Aviation Runway and Ramp Safety: Sustained Efforts to Address Leadership, Technology, and Other Challenges Needed to Reduce Accidents and Incidents
Published: 2007-11-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: While aviation accidents in the United States are relatively infrequent, recent incidents have heightened concerns about safety on airport runways and ramps. As the nation's aviation system becomes more crowded every day, increased congestion at airports may exacerbate ground safety concerns. To safely handle the anticipated larger volumes of air traffic, the Federal Aviation Administration (FAA) is implementing the Next Generation Air Transportation System (NextGen) to better manage air traffic both in the air and on the ground. GAO was asked to evaluate (1) the progress being made in addressing runway safety and what additional measures, if any, could be taken and (2) the factors affecting progress in improving ramp safety and what is being done by FAA and others to address those factors. We reviewed runway and ramp safety data, interviewed agency officials and industry stakeholders, and surveyed experts.
section_title: What GAO Found
paragraphs: FAA and aviation stakeholders have taken steps to address runway and ramp safety, including deploying and testing technology designed to prevent runway incursions, which occur when aircraft enter the runway without authorization, and overruns, which occur when aircraft run off the ends of runways; helping to change airport layout, markings, signage, and lighting; and providing training for pilots and air traffic controllers. In addition, FAA has made progress in addressing runway overruns and reports that 70 percent of the runways at U.S. commercial airports substantially comply with runway safety area standards, up from 55 percent in 2000. However, the rate of runway incursions has not decreased over the last 5 years. In addition, FAA has not prepared a national runway safety plan since 2002, despite agency policy that it be updated every 2 to 3 years, resulting in uncoordinated efforts within the agency. Runway safety technology currently being installed is experiencing some operational difficulties with its alerting function, while additional technology to prevent runway collisions is years away from deployment. FAA also lacks data on runway overruns that could be used to analyze the causes and circumstances of such incidents. Air traffic controller fatigue, which may result from regularly working overtime, continues to be a matter of concern for the National Transportation Safety Board (NTSB), which investigates transportation accidents, and other aviation stakeholders. Efforts to improve safety in airport ramp areas, where departing and arriving aircraft are serviced by baggage, catering, and fueling personnel, are hindered by a lack of complete accident data and standards for ground handling, but the aviation industry is taking steps to address these problems with the goal of reducing ramp accidents. Data from 2001 through 2006 from the Occupational Safety and Health Administration (OSHA), which investigates occupational accidents, NTSB, and FAA indicated that these agencies had investigated 29 fatal ramp accidents during that time. The majority of the fatalities in these accidents were ramp workers. GAO found no comprehensive nonfatal injury data on ramp accidents and neither federal nor industrywide standards for ramp operations. The federal government has generally taken an indirect role overseeing ramp safety; airlines and airports typically control the ramp areas using their own policies and procedures. Meanwhile, some airlines and airports have initiated their own efforts to address ramp safety, and aviation organizations have begun collecting ramp accident data.

section_title: Letter
paragraphs: Ramps are areas of airports where aircraft are readied for arrival and departure.
Taxiways are routes that aircraft follow to and from runways. could be taken? and (2) What factors affect progress in improving ramp  safety and what is being done by FAA and others to address those factors?
