed before every ERC 

meeting. 

FAA Response: Partially Concur. The ATSAP Office has added a statement to the 

confidentiality agreement that all ERC members are required to sign, which reads:

"I agree that I will recuse myself from participating in the resolution of any ATSAP 

report that I submit." 

This statement has already been added to the agreement and notification sent to the 

National Air Traffic Controllers Association ERC members requesting an affirmative 

response. The confidentiality agreement is currently an attachment to the 7200.20 Order 

and will be updated in the first revision, therefore becoming part of the ATSAP 
23

Appendix. Agency Comments

Administration Manual. In addition, this requirement has been added to the new ERCmember training synopsis.

Recommendation 7: Develop an automated “flag” to easily identify repeat ATSAP 

report submitters.

FAA Response: Concur. A programming request will be submitted and programming 

should be updated by the end of FY 2012. 

The flag will only identify whether an individual has previously submitted an ATSAP 

report; not reports concerning a similar instance of noncompliance. Identifying whether a 

similar instance of noncompliance occurred requires an analyst to manually review all 

reports submitted by an individual. The single comment attributed to an ATSAP analyst 

in this audit report does not specify whether or not there were 49 similar events or only 

safety problems reported by a submitter. Many individuals file multiple reports about 

issues they consider safety problems; in fact, ATSAP training encourages them to do so. 

For example, during the implementation of En Route Automation Modernization 

(ERAM), some individuals filed dozens of reports about their experience with the new 

software. Those reports were shared with the ERAM Implementation Office and proved 

to be invaluable in early identification and resolution of programming issues.

In the case of a repeat submitter, the ERC will still have to determine whether causal 

factors are similar and could be corrected by some individual action. Frequent reporting 

does not in and of itself indicate the submitter has performance issues; only that a 

submitter has filed numerous reports. Conversely, because an individual has never 

submitted a report that does not indicate they have never violated a requirement or been 

involved in an event. 

Recommendation 8: Provide clear guidance to ERCs on what constitutes “knowingly 

introducing an unacceptable level of risk.”

FAA Response: Partially concur. The FAA will provide ERC members with training 

that provides examples of actions that could constitute intentional introduction of an 

unjustifiable level of risk. This training will be developed and conducted by the end of 

CY 2012. However, since each situation is unique with distinct circumstances, it is not 

possible to provide in such training a definitive outcome for every possible scenario. For 

example, one of the incidents cited as evidence of a “conduct issue, rather than a 

performance deficiency” was one in which a controller fell asleep. The ERC determined 

there were mitigating circumstances in this isolated case and the FAA ultimately 

corrected several systemic issues. 

Recommendation 9: Develop a process permitting ERCs to validate all reports 

submitted to ATSAP.

FAA Response: Non-concur. ATSAP ERCs validate a far higher number of these 

subjective confidential reports through recorded means than any other ASAP.
24

Appendix. Agency Comments

Additionally, the FAA wishes to emphasize the importance of confidentiality in voluntary 

safety reporting programs. If an incident is not logged in the Comprehensive Electronic 

Data Analysis and Reporting system and a submitter indicates they told their supervisor 

or Controller-in-Charge about it and an ATSAP analyst contacts the facility to validate an 

event, such action may violate the confidentiality of the submitter.

Recommendation 10: Revise ATSAP guidance to exclude accidents from the program.

FAA Response: Non-concur. The FAA understands the analysis that resulted in this 

recommendation; however, we remain concerned that excluding accidents from ATSAP 

(along with any other ASAP) may have unintended consequences. The FAA provided 

similar comments in response to the OIG’s recommendation in the May 2009 audit of 

ASAP. While it is true that accidents are fully investigated by either the FAA or the 

National Transportation Safety Board (NTSB), those investigations often take several 

years to complete. 

Investigations benefit from the most detailed and candid recollections of the people 

involved in the event. Because ATO employees trust the ATSAP process, it is possible 

they will be more accurate and candid in an ATSAP report than they might be in 

interviews with either NTSB or FAA. In addition, an ATSAP report requires that the 

ERC review and recommend corrective actions in a short time frame. This quick 

response allows for safety risks to be mitigated before either FAA or NTSB completes 

their formal investigations. Excluding accidents from the ATSAP program may risk 

losing important details that those involved recall directly after an event. It may also 

delay safety enhancements that can benefit the ATO, employees, and the traveling public. 
25

Appendix. Agency Comments

Attachment: ATSAP Accomplishments

See the following list of safety issues identified and in many cases corrected. 

