Aviation Safety: Better Data and Targeted FAA Efforts Needed to Identify and Address Safety Issues of Small Air Cargo Carriers
Published: 2009-06-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The air cargo industry contributed over $37 billion to the U.S. economy in 2008 and provides government, businesses, and individuals with quick delivery of goods. Although part of an aviation system with an extraordinary safety record, there have been over 400 air cargo accidents and over 900 incidents since 1997, raising concerns about cargo safety. GAO's congressionally requested study addresses (1) recent trends in air cargo safety, (2) factors that have contributed to air cargo accidents, (3) federal government and industry efforts to improve air cargo safety and experts' views on the effectiveness of these efforts, and (4) experts' views on further improving air cargo safety. To perform the study, GAO analyzed agency data, surveyed a panel of experts, reviewed industry and government documents, and interviewed industry and government officials. GAO also conducted site visits to Alaska, Ohio, and Texas.
section_title: What GAO Found
paragraphs: From 1997 through 2008, 443 accidents involving cargo-only carriers occurred, including 93 fatal accidents. Total accidents declined 63 percent from a high of 62 in 1997 to 23 in 2008. Small cargo carriers were involved in the vast majority of the accidents--79 percent of all accidents and 96 percent of fatal accidents. Although accident rates for large cargo carriers fluctuated during this period, they were comparable to accident rates for large passenger carriers in 2007. GAO could not calculate accident rates based on operations or miles traveled for small carriers because the Federal Aviation Administration (FAA) does not collect the necessary data. Although several factors contributed to these air cargo accidents, our review of National Transportation Safety Board (NTSB) data found that pilot performance was identified as a probable cause for about 80 percent of fatal and about 53 percent of non-fatal cargo accidents. Furthermore, GAO's analysis of NTSB reports for the 93 fatal accidents, using an FAA flight-risk checklist, identified three or more risk factors in 63 of the accidents. Risk factors included low pilot experience, winter weather, and nighttime operations. Alaska's challenging operating conditions and remotely located populations who rely on air cargo are also a contributing factor. Many federal efforts to improve air cargo safety focus on large carriers. Air cargo experts that GAO surveyed ranked FAA's voluntary disclosure programs--in which participating carriers voluntarily disclose safety events to FAA--as the most effective effort to improve air cargo, but two of the three main voluntary disclosure programs are used typically by large carriers. Several industry initiatives, however, focus on carriers with smaller aircraft, such as the Medallion Foundation, which has improved small aircraft safety in Alaska through training and safety audits. The two actions experts cited most often to further improve air cargo safety were installing better technology on cargo aircraft to provide additional tools to pilots and collecting data to track small cargo carrier operations. Using flight risk checklists can also help pilots assess the accumulated risk factors associated with some cargo flights.

section_title: Letter
paragraphs: The air cargo industry, which contributed over $37 billion to the U.S.  economy in 2008, provides businesses and individuals with quick delivery of  everything from small packages to heavy equipment. As part of the U.S.  commercial aviation industry, air cargo—along with air passenger service— enjoys an extraordinary safety record. This record reflects the efforts of the  Federal Aviation Administration (FAA), airlines, manufacturers, the National  Transportation Safety Board (NTSB), and others to maintain one of the safest  aviation systems in the world. Nevertheless, over 900 air cargo incidents and  over 400 accidents occurred from 1997 to 2008, including 93 fatal accidents  with 128 fatalities, raising concerns about air cargo safety. Given the  economic importance of the cargo aviation sector and concerns about its  safety, you asked that we examine the nature and extent of safety issues in  the air cargo industry and determine what is being done to address these  issues. While cargo is also carried by passenger air carriers, we focused on all- cargo (cargo-only) air carriers operating fixed-wing aircraft and addressed  the following questions:  1.  What have been recent trends in air cargo safety?  2.  What factors have contributed to air cargo accidents in recent years?  3.  What have FAA and the industry done to improve air cargo safety, and  how do experts view the effectiveness of these efforts?  4.  What do experts say FAA and industry could do to further improve air  cargo safety?
To answer these questions, we obtained and analyzed accident data from  NTSB and incident, oversight, and enforcement data from FAA for all- cargo carriers operating fixed-wing aircraft. We assessed the reliability of  these data and determined that they were sufficiently reliable for our  purposes. We also surveyed a panel of 27 air cargo safety experts and  asked them to rate and provide relative rankings on the effectiveness of  current efforts to improve air cargo safety, the severity of challenges to air  cargo safety, and the potential improvements that additional efforts could  have on air cargo safety. With the assistance of the National Academy of  Sciences, we selected the panel of experts to represent the perspectives of  a cross-section of stakeholders, including pilots, carriers, manufacturers,  airports, federal government, and human factors and safety performance.  We also conducted site visits in Alaska, Ohio, and Texas because they  were geographically diverse and as the states with the largest number of  air cargo accidents or because of the relatively large number of air cargo  carriers of various sizes located there. Finally, we analyzed documents and  interviewed officials from FAA, NTSB, and air cargo industry  organizations and an employee group. We conducted our review from  December 2007 through June 2009 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. More  details of our scope and methodology can be found in appendix I and the  experts’ responses to our survey can be found in appendix II.
subsections: section_title: Background
paragraphs: The U.S. economy depends on the air cargo industry for the delivery of  small, time-sensitive packages under 100 pounds, freight of 100 pounds or  more, and mail. Air cargo carriers fall into two distinct categories: (1) all- cargo carriers that transport only cargo and (2) passenger carriers that  transport cargo as belly freight in passenger aircraft. For the most part, all- cargo carriers can be categorized according to three business models: (1)  large carriers, such as United Parcel Service (UPS) and FedEx, which  operate large narrow-body and wide-body aircraft under part 121 of  federal aviation regulations; (2) feeder carriers, which operate midsize  and small aircraft (e.g., Cessna Caravans, Mitsubishi MU-2B-60s) under  part 135 or part 121 on regularly scheduled flights in support of large cargo  carriers; and (3) ad hoc carriers, which operate small aircraft (e.g., Cessna  401s, Beech Bonanzas) under part 135 and are individually contracted to  haul cargo out of smaller airports while not necessarily operating on a  regular schedule. Throughout this report, we use the term “small carriers”  when referring to both feeder carriers and ad hoc carriers. Some carriers  operate under both part 121 and part 135, and one large carrier leases  aircraft to small carriers to provide feeder operations. (See fig. 1 for an  illustration of a large carrier feeder-ad hoc relationship.) FAA estimated  that as of May 6, 2009, the large all-cargo fleet contained 471 narrow-body  and 593 wide-body aircraft and the small carrier all-cargo fleet contained  1,515 aircraft.
Several federal transportation agencies play significant roles in air cargo  safety. These agencies are FAA, the Department of Transportation’s (DOT)  Pipeline and Hazardous Materials Safety Administration (PHMSA), and  NTSB.
Two FAA offices in particular have important responsibility for the  oversight of air cargo carriers. First, FAA’s Flight Standards Service  oversees cargo carrier operations conducted under parts 121 and 135. For  each carrier, Flight Standards assembles a team of inspectors (known as a  “certificate management team”) led by principal inspectors who focus on  avionics, maintenance, or operations. For large carriers, dedicated teams  of inspectors use the risk-based Air Transport Oversight System (ATOS) to  carry out their duties. Under ATOS, inspectors develop surveillance plans  for each carrier based on data analysis and risk assessment, and adjust the  plans periodically in accordance with inspection results. For feeder and ad  hoc carriers operating under part 135, inspectors—who unlike ATOS’s  dedicated inspection teams may be assigned to multiple air carrier and  other certificates—use the National Flight Standards Work Program  Guidelines (NPG) to ensure that carriers comply with safety regulations.  For NPG, Flight Standards annually identifies a minimum set of required  inspections to be undertaken. In addition, individual inspectors determine  annual sets of planned inspections based on their knowledge of and  experience with the carriers they oversee. Second, FAA’s Office of  Security and Hazardous Materials enforces hazardous materials (hazmat)  safety policies and conducts annual inspections of cargo and passenger  carriers. Inspectors in this office work exclusively on issues related to  compliance with hazmat requirements. When violations of statutory and  regulatory requirements are identified, FAA has a variety of enforcement  tools at its disposal with which to respond, including administrative and  legal sanctions.