To answer these questions, we reviewed data on runway and ramp safety  incidents and accidents from FAA, the National Transportation Safety  Board (NTSB), and the Department of Labor’s Occupational Safety and  Health Administration (OSHA) and Bureau of Labor Statistics; relevant  laws, regulations, and agency policies; and federal government and  aviation industry efforts to address runway and ramp safety, including the  development of new technology. We also looked at how taxiways affect  runway safety. In addition, we interviewed FAA, NTSB, OSHA, airport, and  aviation trade organization officials reflecting various segments of the  industry, as well as pilots, air traffic controllers, and ramp workers and  their union representatives. We also surveyed experts on the causes of  runway and ramp incidents and accidents, the effectiveness of measures  that are being taken to address them, and what additional measures could  be taken. A majority of the experts was selected with the assistance of the  National Academy of Sciences, and we identified additional experts during  our review. The individuals were selected on the basis of their expertise in  areas such as technology and procedures used to address runway  incursions, overruns, and ramp accidents; international aviation safety  practices; human factors issues; general aviation; airports; and ground  operations. We report the survey results in terms of actions that are most  effective or future actions that have the greatest potential. Through our  analyses, the actions that we report as being most effective or having the  greatest potential were ones that a majority of respondents indicated were  very or extremely effective for the effectiveness questions or great or very  great potential for the questions asking about potential. Because we asked  the experts to answer questions only within their areas of expertise, a  different number of responses were received for various survey questions.  Based on interviews with officials knowledgeable about the data  contained in this report, we determined that runway and ramp safety data  were sufficiently reliable for the types of analyses that we performed for  this report such as trends in runway incursions, the incidence of fatalities  in airport ramp areas, and frequency of air traffic controller overtime. We  conducted our work in Atlanta, GA; Atlantic City, NJ; Boston, MA;  Burbank, Long Beach, Los Angeles, and San Diego, CA; Newark, NJ;  Seattle and Spokane, WA; and Washington, D.C. These locations included  airports that have experienced higher rates of runway incursions or where  new aviation safety technology was being researched or tested. We  conducted our work from October 2006 through November 2007 in  accordance with generally accepted government auditing standards.  Appendix I contains additional information about our methods. Detailed  information about our survey methodology and the survey questions are  contained in appendix II.
subsections: section_title: Background
paragraphs: Demand for air travel has increased in recent years, with over 740 million  passengers flying in the United States in fiscal year 2006, and is expected  to climb to an estimated 1 billion passengers per year by 2015. To meet  this demand, the Joint Planning and Development Office (JPDO), housed  within FAA and created to plan and coordinate the transition to NextGen,  has developed a strategy to establish the needed national airspace system  infrastructure, including airports. JPDO’s objectives include providing air  traffic control and airport authorities with greater flexibility to match  capacity with demand, reducing congestion, and establishing a  comprehensive safety management approach. Implementing the plan will  include deploying Automatic Dependent Surveillance-Broadcast (ADS-B),  a satellite-based technology that broadcasts aircraft identification, position  and speed with once-per-second updates, which will provide pilots with  greater situational awareness and help to keep aircraft at safe distances  from each other on the runways.
Safety at airports in the United States is a shared responsibility among  FAA, airlines, and airports. FAA air traffic controllers oversee activity in  the movement areas—runways and taxiways—but airlines and airports  provide primary safety oversight in the nonmovement areas—ramps and  gates. Figure 1 shows the movement and nonmovement areas of the  General Mitchell International Airport in Milwaukee, WI.
Runway safety is a major aviation safety concern that involves measures  to prevent runway incursions and overruns. Through September 2007, FAA  defined a runway incursion as “any occurrence in the runway environment  involving an aircraft, vehicle, person, or object on the ground that creates  a collision hazard or results in a loss of required separation when an  aircraft is taking off, intending to take off, landing, or intending to land.”  On October 1, 2007, FAA began using a definition of a runway incursion  developed by the International Civil Aviation Organization (ICAO), a  United Nations specialized agency. ICAO’s definition of an incursion is  any occurrence at an airport involving the incorrect presence of an  aircraft, vehicle, or person on the protected area of a surface designated  for the landing or take-off of aircraft. Runway incursion prevention has  been on NTSB’s list of most wanted transportation improvements since  1990 because runway collisions can have serious consequences. Six  runway collisions have occurred in the United States since 1990, resulting  in 63 deaths. The worst runway accident in the United States occurred at  the Los Angeles International Airport in 1991, when an aircraft that was  landing collided with another that was holding on the same runway, killing  34 people. The most recent fatal runway collision in the United States  occurred in 2000, when two general aviation aircraft collided on the  runway at the Sarasota Bradenton International Airport in Florida,  resulting in 4 fatalities. Other runway incidents, which FAA did not  classify as incursions, also can have serious consequences. On August 27,  2006, for example, a Comair regional jet crashed in Lexington, KY, after  taking off from a wrong runway that was too short for the aircraft, killing  all but one of the 50 people onboard.