Examples of National Issues addressed by ATSAP 

Included in the examples below are instances where ATSAP identified and took action to 

correct national or National Airspace System (NAS)-wide safety issues. In some cases, 

the information that was reported through ATSAP and supported by existing objective 

FAA data was so overwhelming that national Corrective Action Requests (CARs) were 

issued prior to the completion of the national rollout of ATSAP. In addition to NASwide CARs, ATSAP has also provided valuable information to many other projects and 

initiatives. 

1. CAR 005a: Issued March 8, 2010 identifying a NAS-wide safety issue relating to the 

use of the term “Full Length” during airport construction where the runway has been 

shortened and a displaced threshold is in place. 

2. CAR 013: Issued March 26, 2010 identifying a confliction between FAAO 7110.65 

paragraphs 2-1-14, 5-4-5 and 5-4-6, and the introduction of risk into the NAS 

concerning responsibility of point-out procedures. 

3. CAR 019: Issued May 25, 2010 identifying a long-standing issue concerning the 

introduction of risk into the NAS concerning Cold Weather Altimeter Settings. 

ATSAP was able to provide additional information to those working the issue that 

was previously not available. 

4. CAR 023: Issued June 14, 2010 identifying a NAS-wide safety issue concerning 

Similar Sounding Call signs. ATSAP was able to provide information previously not 

available to the aviation community. 

5. CAR 024: Issued June 24, 2010 identifying a NAS-wide safety issue concerning 

Navigation Aid (NAVAID) use limitations. 

6. CAR 025: Issued July 12, 2010 identifying a NAS-wide safety issue concerning the 

implementation and training of Traffic Management Advisor (TMA). 

7. CAR 031: Issued August 20, 2010 identifying a NAS-wide safety issue concerning 

Weather Deviation procedures. 

8. CAR 2010-008: Issued February 24, 2011, which identified a NAS-wide safety issue 

concerning the lack of a systematic and efficient manner to identify changes to charts 

when these occur on the 28-day interim cycle and the 56-day cycle.

9. CAR 2010-036: Issued October 22, 2010 identifying a NAS-wide safety issue relating 

to Air Force Reserve (AFRES) 53rd Weather Reconnaissance Squadron aircraft 

(using call sign TEAL) and National Oceanic and Atmospheric Administration 

(NOAA) aircraft conducting Hurricane Hunter operations. 

10. CAR 2010-040: Issued November 17, 2010 identifying a NAS-wide safety issue 

concerning aircraft deviating into active Special Use Airspace (SUA) during adverse 

weather events. 

11. CAR 2010-044: Issued December 13, 2010 identifying a NAS-wide safety issue 

concerning language barrier concerns involving foreign pilots in flight schools. 
26

Appendix. Agency Comments

12. CAR 2011-006: Issued March 15, 2011 identifying a NAS-wide safety issue 

concerning the lack of sufficient space for on-the-job-training instructors (OJTIs) to 

effectively monitor their trainees during live operations. 

13. CAR 2011-007: Issued May 10, 2011 identifying a NAS-wide safety issue concerning 

the “QU” function in the En route environment impacting aircraft routings. 

14. CAR 2011-008: Issued May 24, 2011 identifying a NAS-wide safety issue concerning 

display system replacement (DSR) lock-ups at numerous centers across the country. 

15. CAR 2011-009: Issued May 24, 2011 identifying a facility-specific glider operations 

issue, but after reviewing root causes, mitigations will address a NAS-wide safety 

issue. 

16. CAR 2011-010: Issued May 24, 2011 identifying a NAS-wide safety issue concerning 

Traffic Management Unit (TMU) coordination procedures. 

17. CAR 2011-014: Issued August 18, 2011 identifying a NAS-wide safety issue 

concerning Severe Weather operations. 

18. CAR 2011-016: Identifying a NAS-wide safety issue concerning Flight Service 

Station responses. 

19. CAR 2011-017: Issued February 24, 2011, which identified a NAS-wide safety issue 

concerning confusion when reviewing NOTAMS as to the term "AD CLSD".

20. CAR 2011-020: Identifying a NAS-wide safety issue concerning D-BRITE use in the 

tower cab to provide radar services in lieu of opening the approach control facility. 

21. CAR 2011-021: Identifying a NAS-wide safety issue concerning losses of separation 

when visual separation is being applied. 