In addition, PHMSA ensures the safe transport of hazmat by air and other  modes. PHMSA promulgates regulations concerning the types and  amounts of hazmat that can or cannot be transported by air—often  differentiating between what hazmat can be carried on all-cargo versus  passenger aircraft—and maintains its own database of hazmat incidents as  well as a portal that pulls together hazmat data from other databases.
NTSB investigates and determines a probable cause for each U.S. aviation  accident, which is defined as “an occurrence associated with the operation  of an aircraft which takes place between the time any person boards the  aircraft with the intention of flight and all such persons have disembarked,  and in which any person suffers death or serious injury, or in which the  aircraft receives substantial damage.” NTSB makes transportation safety  recommendations to federal, state, and local agencies and private  organizations to reduce the likelihood of recurrences of transportation  accidents but has no authority to enforce its recommendations. NTSB also  conducts annual reviews of aircraft accident data and determines U.S.  aviation accident and fatal accident rates. NTSB also periodically holds  public hearings and forums, and issues special studies on various  transportation safety topics.
section_title: Air Cargo Accidents and Fatal Accidents Have Decreased, but Small Carriers Have Accounted for Higher Proportions of Both
paragraphs: From 1997 through 2008, air cargo accidents and fatal accidents each  declined by about two-thirds. Despite this decline, small cargo carriers  consistently experienced the largest shares of accidents and, especially,  fatal accidents.
subsections: section_title: Air Cargo Accidents and Fatal Accidents Declined from 1997 through 2008
paragraphs: Annually, air cargo accidents decreased 63 percent, from 62 in 1997 to 23 in  2008. Average annual air cargo accidents declined from the first to the second  half of our review period, from an average of 45 accidents per year from 1997  through 2002 to an average of 28 accidents per year from 2003 through 2008.  Fatal air cargo accidents also decreased over our 12-year review period, falling  from 12 in 1997 to 4 in 2008. In addition, from the first to the second half of our  review period, fatal cargo accidents dropped from an average of 10 per year to  an average of 6 per year. The fluctuation in annual air cargo accidents could be  the result of a number of factors, including the general decline in aviation  activity after September 11, 2001; a fluctuation in overall U.S. aviation  accidents; and other factors. (See fig. 2.)
Ad hoc carriers experienced the largest decline in accidents, with 28 fewer  accidents—dropping from 36 to 8—followed by large carriers, with 9  fewer accidents—dropping from 14 to 5 from 1997 through 2008. Feeder  carrier accidents fluctuated during this period, reaching a high of 17  accidents in 2003 compared to a low of 7 accidents both in 1999 and in  2007. We do not know why the spike occurred in 2003. Large carriers had 3  fatal accidents during our review period, which occurred in 1997, 2000,  and 2004. (See fig. 3.) Without actual data on the number of flight hours,  however, we cannot determine an accident rate, and thus we do not know  if the decline in ad hoc carrier accidents represents a better safety record  for that sector of the air cargo industry.
section_title: Small Cargo Carriers Had Higher Proportions of Accidents and Nearly All Fatal Accidents
paragraphs: The small carriers (feeders and ad hoc) in our review experienced 79  percent of the air cargo accidents. Ad hoc carriers accounted for about  half of accidents while the feeders were involved in over a quarter of them.  (See fig. 4.) Feeder and ad hoc carriers averaged 29 accidents per year  while large carriers averaged 8 accidents each year.
Small air cargo carriers accounted for 96 percent of the fatal air cargo  accidents that occurred from 1997 through 2008. Ad hoc carriers  accounted for the majority of fatal accidents and feeders for over one-third  of fatal accidents. (See fig. 5.) Together, feeder and ad hoc carriers  averaged 8 fatal accidents per year while large cargo carriers experienced  a total of 3 fatal accidents from 1997 through 2008.
section_title: Accident Rates Have Fluctuated for Large Cargo Carriers but Are Not Available for Small On- demand Cargo Carriers
paragraphs: The accident rate per departure for large air cargo carriers has fluctuated  over the last 25 years, but the overall trend has been downward, and in  2007 was roughly the same as for passenger carriers. It is possible to  calculate these rates because FAA requires those carriers to report  operational data (e.g., flight hours or departures).
However, FAA does not require small on-demand carriers operating under  part 135 to report operational information, and the majority of feeder and ad  hoc cargo carriers fall into this group. In 2003, NTSB recommended that  FAA collect this type of data and, according to NTSB, FAA is still reviewing  the costs and benefits as well as options for collecting and processing the  data. However, the lack of data about the flight hours for small on-demand  carriers precludes calculation of the industry’s current accident or fatality  rates or changes in the rates over time, making it difficult to determine  whether the industry is becoming more or less prone to accidents. Instead,  FAA relies on an annual survey of aircraft owners to form the basis for  estimates of small carrier operations, but this survey does not distinguish  between passenger and cargo operations, making it impossible to use the  survey estimates to calculate cargo or passenger accident rates for on- demand operations or for the cargo industry as a whole.
Even though operational data are not available for small air cargo carriers,  their fatal accident rates would exceed those of large carriers for the latter  part of our review period. From 2005 through 2008, there were no fatal  accidents among large cargo carriers, so their fatal accident rate for those  years was zero. However, there were 17 fatal feeder and ad hoc accidents  over the same period, meaning that their fatal accident rate, if it could be  determined, would be higher than zero—though it is unclear how much  higher. This logic would not hold for air cargo accidents in general  because large carriers had accidents in each year from 1997 through 2008,  though they had fewer accidents than the feeder and ad hoc carriers. The  lack of data makes it difficult for FAA and industry to target further  improvements to the areas with the highest risk.
section_title: Pilot Performance, Accumulated Risk, and Other Factors Have Contributed to Air Cargo Accidents
paragraphs: Our review of NTSB and FAA air cargo accident and incident data as well  as our interviews with industry officials and analyses of industry  documents revealed that pilot performance was a prominent factor in air  cargo accidents. Additionally, we concluded that accumulated risk,  challenging operating conditions in Alaska, and undeclared hazmat were  also prominent contributors to air cargo accidents.
subsections: section_title: Pilot Performance Was a Major Contributor to Air Cargo Accidents from 1997 through 2008
paragraphs: Our review of NTSB reports for 417 completed air cargo accident  investigations found that pilot performance was cited as the probable  cause for about 59 percent of them. Specifically, we found that NTSB  cited pilot performance as the probable cause for about 53 percent of non- fatal and about 80 percent of fatal air cargo accidents. (See fig. 6.)  Examples of pilot performance issues in these accidents included the  pilot’s failure to maintain control of the aircraft or to execute the  appropriate procedure. Our review determined that the second most  prominent cause of air cargo accidents was some type of equipment   equipment  failure or malfunction.  failure or malfunction.
Pilots of small cargo aircraft have fewer human and other resources  available to them to help avoid mistakes or recover from unexpected  circumstances. Typically, there is no second pilot to share in the pilot’s  many duties and help respond to emergencies. Eighty-one percent of the  fatal air cargo accidents from 1997 through 2008 were single-pilot flights.  The lack of a second pilot coupled with the many duties of a single pilot  merits a mention of the issue of pilot fatigue. Although NTSB indicated  fatigue as a contributing factor—not a probable cause—in just 4 of the 443  accidents in our data, 12 of 27 experts we surveyed ranked pilot fatigue as  one of the three most serious challenges to safe air cargo operations. The  view of the experts is not out of line with the accident record to the extent  that the concern about pilot fatigue has led to vigilance in identifying and  addressing fatigue issues.
Further compounding the lack of pilot resources, cargo aircraft operated  under part 135 are not required to have on-board safety technology such as  a traffic collision and avoidance system, a terrain awareness and warning  system, or an autopilot, which could aid a single pilot in monitoring the  environment or responding to changing weather conditions. Most of these  systems are required for small passenger aircraft that also operate under  part 135.