The number and rate of runway incursions rose in the 1990s before  peaking in fiscal year 2001 (see fig. 2). In fiscal year 2001, there were 407  incursions at a rate of 6.1 incursions per 1 million air traffic control tower  operations, compared to fiscal year 2006, when there were 330 incursions  at a rate of 5.4 incursions per 1 million tower operations. As shown in fig.  2, the rate of incursions remained relatively constant from fiscal year 2002  through fiscal year 2006, at an average rate of 5.2 incursions per 1 million  tower operations. However, preliminary FAA data indicate 370 incursions  occurred during fiscal year 2007, representing a rate of 6.05 incursions per  1 million air traffic control tower operations. The preliminary rate of  incursions for fiscal year 2007 is about 12 percent higher than during fiscal  year 2006 and is nearly as high as when the rate of incursions reached a  peak in fiscal year 2001.
Since 2001, FAA has classified the severity of runway incursions into four  categories—A through D. The number and rates of serious incursions— categories A and B, where collisions were narrowly or barely avoided— have continued to occur at about the same level from fiscal year 2002  through fiscal year 2006 at an average of about 30 serious incursions per  year and an average rate of 0.5 serious incursions per 1 million air traffic  control tower operations. Preliminary data indicate that 24 serious  incursions occurred during fiscal year 2007, compared to 31 during fiscal  year 2006. The preliminary rate of serious incursions for fiscal year 2007 is  0.39 per 1 million air traffic control tower operations, which is about 24  percent less than during fiscal year 2006, when the rate of serious  incursions was 0.51 per 1 million tower operations.
Although most runway incursions involve general aviation aircraft, about  one-third of the most serious incursions from fiscal year 2002 through  fiscal year 2007 (categories A and B)—about 9 per year—involved at least  one commercial aircraft that can carry many passengers (see fig. 3). For  example, on July 11, 2007, a collision between two aircraft carrying 172  people was narrowly averted at the Fort Lauderdale-Hollywood Airport in  Florida, when a Boeing 757 that had just touched down was able to  become airborne again to avoid hitting an Airbus A320 aircraft that was  approaching the same runway. An NTSB preliminary report indicated that  the two aircraft missed each other by less than 100 feet. According to  NTSB, it has investigated several near collisions in recent years that could  have been catastrophic if they had not been averted through pilot skill and  luck. Appendix III contains a list of serious incursions involving at least  one commercial aircraft during fiscal year 2006 and fiscal year 2007.
FAA officials, experts we surveyed, and officials at some airports that have  experienced the most incursions said that runway incursions were caused  by many different factors, including airport complexity, frequency of  runway crossings, the amount of air traffic, miscommunication between  air traffic controllers and pilots, a lack of situational awareness on the  airfield by pilots, and performance and judgment errors by air traffic  controllers and pilots. According to FAA, 54 percent of incursions from  fiscal year 2003 through fiscal year 2006 were caused by pilot errors, 29  percent were caused by air traffic controller errors, and 17 percent were  caused by vehicle operator or pedestrian errors.
In the United States, most runway incursions have occurred at major  commercial airports. Figure 4 shows the 10 U.S. commercial airports that  have experienced the most runway incursions from fiscal year 2001  through fiscal year 2006 and the overall number of incursions and the  number of serious incursions that occurred at those airports during that  time.
In addition to incursions, overruns are a runway safety concern. When an  aircraft overruns the end of a runway during an aborted takeoff or while  landing, the results can be serious. In December 2005, for example, a  Southwest Boeing 737 overran the runway at the Chicago Midway Airport  during a snowstorm, ran through airport fencing, and collided with a car  on an adjacent roadway, resulting in one fatality (see fig. 5). Since 2001,  NTSB has investigated 12 runway overruns that resulted in 18 fatalities,  usually involving smaller general aviation aircraft. NTSB attributed the  overruns primarily to pilot error, such as misjudgments of speed and  distance.