22. CAR 2011-025: Issued December 21, 2011 that identified a NAS-wide safety issue 

concerning VIP Movements including POTUS, VPOTUS, and FLOTUS. 

23. CAR 2011-026: Issued February 24, 2011 that identified a NAS-wide safety issue 

concerning the "Auto-Handoff" functionality within "HOST".

24. CAR-2012-003: Issued May 24, 2012 that identified a NAS-wide safety issue 

concerning controllers' responsibilities in resolving conflict between IFR and VFR 

aircraft.

25. CAR-2012-004: Issued April 6, 2012 that identified a NAS-wide safety issue 

concerning inconsistencies in the display of Next Generation Weather Radar 

(NEXRAD) and Weather and Radar Processor (WARP) indicating erroneous 

indication of precipitation density on radar displays.

Additionally: 

26. ATSAP added questions to the submitter form in May 2011 that allow controllers to 

self-identify acute and chronic fatigue. This information will be used in the 

development of mitigations that are responsive to NTSB recommendations and 

improve the health and well-being of FAA employees in safety-critical positions.

27. ATSAP provided valuable information reported by front line personnel to ATO 

Technical Training for use in the creation of new Recurrent Training for 2012. This 

information provided training and subject matter experts (SMEs) with the root causes 

of mistakes, allowing them to tailor the training to correct those causes. Training 

included Wake Turbulence, Bird Activity, Runway Incursions, Controller Weather 
27

Appendix. Agency Comments

Responsibility, Traffic Advisories/Safety Alerts, Icing, Thunderstorms, and visual 

flight rules (VFR) aircraft in weather. 

28. ATSAP provided real-world scenarios where the lack of Crew Resource Management 

(CRM) fundamentals was contributory to a larger issue. The use of these scenarios is 

included in the Integrated Safety Training (IST) workshop, allowing ATO to train 

CRM more effectively. 

29. The ATSAP Analysis Team identified a safety issue, including root causes, involving 

OJTI. This information has been included in the IST workshops being deployed 

nationwide. 

30. In support of NextGen planning, ATSAP provided analysts hundreds of reports 

concerning Radar Handoffs. These analysts have been successful in identifying root 

causes and potential mitigation strategies. Concurrently, ATSAP issued CAR 2011-

26 on Auto-Handoffs. 

31. Through the Confidential Information Sharing Program (CISP) with the airlines, 

ATSAP has been able to identify root causes to a national safety issue concerning 

Non-Reduced Vertical Separation Minima (RVSM)-equipped aircraft operating in 

RVSM airspace. This has raised awareness throughout the General Aviation (GA) 

and Commercial pilot workforce and has been reinforced in a publication called 

“InFO,” which is distributed by Flight Standards. Additionally, as a result of 

recognition of this issue, specialized training is being developed for all controllers. 

32. ATSAP data was used in support of an ASIAS-directed study concerning the risks 

associated RNAV Off The Ground procedures. 

33. ATSAP data was used in support of an ASIAS-directed study concerning the risks 

associated with Pilot/Controller Communications. 

34. ATSAP provided the Risk Analysis Program (RAP) with supporting data to ensure 

that all safety issues reported through the program were taken into account when 

determining ATO’s Top 5 Hazards. 

35. Through ATSAP's CISP, a serious deficiency in existing wind equipment at Chicago 

Midway International Airport (MDW) was identified and quickly funded, and 

equipment was procured to replace failed systems.

36. Also through CISP, partner airlines were alerted to a large Sailplane event at a large 

southwest airport, and participating companies forwarded information to their flight 

crews about the event.

37. The ATSAP office has distributed 113 Briefing Sheets and eight Alert Bulletins 

covering issues identified in ATSAP reports including Pilot-Controller 

Communications, Wake Turbulence, Aircraft Early Turns, Coordination of Interim 

Altitudes, the effects of Hypoxia on Pilots, Position Relief Briefings and Point-outs, 

Opposite Direction operations, TCAS RA notifications, Controller Professionalism, 

Prohibitions on Cell Phone Usage on duty, and understanding Fatigue.

38. ATSAP has or is currently fulfilling data requests regarding Human Factors issues in 

Handoffs, Separation Standards, ERAM, Runway Safety, NOTAMs, Unmanned 

Aerial Systems (UAS), Standard Terminal Automation Replacement Systems 

(STARs), LOAs, Class B Airspace, and Airport Surface Detection Equipment-Model 

X (ASDE-X), among others.