Additionally, small cargo aircraft may fly into airports where FAA does not  provide air traffic control services at all hours and the airports offer fewer  services than might be required for passenger operations. For example, at  the Bethel, Alaska, airport—the transportation hub for the remote villages  in the area and the third-busiest airport in Alaska—FAA provides air traffic  control services from 7 a.m. to 8 p.m. from November to March and 2  hours later in other months, and the airport clears its runway of snow and  staffs its aircraft rescue and fire-fighting equipment only during operations  of passenger aircraft with more than 30 passenger seats.
section_title: Our Analysis Indicates That Most Fatal Accidents Involved Multiple Risk Factors
paragraphs: We analyzed NTSB reports of the 93 fatal air cargo accidents that occurred  from 1997 through 2008 using FAA’s Flight Risk Assessment Tool and identified  three or more risk factors in 63 of the accidents and four or more risk factors in  41 accidents. FAA’s tool is located in appendix III and includes 38 risk factors— in the areas of pilot qualifications and experience, operating environment, and  equipment—each with an assigned value ranging from 2 to 5, with 5 indicating  the highest risk. While we do not know how the presence of these risk factors  differs from their occurrence during normal operations, the experts told us that  the unrecognized accumulation of multiple risk factors can create a potentially  dangerous situation. One 1997 fatal accident, which NTSB attributed to the  pilot’s disregard of the preflight weather briefing for severe weather, involved  six risk factors. The pilot had not flown a minimum number of hours during the  previous 90 days, had not accumulated a minimum amount of experience flying  the aircraft type involved in the accident, and was flying solo. Additionally, the  pilot encountered severe turbulence and icing during the night flight. Table 1  lists the five most common risk factors we identified in the 93 fatal air cargo  flights.
section_title: Alaska’s Challenging Operating Conditions Factored Prominently in Air Cargo Accidents
paragraphs: With 18 fatal air cargo accidents from 1997 through 2008, Alaska led all  states in this statistic because aviation operations in that state face several  unique challenges. Alaska is more dependent on aviation for the transport  of goods and people than other states because it lacks a comprehensive  road system. Less than 10 percent of the state is accessible by road.  Therefore, goods must be transported to remote villages via air or barge,  and barge transport is not an option during the winter months. These  factors make Alaska highly dependent on cargo aircraft, which often fly  into poorly maintained airports that often do not meet FAA standards.  Consequently, most of the accidents in Alaska involved small aircraft.  Alaska is also subject to unusual weather conditions. Taken together, we  believe these challenges render Alaska more susceptible to aviation  accidents and fatal accidents than other states.
Of the 27 experts we surveyed, 5 ranked operating conditions in Alaska as  one of the top three challenges to the safe operation of cargo flights; in  addition, 12 experts in our panel indicated that Alaskan operating  conditions do pose at least moderate challenges to safety, whereas 2  experts (a pilot of large aircraft and a government official) said these  conditions were not a challenge. Seven experts said they did not have  enough specific knowledge to judge the degree of challenge that Alaskan  operating conditions pose to safety.
section_title: Some Experts Indicated that One of the Most Serious Challenges to Safe Air Cargo Operations Is Undeclared Hazmat, but Few Accidents Have Been Attributed to Hazardous Cargo
paragraphs: Very few of the cargo accidents occurring from year to year were  conclusively caused by hazmat. However, 11 experts on our panel ranked  undeclared hazmat—materials not noted as hazardous in shipping  documents and/or labeled as such on their packaging—-among the  greatest challenges to safe cargo operations, second only to pilot fatigue.  According to our review of the NTSB accident data, only three cargo  accidents involved hazmat. They occurred in 1997, 1998, and 2006 to large  carriers, and none resulted in fatalities. The 2006 accident resulted in an  NTSB hearing and recommendations that we discuss later in this report.
The problem of undeclared hazmat was cited primarily by government and  large carrier experts in our survey. Specifically, three of the four  government experts and two of the three large carrier experts cited it as  the most serious challenge to air cargo safety. These opinions may stem  from the previously cited fires and the relative rarity of a destroyed  aircraft among large carriers, as well as government concerns about the  transport of lithium batteries on aircraft.
FAA hazmat officials told us that undeclared shipments of hazardous  materials represent the biggest challenge they face and that lithium batteries  are the most challenging type of hazmat in air transportation. We reported in  January 2003 that FAA, in the early 1990s, identified a number of incidents  associated with batteries, particularly lithium batteries, aboard aircraft in  which the batteries caused fires, smoke, or extreme heat. In response to  these and other concerns, DOT took a number of actions designed to  strengthen the regulations for the transportation of lithium batteries. In  January 2008, NTSB noted that lithium batteries had been involved in at least  9 aviation incidents, and both primary and secondary lithium batteries are  regulated as hazardous materials for the purposes of transportation. In  December 2007, NTSB made six recommendations to PHMSA following a  UPS aircraft fire at Philadelphia International Airport in February 2006, in  which a number of secondary lithium batteries were found in the accident  debris. The recommendations included requirements for transporting  primary lithium batteries in fire-resistant containers and stowing cargo  containing secondary lithium batteries in crew-accessible locations so that  any fire hazards can be quickly addressed. These recommendations remain  open with acceptable responses from PHMSA because they have not yet been  implemented, but according to NTSB, actions are planned that, if  satisfactorily completed, may comply with the safety recommendations. FAA  and PHMSA have embarked on a lithium battery action plan, which aims to  reduce the risk associated with the transport of batteries on aircraft by  passengers and as cargo. The primary focus of this plan is all types of lithium  batteries. According to DOT, PHMSA and FAA have also initiated a rule- making project to consider additional measures to enhance the safety of  lithium battery shipments such as packaging, hazard communication, and  stowage requirements.  PHMSA plans to publish a notice of proposed  rulemaking by December 2009. FAA, the Air Line Pilots Association, and  PHMSA also issued safety alerts or advisories in 2007 that addressed smoke  and fire hazards, recommended crew actions in the event of a battery fire,  noted the availability of guidance for the safe transport of batteries and  battery-powered devices on board aircraft, and provided information on  proper packing and handling procedures for these batteries.
section_title: Large Numbers of Air Cargo Incidents May Be Precursors to Accidents
paragraphs: Although our analysis for this study included 443 air cargo accidents,  cargo carriers were involved in more than twice as many incidents during  the first 11 years of our review period, and FAA and others recognize that  incidents are potential precursors to more serious accidents. In an analysis  of air cargo data for 1997 through 2007 from FAA’s Accident/Incident Data  System, we identified over 900 air cargo incidents. These incidents  covered a broad set of events, such as an engine losing power at 7,000 feet;  a cargo door opening in flight; and an aircraft engine coming into contact  with a fuel truck. FAA does not use incident data to identify precursors to  aviation accidents, because the data were not developed for this purpose.  However, the agency is moving toward using data to better identify  precursors to accidents, but until it does so, it may be missing  opportunities to make air cargo operations and aviation, in general, safer.  For example, from 2000 to 2007, one ad hoc cargo carrier was listed in  FAA’s database 10 times with incidents that resulted in varying degrees of  damage to its aircraft, from none to substantial, and in NTSB’s database  with one non-fatal accident. This carrier subsequently experienced a fatal  accident in 2008. Had this carrier’s incident data been used to identify  accident precursors, inspectors might have been alerted to underlying  problems that might have been addressed, potentially preventing the  subsequent fatal accident. In addition, NTSB’s accident database also does  not track incidents in a way that would allow empirical analysis.