FAA has established standards for runway safety areas, which are  unobstructed areas surrounding a runway, to enhance safety in the event  that an aircraft overruns, undershoots, or veers off a runway. FAA airport  design standards generally require commercial airports to establish, to the  extent practicable, 1,000-foot runway safety areas at both ends of a  runway. In 1999, FAA established its Runway Safety Area Program,  administered by the Office of Airport Safety and Standards, to help  commercial airports meet runway safety area standards. In 2005, FAA set  a goal of having commercial service airports make all practicable  improvements to runway safety areas by 2015. Also in 2005, Congress  enacted legislation requiring the owner or operator of a commercial  service airport to meet FAA runway safety area standards by December  31, 2015. The importance of establishing a runway safety area was  demonstrated during the crash of an American Airlines MD-82 in Little  Rock, AR, on June 1, 1999, when it overran the runway, went down a rock  embankment, and collided with a structure supporting a lighting system,  killing 11 passengers and crew. According to NTSB, the airport had a  runway safety area that was only 550 feet in length beyond the end of the  runway. Experts we surveyed said that runway overruns are caused by  factors such as pilot misjudgments about speed, altitude, or distance;  inadequate information on weather and runway conditions; and aircraft  equipment failure.
Although not considered part of the movement area of an airport, ramp  areas can be dangerous for ground workers and passengers. Airport ramps  are typically small, congested areas in which departing and arriving  aircraft are serviced by ramp workers, including baggage, catering, and  fueling personnel. Other personnel present on ramps include airport  police, FAA officials, and other airport, airline, and vendor staff. The  presence of a large number of people utilizing equipment in a relatively  small area, often under considerable time pressure, creates an  environment in which injuries and fatalities and aircraft and equipment  damage can occur. Figure 6 shows an example of a ramp accident.
Activities in the ramp area can also affect the safety of air crew and  passengers once they leave the ramp area. Undetected aircraft damage  from ramp activities can cause in-flight emergencies. In December 2005,  for example, an Alaska Airlines MD-80 that had departed from Seattle to  Burbank, CA, experienced a sudden cabin depressurization. After the  aircraft safely returned to Seattle, it was discovered that a ramp vehicle  had punctured the aircraft fuselage, but the incident had not been  reported.
Aviation organizations have attempted to quantify the nature, extent, and  cost of ramp accidents. According to the experts we surveyed, these errors  occur as a result of multiple causes, such as carelessness, distractions,  confusion, and inadequate training of ramp workers; lack of supervision;  and time pressure. The Flight Safety Foundation, an aviation safety  research organization, has estimated that ground accidents worldwide  cost air carriers $10 billion annually, including costs associated with  injuries and fatalities and other indirect costs such as cancelled flights.  However, these research efforts have also been hindered by a lack of data.  In a 2002 study of ramp worker accidents, FAA noted the difficulty of  obtaining nonfatality data. The Flight Safety Foundation also noted the  limited amount of data available for its 2004 study of damage and injury on  airport ramps.
subsections: section_title: Federal Roles in Runway and Ramp Safety
paragraphs: FAA has primary federal responsibility for runway safety. Several FAA  offices carry out these responsibilities, including  the Air Traffic Organization, which manages air traffic control—including  the hiring, training, and managing of more than 14,300 air traffic  controllers—and develops and maintains runway safety technology; the Office of Runway Safety, created in 1999 as part of the Air Traffic  Organization to lead and coordinate the agency’s runway safety efforts— including developing a national runway safety plan and metrics for runway  safety—and evaluate the effectiveness of runway safety activities;  the William J. Hughes Technical Center in Atlantic City, NJ, which  conducts aviation safety research;  the Office of Airports—which, as of July 2007, employed 45 safety  inspectors to check airports’ compliance with regulations—develops  standards for airport signage, markings, and lighting, and manages the  agency’s Runway Safety Area Program to address runway overruns; the Office of Aviation Safety, which conducts safety inspections of airlines,  audits air traffic safety issues, and administers a program to obtain  information from pilots about the circumstances of runway incursions;  and  the Civil Aerospace Medical Institute in Oklahoma City, which conducts  aerospace medical and human factors research.
FAA’s oversight of ramp areas is provided indirectly through its  certification of airlines and airports. FAA has statutory authority to  investigate aviation accidents including those that occur in ramp areas.  Pursuant to an FAA order, it is responsible for “ensuring that all facts,  conditions, and circumstances leading to the accident are recorded and  evaluated and action is taken to prevent similar accidents.” According to  NTSB officials, that agency also investigates aviation accidents, including  incursions and overruns that result in accidents, and selected runway  incursions—those that are the most severe or those that the board  believes represent the most safety benefit. NTSB investigates ramp  accidents when someone is onboard the aircraft, when flight is intended or  when a death or serious injury or substantial damage to the aircraft  occurs. Under the Occupational Safety and Health Act (OSH Act), OSHA  has statutory authority to govern the occupational safety and health of  employees. According to OSHA officials, the agency investigates ramp  accidents when they involve fatalities or the hospitalization of three or  more employees and conducts workplace inspections in response to  complaints from workers. According to a 2000 memorandum of  understanding between OSHA and FAA relating to coordination and  enforcement of the OSH Act, OSHA does not investigate accidents  involving crew members on aircraft in operation.
section_title: Challenges Remain Despite Numerous Efforts to Address Runway Safety
paragraphs: FAA has undertaken a number of efforts to address runway safety  problems involving incursions and overruns. The agency has taken a  layered approach to meet many of the runway safety strategic objectives it  set in 2002. However, the lack of coordination and leadership among  FAA’s runway safety efforts, technology challenges, the lack of data, and  human factors issues impede further progress in addressing runway safety.  Because the number and rate of runway incursions did not decrease from  fiscal year 2002 through fiscal year 2006 and remains at a level higher than  any time during the 1990s, FAA could take additional cost-effective  measures to improve runway safety. These measures include ensuring that  FAA’s Office of Runway Safety operates as a coordinating entity for the  agency’s runway safety efforts, as well as establishing a new voluntary  safety incident reporting program for air traffic controllers.
subsections: section_title: FAA Uses a Layered Approach to Reduce the Risks of Runway Incursions and Overruns
paragraphs: FAA’s layered approach to addressing runway safety includes a range of  actions, such as deploying, researching, and testing new technology;  encouraging airport improvements, such as changes to layout, markings,  signage, and lighting; and providing human factors training for pilots and  air traffic controllers. Our analysis found that FAA completed or was in  the process of implementing 34 of the 39 runway safety objectives it set in  its most recent national runway safety plan, issued in 2002, as a means of  reducing the severity, number, and rate of runway incursions (see app.  IV). Most of the completed objectives involved (1) developing and  distributing runway safety education and training materials to controllers,  pilots, and other airport users; (2) supporting and developing new  technologies intended to reduce the potential for runway collisions; and  (3) assessing and modifying procedures to enhance runway safety. The  results of our survey of experts indicated that the most effective actions  that FAA was taking were lower-cost measures, such as enhancing airport  markings, lighting, and signage (see table 1). Some experts noted that  markings, lighting, and signage help keep aircraft from becoming lost on  the airfield and accidentally entering an active runway. The testing of  runway status lights—technology that is more expensive to deploy than  improving airport markings, lighting, and signage—is another action that a  majority of the experts rated as being most effective. Further, one expert  noted that all of FAA’s actions in addressing runway incursions must be  continued because one fix alone will not improve safety.
Surface surveillance technology is a major part of FAA’s strategy to  improve runway safety. FAA has deployed the Airport Movement Area  Safety System (AMASS), which uses the Airport Surface Detection  Equipment, model 3 (ASDE-3) radar, and is deploying the Airport Surface  Detection Equipment, Model X (ASDE-X) to provide ground surveillance,  both of which give air traffic controllers better visibility of activity on the  airfield and could help prevent collisions. FAA completed the deployment  of ASDE-3/AMASS at 34 of the nation’s busiest airports (see app. V) in  2003, and is now deploying ASDE-X at 35 major airports (see fig. 7).  Although ASDE-3/AMASS and ASDE-X are both radar-based, ASDE-X  integrates data from a variety of sources, including radars and aircraft and  vehicle transponders, to give controllers a more complete view of airport  activities. ASDE-3/AMASS and ASDE-X are both designed to provide  controllers with alerts when the system detects a possible collision.