The notion that incidents can be precursors to more serious accidents is  accepted both inside and outside aviation. NASA’s Aviation Safety  Reporting System collects, analyzes, and responds to aviation safety  incident reports voluntarily submitted by pilots and others to lessen the  likelihood of aviation accidents. In its 2005 Safety Management Manual,  the International Civil Aviation Organization noted that for accidents,  there are precursors evident before the accident, and focusing solely on  instances of serious injury or significant damage is a wasted opportunity,  since the factors contributing to such accidents may be present in  hundreds of incidents. The International Civil Aviation Organization  further noted that “effective safety management requires that staff and  management identify and analyze hazards before they result in accidents,”  particularly since there is the opportunity “to identify why the incidents  occurred and, equally, how the defenses in place prevented them from  becoming accidents.” The National Academy of Engineering undertook an  accident precursor project in February 2003, which culminated in a report  that included aviation accident precursor analysis and management. The  report concluded that existing initiatives are not as effective as they could  be and encourages government agencies that regulate high-hazard  industries to increase their support of research into methods for  effectively analyzing and managing precursors.
section_title: FAA Safety Improvement Efforts Focus Primarily on Large Carriers and, According to Experts, Vary in Effectiveness
paragraphs: Many government and industry efforts to improve safety focus primarily  on large carriers. Such efforts include programs in which carriers and  employees voluntarily disclose potential safety issues, attempts by carriers  to institutionalize their safety procedures through safety management  systems (SMS)—a proactive, risk-based approach to addressing potential  hazards—and FAA’s ATOS oversight program even though there is nothing  intrinsic to preclude these concepts from being implemented among small  cargo carriers. Cargo experts view voluntary disclosure programs, efforts  by associations to improve their members’ safety procedures, and carrier- implemented SMSs as the most effective current safety programs affecting  air cargo (see fig. 7).
subsections: section_title: Experts Rate Voluntary Disclosure Programs as One of the Most Effective Cargo Safety Programs, but Primarily Large Carriers Participate
paragraphs: The intent of voluntary disclosure programs is to identify and correct  safety problems in a nonpunitive way and to provide additional safety  information to FAA. Our panel of experts ranked FAA’s voluntary  disclosure programs as the most effective current program for improving  air cargo safety. Specifically, 16 of 27 experts ranked FAA’s voluntary  disclosure programs as one of the most effective current efforts to  improve air cargo safety, and all experts able to judge indicated that the  programs were effective on some level. FAA operates multiple voluntary  disclosure programs, which use different data sources to help identify  safety deficiencies. The three major ones are Flight Operations Quality  Assurance (FOQA), the Aviation Safety Action Program (ASAP), and the  Voluntary Disclosure Reporting Program (VDRP). At the current time,  FOQA is used only by large carriers because of the level of technology  required and ASAP is not typically used by small carriers.
FOQA collects and makes available for analysis digital flight data  generated during the normal operations of the 23 participating carriers. As  of January 2008, the only cargo carriers participating in FOQA were large  carriers. Participating carriers pay for the special flight data recorders that  can record FOQA data; these recorders cost approximately $20,000 each.  Although such an investment can be expensive for some air carriers, some  aircraft models come with the data recorder already built in. However,  smaller carriers tend to operate older aircraft, which lack the data  recorder equipment.
ASAP encourages industry employees to report safety information that  may be critical in identifying potential precursors to accidents. Under this  program, employees of air cargo carriers and other participating entities  report safety events, which a committee that includes the carrier, the  employee labor group, and FAA then reviews and determines appropriate  corrective actions, such as remedial training. FAA agrees not to pursue  enforcement actions for safety violations reported exclusively under this  program. As of December 2008, 73 carriers participated in ASAP,  including 8 cargo carriers. Seven of these 8 cargo carriers were large  carriers, possibly because large carriers are more likely than small carriers  to have the time and resources required for participation. Officials from an  ad hoc carrier we interviewed said it was not practical for their carrier to  enter into an agreement with FAA and then organize meetings to discuss  disclosures when the carrier could operate an informal safety issue  disclosure program internally.
VDRP encourages regulated entities, such as air carriers or repair stations,  to voluntarily report instances of regulatory noncompliance. FAA does not  take legal action on VDRP disclosures, but a violation with the same root  cause can be reported only once by a carrier. Cargo carriers of all types we  interviewed indicated that they have participated or would participate in  VDRP. However, a 2008 DOT Blue Ribbon Panel found FAA does not  routinely analyze VDRP data to identify trends and patterns that could  indicate safety risks. FAA noted in commenting on a draft of this report  that it began conducting regular analysis of VDRP data in January 2009  and that it modified the VDRP data software system and associated  guidance to enable the identification of national trends of disclosures that  represent the highest risk to safety.
section_title: Numerous Other Initiatives Including Industry Association Efforts Are Aimed at Improving Safety for Carriers of All Sizes; Some Experts Believe These Are among the Most Effective at Improving Air Cargo Safety
paragraphs: Numerous industry efforts to improve safety are aimed at different sectors  of the air cargo industry. These include efforts by membership  associations to improve safety among their members, which 14 of the 27  experts on our panel ranked among the top three most effective current  efforts to improve air cargo safety—second only to voluntary disclosure.  In addition, all experts in a position to comment indicated that these  association efforts were at least slightly effective, and 11 of those experts  indicated that they were greatly effective. We were unable to identify a  central clearinghouse for these association efforts, but the ones we did  identify fell into the following six general categories: establishing SMSs,  providing fatigue awareness training, providing pilot skills training, adding  on-board safety systems, improving flight risk assessments, and providing  cargo-specific aircraft rescue and fire-fighting training. One expert said  that membership-based efforts are often the most effective because they  directly reflect the voluntary priorities of the membership organization  and are often directly tailored to the group’s specific needs. Examples of  industry efforts, including some by industry associations and one joint  industry-federal effort, follow.
The Regional Air Cargo Carriers Association—an association of primarily  feeder cargo carriers—has developed an SMS template tailored to the  needs of smaller, feeder cargo carriers. A Regional Air Cargo Carriers  Association official said that the organization’s members found FAA’s SMS  guidance appropriate for large carriers with safety departments, but less  useful for feeder or ad hoc carriers that might have only a few employees.  SMSs are considered in the international community to be an important  way to improve safety in aviation operations and are required by the  International Civil Aviation Authority. In commenting on a draft of this  report, FAA indicated that it has not endorsed the Regional Air Cargo  Carriers Association’s SMS program, nor does FAA believe it is consistent  with FAA training and program guidelines for SMS. SMS is discussed in  more detail later in this report.
The National Air Transportation Association (NATA)—an association  primarily of general aviation service companies whose members include  some feeder and ad hoc carriers—has tailored flight risk assessments to  the needs of its members by automating much of the assessment process.  NATA officials said that feeder or ad hoc cargo carriers, like many general  aviation operators, do not have the support personnel that larger carriers  have to help with preflight checklists and other tasks, and that risk  assessments would just add to those tasks unless they were largely  automated. NTSB has recommended that a segment of the part 135  community—emergency medical services—utilize flight risk assessments  before accepting flights.
In some cases, large carriers act as membership associations by helping  their feeder network acquire safety enhancements. For example, the  Federal Express feeder program, which helps finance on-board safety  enhancements on feeder aircraft, has reduced the number of accidents  among its feeder network according to Federal Express officials.
Since 2002, Alaska’s Medallion Foundation—a federally-funded, safety  promotion organization that is overseen by FAA—offers  training for part  135 pilots and has developed safety audits that can lead to carrier  certifications in various areas, such as operational risk management,  maintenance and ground service, and internal evaluation, to improve air  transportation safety in Alaska. According to FAA, it has also approved a  modified protocol for ASAP administered centrally by the Medallion  Foundation in order to increase the feasibility of ASAP for small operators  in Alaska. Meetings with FAA personnel to review reports submitted under  the program are conducted by telephone, and all reports are tracked in a  central database according to the agency. DOT said that the modified  ASAP protocol with the Medallion Foundation has worked well for  enabling small, remotely situated operators in Alaska to participate in the  program.
The Commercial Aviation Safety Team, a joint FAA-industry effort, has  developed an integrated, data-driven strategy to reduce the commercial  aviation fatality risk in the United States and promote new government  and industry safety initiatives throughout the world. The Team has  completed work on 40 of its 65 safety enhancements aimed at eliminating  accident causes. Six of the safety enhancements specifically target cargo  operations, and each of them is still under way as of the Team’s most  recent update in May 2007.