Runway status lights, which FAA is testing at the Dallas-Ft. Worth  International Airport and the San Diego International Airport, are a series  of lights embedded in the runways that give pilots a visible warning when  runways are not clear to enter, cross, or depart on. They are a fully  automatic, advisory safety system requiring no input from controllers, and   currently consist of takeoff hold lights and runway entrance lights (see   fig. 8). Ten of 17 experts we surveyed indicated that FAA’s testing of  runway status lights was very or extremely effective in addressing runway  incursions. Surface surveillance systems, such as ASDE-3/AMASS and  ASDE-X, provide the data needed to operate runway status lights, and the  systems’ safety logic assesses any possible conflicts on the airfield and  provides alerts of potential collisions.
Another technology that FAA is testing, the Final Approach Runway  Occupancy Signal, is designed to provide a visible warning to aircraft on  approach. This system, which is being tested at the Long Beach  (Daugherty Field) airport in California, activates a flashing light visible to  aircraft on approach as a warning to pilots when a runway is occupied and  hazardous for landing. FAA is also testing low cost surface surveillance  systems for small to medium airports at the Spokane International  Airport.
According to  Atlanta airport officials, use of the perimeter taxiway eliminates about 560  aircraft runway crossings per day, or about one-third of the airport’s total  daily runway crossings. Figure 9 shows the typical route that aircraft  landing on the northern runways at the Hartsfield-Jackson Atlanta  International Airport would take to taxi to the gate without using the  perimeter taxiway. Figure 10 shows that, by using the perimeter taxiway,  aircraft landing on the northernmost runway no longer need to cross a  parallel runway to reach the gates. Eleven of 16 experts we surveyed  indicated that FAA’s approval of perimeter taxiways was very or extremely  effective in addressing runway incursions.
FAA has also helped fund other runway and taxiway changes at various  airports. For example, the Los Angeles International Airport, the U.S.  commercial airport that has experienced the most runway incursions in  recent years, is modifying its runway and taxiway configuration in an area  where many of the incursions have occurred. FAA and airports have  made many runway safety improvements at airports that were identified  by local and regional Runway Safety Action Teams, which are groups of  FAA and airport officials, as well as other aviation safety stakeholders,  which were formed as part of the agency’s runway safety program in 2002.  In addition, FAA has standardized airport signage and markings, including  issuing new standards for surface markings that require the use of glass  beads for better reflectivity, requiring new taxiway markings that alert  pilots that they are approaching runway entrances, and doubling the size  of markings indicating where aircraft should hold before proceeding onto  the runway. A majority of the experts we surveyed confirmed the  measures’ effectiveness, indicating that FAA’s enhancement of airport  markings, lighting, and signage was very or extremely effective.
FAA has funded runway safety research that has led to the testing and  deployment of new technology and other measures. During fiscal year  2006, FAA spent about $3.5 million on runway incursion prevention  research at its William J. Hughes Technical Center on projects such as  visual guidance, including signs and lighting; and about $55,000 on  research at its Civil Aerospace Medical Institute regarding vehicle  incursions and operational errors. Also during fiscal year 2006, FAA  funded about $1 million for runway safety-related research that was  conducted at DOT’s Volpe National Transportation Systems Center on  projects such as runway status lights, analyses of runway incursion data,  FAA’s runway incursion severity calculator, and the electronic flight bag.