The Dallas-Fort Worth International Airport is developing a curriculum  and a cargo-specific aircraft rescue and fire-fighting training course.  Airport officials said that the course will focus on the unique challenges  and approaches to fighting a cargo fire. For example, airport officials said  that many aircraft rescue and fire-fighting teams treat passenger/cargo  fires and cargo fires similarly when they should be treated differently,  because passenger/cargo fires can involve hundreds of people whereas  cargo fires typically only endanger the flight crew. The course will also  provide hands-on training in the use of cargo-specific fire-fighting tools,  such as hull-penetrating tools or devices for locating hot spots—tools that  most fire fighters rarely use.
section_title: Carrier-Based SMSs Are Viewed as Effective by Experts but Are Currently Geared toward Large Carriers
paragraphs: Thirteen cargo experts ranked carrier SMSs as one of the most effective  current efforts to improve air cargo safety, making this the third most  frequently cited current safety effort. SMSs can differ in their specifics, but  FAA defines SMS as a proactive, risk-based approach to addressing  potential hazards by categorizing the risk level and taking appropriate  mitigating actions to reduce the risk to an acceptable level. Some  countries, such as Canada, require carriers to implement an SMS, but the  United States does not yet require domestic carriers to do so. FAA and  industry officials agreed that FAA will require part 121 carriers to  implement SMSs in the next few years. In addition, FAA has issued  guidance on developing an SMS, but none of the air cargo carriers we  interviewed have implemented one. However, several of the air cargo  carriers we interviewed said they had safety programs that are similar to  SMSs. An expert in aviation safety said that effective SMSs are good for  institutionalizing safety improvements and taking proactive steps to  reduce the number of accidents. He further noted that larger companies  with more airplanes and more resources are better positioned to do this.  By contrast, companies with one airplane and one pilot will not have  enough staff time to submit the paper work. As a result, the Regional Air  Cargo Carriers Association—a membership organization for feeder  carriers—has developed simplified SMS guidance specifically for part 135  cargo carriers. Some airports are also implementing SMSs. Most experts in  our panel did not rank airport SMSs among the most effective current  efforts, possibly because cargo airports have not implemented them  nationwide.
section_title: FAA Uses Airworthiness Directives and Operations Specifications to Improve Aviation Safety
paragraphs: FAA uses airworthiness directives (AD) and operations specifications to  improve aviation safety. An AD is a notification to owners and operators of  aircraft that a particular model of aircraft, engine, avionics, or other  system has a known safety deficiency that must be corrected. Carriers are  prohibited from operating any aircraft that is out of compliance with any  applicable AD. Operations specifications are specific limits and  requirements developed for individual operators, such as the specific  aircraft the carrier is allowed to operate. Ten experts on our panel ranked  ADs and operations specifications among the three most effective current  efforts to improve air cargo safety. Our interviews with carriers showed  that some carriers depend on ADs and operations specifications to learn  about safety issues that other carriers have discovered. An official from  one feeder carrier said that ADs are like product recalls, and without  them, she would never know that there was a problem until there was an  accident. FAA also uses other methods for communicating with carriers,  such as informational messages, alerts, advisory circulars, and seminars.  However, none of the 27 experts on our panel indicated that FAA  informational materials and seminars were any more than moderately  effective at improving the safety of air cargo operations.
section_title: FAA Uses Risk-Based Inspection System for Large Carriers Only, and Experts Did Not Rate FAA’s Oversight as One of the Most Effective Efforts to Improve Air Cargo Safety
paragraphs: FAA oversees the compliance with safety regulations of all 58 part 121  cargo large carriers by using ATOS, which applies a risk-based inspection  system tailored to each carrier regulated under part 121. For example,  under ATOS, principal inspectors develop surveillance plans for each  airline based on data analysis and risk assessment, and adjust the plans  periodically to reflect inspection results. Under ATOS, principal inspectors  are assigned to just one part 121 carrier. Our interviews with part 121  carriers and FAA inspectors revealed mixed opinions about ATOS. Some  of the carriers, particularly the smaller part 121 carriers, indicated that  transitioning to ATOS was too complicated and costly and that its focus on  administrative reviews has reduced the number of on-site FAA inspections  they receive. In addition, some FAA inspectors said that the ATOS  paperwork is time consuming and can have the effect of tethering them to  their computers. For example, officials from a small part 121 air carrier  said that they had to hire a full-time person to work on implementing  ATOS as well as spend over $500,000 to hire a company to help revise the  carrier’s manuals to satisfy FAA requirements under ATOS. However,  officials from a large carrier indicated that ATOS is a more effective  oversight system than NPG once it is fully implemented. In addition, some  officials from large carriers said that the bureaucratic nature of ATOS  limited the amount of direct oversight they receive. FAA officials said that  ATOS does not impose new requirements on carriers, and FAA does not  require carriers to set up an ATOS program. FAA officials also said that  because ATOS is more robust than the oversight system it replaced— NPG—inspectors may find omissions in manuals that were overlooked  before. Carriers may then be required to correct these deficiencies to meet  regulatory requirements. In addition, FAA officials said they are exploring  options for reducing the time inspectors spend at their computers and  increasing the time they spend doing hands-on inspections. For example,  FAA officials said that FAA is reducing the number of ATOS program  elements in order to make inspection planning and management easier.
The 303 part 135 carriers remain under the NPG system, which requires  all active carriers to be inspected at least once a year and sets the numbers  of required inspections nationally and planned inspections at the local  level. Some FAA inspectors we interviewed who use the NPG system said  they do not base their planned inspections on risk factors but, rather, on  what was done the previous year or what they have time to do (NPG  inspectors typically oversee several carriers). FAA officials said that FAA  is moving toward a risk-based oversight “Safety Assurance System” for  part 135 carriers. FAA has completed a gap analysis that compared the  existing part 135 oversight system to the system requirements of the new  system, and it plans to have the risk-based system developed for part 135  carriers by 2013.
The number of inspections that part 135 carriers receive each year varies  greatly under NPG. For fiscal years 2004 through 2007, we found 18 part  135 carriers received one inspection in a year, while 6 part 135 carriers  received hundreds of inspections in a year. An FAA official said that  variation should be expected. For example, carriers with more airplanes,  airplanes of more types, and routes to more regions will receive more  required inspections under NPG.
The number of part 135 carriers that each cargo inspector oversees also  varies greatly. On the low end (bottom 10 percent), part 135 cargo  inspectors oversee 5 passenger and cargo carriers on average, and on the  high end (top 10 percent), inspectors oversee 34 passenger and cargo  carriers. While some variation is unavoidable, FAA officials said that FAA  has not established guidelines to ensure that the workload is balanced  among inspectors. The National Academy of Sciences also found FAA had  inadequate staffing standards for its safety inspectors.
The majority of the experts on our panel did not rank FAA oversight and  inspections among the most effective current efforts to improve air cargo  safety. Although 5 of the 27 experts rated FAA oversight and inspections  among the three most effective current efforts to improve air cargo safety,  none of the experts representing carriers’ perspectives listed FAA  oversight among the most effective current efforts. Officials from an ad  hoc cargo carrier said that FAA inspectors do not have enough specific  knowledge of cargo operations to effectively oversee cargo operations.  Two FAA cargo inspectors that also oversee passenger carriers said that  their formal cargo oversight training consisted of a 2-hour online course.  FAA officials said part 135 does not differentiate between passenger and  cargo operations. However, FAA officials recognized that inspectors that  oversee part 135 ad hoc operations may benefit from additional training  and are revising an existing multiday course for maintenance inspectors to  address cargo operations. Our analysis of oversight data for part 135  carriers showed that cargo inspectors also oversee passenger carriers,  often in larger numbers. This could limit inspectors’ ability to focus on  cargo-specific issues. Officials from several cargo carriers of different  types said that FAA inspectors do not do enough on-site inspections to  effectively find and correct safety problems. For example, FAA inspectors  and carrier officials said that part 135 inspectors often focus on  administrative reviews. FAA officials said there needs to be an appropriate  balance of on-site inspections and administrative reviews, both of which  are important for determining carrier compliance and ensuring safe  operations. Ultimately, however, FAA officials said that regulatory  compliance is an air carrier responsibility; FAA is responsible for ensuring  that air carriers are capable of complying and, in some cases,  administrative reviews may be the best way for FAA to do that.
section_title: FAA Rarely Responds to Cargo Carrier Regulatory Violations with Legal Action or Fines
paragraphs: FAA’s oversight includes enforcement efforts, which are designed to  promote compliance with statutory and regulatory requirements for  aviation safety. When violations are identified, an FAA order calls for  inspectors to take the actions most appropriate to achieve future  compliance. These actions range from educational and remedial efforts, to  administrative actions (such as warning notices), to punitive legal  sanctions (such as fines or loss of operation certificate). Violations can be  identified by FAA inspectors or by others, such as air traffic controllers or  state or local government officials. The relevant FAA inspector prepares a  report and recommends an enforcement action. That report and proposed  enforcement action are then reviewed and possibly changed at various  levels depending on the nature of the recommended enforcement action.
FAA closes most air cargo regulatory violations with administrative action,  such as a warning notice, or without taking any action. For 1997 through  2008, over half (56 percent) of the 6,564 enforcement actions against cargo  carriers were administrative, and another 17 percent involved no action.  These were very similar to the percentages for passenger carriers. Within  cargo, the ad hoc sector had the lowest percentage of legal actions.  Fourteen percent of ad hoc carrier enforcement actions were legal,  compared with 24 percent of larger carrier enforcement actions and 16  percent of feeder carrier enforcement actions. Ad hoc cargo carriers also  had the largest reductions, on average, among cargo carrier types, with the  reduced fines 64 percent below the initially recommended fines. Our  previous work found that FAA reduced legal actions for several reasons,  including proof that the violator took corrective action to prevent a  reoccurrence of the violation or economic hardship that might accrue to  the entity that caused the violation.
The percentages of cargo carrier violation cases closed with  administrative or no action represent a continuation of trends that we  observed in our last work on FAA enforcement in 2004. At that time, we  found that FAA generally closes cases against passenger and cargo  carriers with administrative actions, and reducing the amounts of fines  may reduce the deterrent effects of those actions. Since then, our analysis  of FAA’s Enforcement Information System data shows that the share of  violations resolved using administrative or no action has increased  slightly. Moreover, FAA still lacks information on how these actions have  influenced the effectiveness of the enforcement actions, and the  recommendation we made in that report—that FAA develop a process for  measuring the performance and effectiveness of its enforcement actions— remains open.
section_title: Some NTSB Recommendations for Improving Cargo Safety Have Not Been Implemented, and the Experts Did Not Consider These Recommendations among the Most Effective Measures
paragraphs: NTSB investigates transportation accidents, including air cargo accidents,  and makes recommendations to improve safety. NTSB made numerous  recommendations based on air cargo accidents but not all of those were  related specifically to cargo issues. For example, after an air cargo  accident in 1997, NTSB recommended that FAA require all part 121 air  carriers to include additional information and training to flight crews in  order to avoid that type of accident in the future. Other NTSB  recommendations, however, are cargo-specific recommendations, and all  of them remain open. Table 2 summarizes the status of NTSB’s cargo- specific recommendations.
Most experts did not rank NTSB recommendations among the top efforts  to improve air cargo safety. One expert on our panel described NTSB  recommendations as the most effective effort to improve air cargo safety,  and another 8 of the experts in our panel ranked NTSB recommendations  as one of the top three efforts, but 18 experts did not include them among  the top three efforts. According to our interviews, NTSB recommendations  related to cargo operations are not always practical to implement. For  example, one carrier noted that NTSB’s recommendation related to  aircraft fire-fighting information (cited above) is challenging to implement  because there are many cargo aircraft configurations, and even knowledge  of the configuration involved in the incident that prompted the  recommendation would not have helped firefighters respond to the  incident. Despite these reservations, the carrier indicated that it is helping  to implement the recommendation because NTSB believes it would  improve safety.
NTSB also holds public hearings and meetings on topics of particular  interest to transportation safety personnel. For example, it held a forum  on air cargo safety in 2004, but no explicit recommendations emerged  from the forum. Five experts on our panel ranked NTSB’s meetings as one  of the three most effective current air cargo safety efforts and none of the  experts ranked the meetings as the most effective effort.
section_title: Experts Believe Additional Improvements to Air Cargo Safety Could Be Achieved through Better Technology, Data, and Standards
paragraphs: The 27 experts in our panel commented on numerous additional steps that  could further improve air cargo safety. Experts in our panel ranked  installing state-of-the-art on-board safety systems on all cargo aircraft and  tracking part 135 operations as the potential measures that would most  improve air cargo safety (see fig. 8).
subsections: section_title: Experts Believe Improved On-Board Safety Technology Would Most Improve the Safety of Air Cargo Operations
paragraphs: Adding state-of-the-art on-board safety technology was the potential  measure to improve air cargo safety endorsed by the most experts in our  panel. Better on-board technology, particularly for smaller aircraft, could  provide additional tools to better inform pilots’ judgment and decision  making. One expert said that the type of technology needed depends on  the type of carrier. He noted that large carriers often already have state-of- the-art technology, and that keeping pace with new technologies as they  emerge is the challenge for them. However, he said that feeder and ad hoc  air cargo carriers are not required to have certain on-board technologies,  and that they would benefit from installing better situational awareness  technologies, like Traffic Alert and Collision Avoidance Systems (TCAS)  or Automatic Dependant Surveillance Broadcast (ADS-B), on their aircraft.  TCAS monitors warn the pilot of potential collision dangers, and ADS-B  uses satellite-based technology to broadcast aircraft identification,  position, and speed with once-per-second updates. Other experts on the  panel also indicated that TCAS and ADS-B would most improve safety on  the smaller aircraft that lack it.
FAA’s Capstone Program in Alaska has shown that better technology can  reduce aircraft accidents. As described earlier, Alaska’s challenging operating  conditions factored prominently in air cargo accidents over the last decade.  The Capstone Program funded technology upgrades that provide pilots with  information on terrain, weather, and air traffic. FAA’s goal was to reduce  Alaska’s higher-than-average aviation accident rate. FAA has stated that an  independent study found that, from 2000 through 2004, accidents for  Capstone-equipped aircraft were reduced by 47 percent.
However, the experts on our panel were not unanimous about the  potential for improving safety through better on-board technologies. The  experts who represent the part 135 perspective did not rate improving on- board safety systems as highly as the other experts did. Only one of the six  part 135 pilots or carriers we surveyed ranked this as one of the top three  potential improvements. The other five indicated that improving on-board  safety systems is not feasible or would only slightly improve air cargo  safety. For example, some part 135 ad hoc and feeder carriers we  interviewed indicated that state-of-the-art on-board safety systems are not  affordable relative to the value of the aircraft. Specifically, officials from  one ad hoc cargo carrier said that traffic collision avoidance systems (such  as TCAS or ADS-B) installed on a Cessna, valued at $100,000 to $200,000,  would make the biggest improvement in safety, but such a system would  cost about $25,000 to install on each aircraft, which the officials said was  not practical.
section_title: Tracking Part 135 Cargo Operations Ranked Second among Top Steps toward Improving Air Cargo Safety among Experts
paragraphs: As stated earlier, we were unable to determine accident rates for small  feeder or ad hoc cargo carriers because FAA does not track part 135  operations. However, operational data—such as flight hours or landings— for on-demand part 135 cargo operations would allow analysts to  determine accident rates for all cargo carriers as they currently can do for  all part 121 (large) carriers. This is important because a higher proportion  of air cargo accidents and nearly all fatalities occur to part 135 (small)  carriers. Many experts who responded to our survey indicated that better  data on part 135 cargo flight and operations could improve air cargo  safety. Specifically, tracking these data was ranked among the top  measures with the greatest potential by the second largest share of experts  in our panel.
Industry experts and officials we spoke with said there is a need for FAA  to have this type of data. For example, NTSB has recommended in 2003  that FAA collect additional operational data from small air carriers in  order to generate accident and incident rate information for all sectors of  commercial aviation, including air cargo, but the recommendation remains  open because an FAA official said that FAA chose not to collect the  information. In addition, numerous industry stakeholders told us that not  having these data precludes FAA from effectively targeting its safety  initiatives. One of the experts on our panel said that people might assume  that the part 135 carriers with the most accidents are the ones with the  poorest safety records, but that may not be the case when the number of  operations is considered.
One official from a part 135 carrier said that the industry is generally  against greater reporting because it would increase workload. However,  he stated that if FAA begins requiring such data, companies will find a way  to comply because they already collect the data. We interviewed part 135  carriers of various sizes, and they all indicated that they already track  operational data internally and could report these data to FAA without a  substantial additional effort, but this was not designed to be a  representative sample.
section_title: Pilot and Carrier Experts Are Divided on How Aligning Cargo Regulations with Passenger Regulations Would Affect Air Cargo Safety
paragraphs: As discussed earlier in this report, the regulations under which most large  cargo carriers typically operate (supplemental) differ from the regulations  under which most passenger carriers operate (domestic or flag). Although  part 121 pilot experts on our panel indicated that aligning cargo  regulations with passenger carrier regulations would improve safety,  carrier experts generally disagreed. All three pilots, who fly under part  121, ranked alignment of regulations as the top potential measure to  improve air cargo safety. As an example, the Air Line Pilots Association,  the employee organization for most commercial U.S. pilots, supports the  alignment of duty time regulations for all part 121 carriers. The  Association believes that longer flight times can increase pilot fatigue and  thus increase mistakes and accidents, and, as stated earlier in this report,  the experts rated pilot fatigue as a serious challenge to safe cargo  operations. On the other hand, none of the seven carrier experts ranked  aligning cargo regulations with passenger regulations among their top  three potential measures for improving air cargo safety. Five of them  indicated that aligning regulations would have a slight or no improvement,  and the other two indicated that aligning regulations would not be  feasible.
Although not specifically related to cargo operations, NTSB has also  recommended that FAA revisit its time and duty regulations as they may  be related to fatigue. For example, in 2008, it recommended that FAA  develop guidance for operators to use in establishing fatigue management  systems and then continually assess the effectiveness of the systems. It  also recommended in 1995 that FAA review its flight and duty time  regulations to include the findings of fatigue and sleep research. These  recommendations remain open because FAA has not completed its actions  related to these issues. In commenting on a draft of this report, FAA said  that it convened a committee to address pilot fatigue issues and that the  data it collects may be used in future rule-making efforts regarding pilot  flight time, duty, and rest regulations.
section_title: Conducting Flight Risk Assessments before a Flight Can Help Reduce Accumulated Risk and, According to Experts, Improve Safety
paragraphs: As described earlier, many air cargo accidents over the last 10 years  occurred in conditions of accumulated risk—when several risk elements  were present, but none was individually significant enough to result in the  flight’s cancellation. FAA, the Flight Safety Foundation, and NATA have  each developed tools that pilots or carriers could voluntarily use to assess  accumulated risk factors and determine if the flight should go forward.  These tools assign values to various risk elements, such as single pilot  operations, night flights, and flights into areas without accurate weather  reports. See appendix III for FAA’s sample flight risk assessment tool.
Eight of the 27 experts on our cargo safety panel ranked flight risk  assessment as one of the three potential efforts that could most improve  safety. Additionally, 18 experts indicated that incorporating flight risk  assessment checklists into air cargo daily operations would have a  moderate or great effect on improving the safety of their operations. One  expert on our panel said that flight risk assessment cannot prevent all  accidents and that not all flights with multiple accumulated risk factors  have accidents, but assessing the risk factors may help pilots reduce the  number of cargo accidents by recognizing when the accumulated risks  become unacceptably high and at which point pilots would either find  ways to mitigate those risk factors or delay the flight.
Despite the high level of support among our expert panelists for using  flight risk assessment checklists, only 1 of the 10 carriers we interviewed  used them in their daily operations. Officials from one part 135 carrier said  that carriers are busy enough doing all the things that FAA requires to  worry too much about ideas that might be very productive but are  nonetheless optional. Other experts pointed out that all of the flight risk  assessment checklists currently available were designed for passenger  operations and that cargo carriers would have to tailor the tools to their  needs—potentially a critical obstacle to implementation.
section_title: Conclusions
paragraphs: Aviation in the United States remains safe and air cargo accidents have  declined over the last 10 years, although fatal accidents do occur every  year. Most of those accidents and nearly all of the fatal accidents in the  last decade have happened to feeder and ad hoc carriers. However, the  lack of operational data for part 135 carriers, which make up the bulk of  the feeder and ad hoc carriers, makes it impossible to determine accident  and fatality rates for small carriers or to track cargo-wide accident or  fatality rates over time. FAA’s information on small carrier operations is  based on its annual survey of aircraft owners, which does not differentiate  between passenger and cargo operations, making it impossible to use the  survey results for cargo operators. While the numbers of accidents suggest  that the fatality rates for feeder and ad hoc carriers are higher than the  rates for large carriers, it is impossible to know how much higher the  fatality rates are for feeder and ad hoc carriers without data on the  numbers of operations for all types of cargo aircraft. It is also difficult for  FAA and industry to target further safety improvements to the areas with  the highest risk.
Despite the higher numbers of accidents and fatal accidents among small  cargo carriers, FAA’s safety programs have focused primarily on large  cargo carriers, the industry segment in which accidents and accident rates  have steadily declined. While it makes sense to focus first on large  carriers, which operate larger aircraft with larger crews and cargo holds,  the safety of the smaller aircraft is also important. There is nothing  intrinsic to small carriers that precludes risk-based oversight, voluntary  disclosure programs, or the use of SMSs, but these efforts are usually  targeted toward, or at least primarily used by, the large cargo carriers.  However, cost is a concern for carriers, and poor economic conditions  throughout the air cargo sector may mean that few funds will be available  in the near term for new safety initiatives.
In addition, FAA has increasingly focused on potential accident precursors  that would reduce the risk of accidents before a related accident even  occurs. However, neither FAA nor NTSB systematically tracks incidents in  a way that would allow empirical analysis, even though incidents are  widely viewed as accident precursors. Over half of the fatal air cargo  accidents since 1997 had multiple risk factors. However, preflight risk  assessment checklists are not required to be used within the cargo  industry. The concept of assessing and recognizing accumulated risk  through flight risk assessment presents an additional low-cost opportunity  for identifying and reducing the risk associated with some cargo flights  that might otherwise go unnoticed.
section_title: Recommendations
paragraphs: To help FAA improve the data on and the safety of air cargo operations,  we recommend that the Secretary of Transportation direct the FAA  Administrator to take the following four actions:    Gather comprehensive and accurate data on all part 135 cargo operations  to gain a better understanding of air cargo accident rates and better target  safety initiatives. This can be done by separating out cargo activity in  FAA’s annual survey of aircraft owners or by requiring all part 135 cargo  carriers to report operational data as part 121 carriers currently do.
Promote the increased use of safety programs by small (feeder and ad  hoc) cargo carriers that use the principles underpinning SMS and  voluntary self-disclosure programs.
Evaluate the likelihood that cargo incidents could be precursors to  accidents and, if FAA determines they are, create a process for capturing  incidents that would allow in-depth analysis of incidents to identify  accident precursors related to specific carriers, locations, operations, and  equipment.
Create incentives for cargo carriers to use flight risk assessment checklists  in their daily operations, including tailoring a sample flight risk assessment  checklist for part 135 cargo carriers.
section_title: Agency Comments
paragraphs: We provided copies of a draft of this report to DOT and NTSB for their  review and comment.  Both agencies provided technical comments, which  we incorporated as appropriate.
We are sending copies of this report to interested congressional  committees, the Secretary of Transportation, and the Chairman of the  National Transportation Safety Board. We are also making copies available  to others on request. In addition, this report is available at no charge on  the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-2834 or dillinghamg@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix IV.
section_title: Appendix I: Objective, Scope, and Methodology
paragraphs: Our objective in conducting this study was to review the nature and extent  of safety issues in the air cargo industry and what the Federal Aviation  Administration (FAA) and others are doing and could do to address them.  To accomplish this objective, we established the following research  questions: (1) What have been recent trends in air cargo safety? (2) What  factors have contributed to air cargo accidents in recent years? (3) What  have FAA and the industry done to improve air cargo safety, and how do  experts view the effectiveness of these efforts? (4) What do experts say  FAA and industry could do to further improve air cargo safety?
To determine trends in air cargo safety, we obtained and analyzed  accident and incident data for calendar years 1997 through 2008.
From the National Transportation Safety Board (NTSB), we obtained  accident data for part 121 and part 135 all-cargo and mail operations that  occurred from January 1, 1997, through December 31, 2008. To capture the  full extent of cargo operations in Alaska, however, we also included  passenger/cargo accidents because Alaska’s by-pass mail system, which  requires carriers to have a certain share of the passenger market to obtain  a by-pass mail contract, resulted in fewer all-cargo carriers in that state.  From these data we identified 443 fixed-wing aircraft accidents, including  93 fatal accidents. Six of the accidents involved 2 aircraft, so our data  included a total of 449 accident aircraft.
From FAA, we obtained data on part 121 and part 135 fixed-wing all-cargo  accidents and incidents that occurred from January 1, 1997, through  December 31, 2007. From these data, we eliminated accidents that were  also included in the NTSB data, for a total of 937 accidents and incidents.  To avoid confusion when discussing the two data sets, we refer to the FAA  data as “incidents” and the NTSB data as “accidents.”
Because we are familiar with and have previously determined that these  data were sufficiently reliable for the nationwide descriptive and  comparative analyses used in this report, we interviewed agency officials  knowledgeable about the databases from which the data were derived to  determine that the accident and incident data used in this report continue  to be sufficiently reliable for the types of analyses we performed. We also  obtained information on industry trends by conducting a literature search  and reviewing the resulting documents, conducting a survey of air cargo  experts, and interviewing officials and reviewing relevant documents from  FAA, the Pipeline and Hazardous Materials Safety Administration  (PHMSA), air cargo industry associations, air cargo carriers, airports, an  employee group, and others.
We also conducted site visits to Alaska, Ohio, and Texas. Those locations  were selected to be geographically diverse and as the states with the  largest number of air cargo accidents or because of the relatively large  number of air cargo carriers of various sizes located there.
To assess what factors have contributed to air cargo accidents in recent  years, we conducted several analyses. First, to determine prominent  accident causes, we analyzed data on probable causes and contributing  factors from completed NTSB investigations of 417 air cargo accidents.  Second, to assess accumulated risk, we applied FAA’s proposed flight risk  assessment tool to NTSB’s reports on the 93 fatal cargo accidents that  occurred during our review period. To do this, we searched each accident  report for the 38 risk factors in the tool, such as “pilot flight time less than  100 hours in the last 90 days.” For each factor found, we noted its  corresponding risk value on an Excel spreadsheet and tabulated the total  score as well as the total number of risk factors for each fatal accident.  Third, for indications of other factors contributing to air cargo accidents,  we surveyed a panel of air cargo experts, which is discussed in more detail  later below; analyzed documents and interviewed officials from FAA,  PHMSA, NTSB, air cargo industry associations, air cargo carriers, airports,  an employee group, and others; and conducted site visits to Alaska, Ohio,  and Texas (see the previous paragraph).
To determine what FAA and the air cargo industry have done to improve  safety, we interviewed FAA and industry officials, reviewed key  documents, and analyzed FAA’s oversight and enforcement data for all- cargo carriers. We interviewed officials and tested the data and found it  sufficiently reliable for our purposes. To obtain experts’ opinions about  how FAA and the air cargo industry could further air cargo safety, we  surveyed a panel of 27 air cargo safety experts. The experts rated and  provided relative rankings on the effectiveness of current efforts to  improve air cargo safety, the severity of safety challenges faced by the air  cargo sector of aviation, and the potential improvements that additional  efforts could have on air cargo safety. We selected the panel of experts  with the assistance of the National Academy of Sciences to represent the  perspectives of a cross-section of air cargo stakeholders. The specific  experts, their affiliation, and their expert perspectives are listed below.
To develop our survey of air cargo experts, we reviewed existing studies  about air cargo safety, including previous and ongoing GAO work, and  interviewed air cargo safety stakeholders. GAO subject matter experts  designed draft questionnaires in close collaboration with a social science  survey specialist. We conducted pretests with four people knowledgeable  in the field of air cargo (representatives from air carriers, airports, and air  transportation associations) to help further refine our questions, develop  new questions, clarify any ambiguous portions of the survey, and identify  any potentially biased questions. These pretests were conducted in-person  and by telephone. We worked with the National Academy of Sciences and  internally to develop the panel of experts and obtain contact information.
We launched our Web-based survey on August 18, 2008, and received all  responses by November 5, 2008. Log-in information to the Web-based  survey was e-mailed to participants. We sent one follow-up e-mail message  to all nonrespondents a week later, and contacted by telephone all those  who had not completed the questionnaire within 3 weeks. We received  responses from all 27 of our selected experts.
Because our survey was not a sample survey, there are no sampling errors;  however, the practical difficulties of conducting any survey may introduce  nonsampling errors. For example, differences in how a particular question  is interpreted, the sources of information available to respondents, or the  types of people who do not respond can introduce unwanted variability  into the survey results. We included steps in both the data collection and  data analysis stages for the purpose of minimizing such nonsampling  errors. As indicated above, GAO subject matter experts collaborated with  a social science survey specialist to design draft questionnaires, and  versions of the questionnaire were pretested with four knowledgeable  people in the air cargo field. From these pretests, we made revisions as  necessary. We examined the survey results and performed computer  analyses to identify inconsistencies and other indications of error. A  second, independent analyst checked the accuracy of all computer  analyses.
section_title: Appendix II: Expert Responses to GAO Survey
paragraphs: We worked with the National Academy of Sciences to identify air cargo  experts that included carrier, pilot, airport, aircraft manufacturer,  government, and human factors and safety performance perspectives. We  sent our Web-based survey to 27 air cargo experts and received responses  from all 27 experts. Our survey was composed of closed- and open-ended  questions. In this appendix, we include all the survey questions and  aggregate results of responses to the closed-ended questions; we do not  provide information on responses provided to the open-ended questions.  For a more detailed discussion of our survey methodology, see appendix I.
Q1. In your opinion, how effective, if at all, is each of the following current  efforts to improve the safety of cargo-only flights?
Q2. Considering the above list of efforts (question 1 a-j), which three do  you believe are the most effective in improving air cargo safety?
Q3. Besides the efforts listed above, do you know of any other current  significant efforts to improve cargo-only aviation safety? If so, please  explain.
Q4. In your opinion, how much of a challenge, if any, does each of the  following issues pose to safely operating cargo-only flights?
Q5. Considering the above list of challenges (question 4 a-n), which three  do you believe are the greatest challenges to air cargo safety? a.  Pilot fatigue related to nighttime  flying, ineffective rest periods, or  commuting  b.  Carrier policies that, by their  nature, give pilots economic  incentive to fly in less-than-ideal  conditions  c.  Flights scheduled with less than  4 hours of notice given to the  crew  d.  Low piloting experience overall,  as well as low piloting experience  in the specific types of cargo  aircraft operated  f.  Variation within the cargo-only  sector regarding the priority given  to safety  g.  Availability of aircraft rescue and  fire-fighting services provided by  persons with cargo-specific  knowledge and training  h.  Difficult cargo-only flight and  operating conditions (e.g.,  airports with limited technology,  mountainous terrain, nighttime  operations)  i.  Alaska's aviation and operating  j.
Q6. Besides the challenges listed above, do you know of any other  significant challenges to safe cargo-only air operations? If so, please  explain.
Q7. In your opinion, how much improvement, if any, in the safety of cargo- only air operations would be provided if each of the following measures  were implemented?
Q8. Considering the above list of possible measures (question 7 a-k),  which three do you believe would provide the greatest improvement to air  cargo safety? a.  FAA increasing the amount  of on-site inspections that it  conducts  training and knowledge of  cargo-only air operations  c.  Carriers and flight schools  providing better training for  cargo-only pilots  Transportation (DOT) or  Transportation Security  Administration (TSA)  increasing shipper  knowledge and declaration  of hazardous materials  e.  DOT or TSA promoting  better shipper compliance  with rules for the handling  and transport of declared  hazardous materials  standards for ramp  employees involved in  loading and unloading cargo g.
Industry setting uniform  standards for ramp  employees involved in  loading and unloading cargo 3 incorporating flight risk  assessment checklists into  their daily operations  i.
FAA collecting and using  part 135 and part 91 cargo  flight and operations data to  better target safety efforts  j.
Q9. Besides the possible measures listed above, do you have any other  suggestions for significantly improving cargo-only aviation safety? If so,  please explain.
Q10. Please provide any other comments that you have regarding cargo- only safety.
section_title: Appendix III: FAA’s Sample Flight Risk Assessment Tool
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to those named above, Teresa Spisak (Assistant Director),  Richard D. Brown, Keith Cunningham, Elizabeth Eisenstadt, Michele  Fejfar, David Hooper, Mitchell Karpman, Valerie Kasindi, Sara Ann  Moessbauer, Susie Sachs, Christine San, Pamela Vines, and Crystal Wesco  made key contributions to this report.