subsections: section_title: FAA Training and Industry Outreach Includes Human Factors Issues
paragraphs: Because most incursions are caused by human error, FAA is making  outreach and awareness efforts to address errors made by pilots, air traffic  controllers, and airport vehicle operators. The agency issued booklets in  2004 and 2005 for pilots that highlight communication procedures for safe  surface operations at towered and nontowered airports. In collaboration  with the aviation industry, FAA helped to create two online courses that  educate pilots on runway safety and conducts safety seminars for pilots  across the country to encourage safe practices on the airfield. To enhance  air traffic supervisor and controller education, FAA is developing for  training purposes simulated recreations of actual incursions. In addition,  in recent years, FAA developed and initiated controller training on human  factors, including skills enhancement regarding teamwork,  communication, problem solving, situational awareness, and managing  workloads. FAA also provided airline maintenance personnel operating  “tug and tow” vehicles with best practices while operating on the airport  surface and requires driver training programs for all airport workers who  access the airfield movement areas at commercial airports. Many of the  items implemented as a result of recommendations made by Runway  Safety Action Teams also involved human factors. FAA data indicated that  Runway Safety Action Teams recommended 4,441 action items for  implementation between April 2001 and mid-December 2006. Of these,  3,338 actions, or about 75 percent, were completed, with the largest  combined grouping (945 actions) relating to pilots, air traffic controllers,  and vehicle drivers regarding actions such as training and improved  procedures. Ten of 19 experts we surveyed indicated that FAA’s  establishment of Runway Safety Action Teams was very or extremely  effective in addressing runway incursions. Only 5 of 22 experts we  surveyed indicated that FAA’s pilot educational initiatives were very or  extremely effective and 8 of 21 experts said that FAA’s air traffic controller  training was very or extremely effective in addressing runway incursions.
section_title: FAA and Airports Have Improved Runway Safety Areas in Case of Overruns
paragraphs: To address runway overruns, FAA and airports have made progress in  recent years to bring runway safety areas into compliance with FAA  standards. According to FAA, as of May 2007, 70 percent of the 1,014  runways at 573 commercial airports in the United States substantially  comply with runway safety area standards, up from 55 percent in 2000.  Progress has also been made in bringing runways at the nation’s busiest  airports into compliance with FAA runway safety area standards pursuant  to the congressional mandate to have all airports in compliance by  December 31, 2015. As of June 2007, 21 of 47 runways at the 10 busiest  U.S. commercial airports did not meet FAA runway safety area standards,  down from 30 runways at those airports that did not meet standards in  October 2006. Increased compliance with runway safety area standards  reduces the chance of aircraft being damaged from overruns.
Recognizing the difficulties of meeting the runway safety area standards at  airports that do not have enough space to establish 1,000-foot runway  safety areas, FAA conducted research during the 1990s that led to the  development of the Engineered Materials Arresting System (EMAS), a bed  of crushable concrete designed to stop overrunning aircraft. In 1999, FAA  began accepting EMAS as an alternative to constructing a runway safety  area when its construction is not practicable and, in 2004, began  considering EMAS as generally equivalent to a full-length runway safety  area. As of June 2007, EMAS was installed at 24 runway ends at 19 U.S.  airports and 12 additional EMAS systems were under contract at 8  airports. In addition, EMAS had successfully stopped four aircraft that had  overrun runways, including a Boeing 747 that overran a runway at the  John F. Kennedy International Airport in January 2005 and was traveling at  an exit speed of about 70 knots, or about 80 miles per hour. Figure 11  shows an example of how EMAS can stop an aircraft. The effectiveness of  this measure was supported by a majority of experts we surveyed, who  indicated that FAA’s acceptance of EMAS as an alternative to constructing  a runway safety area when its construction is not practical was very or  extremely effective in addressing runway overruns. One expert, for  example, said that because many airports no longer have the ability to  expand existing runway safety areas, EMAS may be the only practical  solution. Other experts noted that preventive measures, such as training to  improve pilot skills, are also needed.
Since 2000, about $300 million per year from FAA’s Airport Improvement  Program has been spent on runway safety area improvements, and $1.1  billion is expected to be needed to complete the remaining 207 projects.  FAA officials told us that, if the current funding levels are maintained for  the Airport Improvement Program, sufficient resources will be available to  complete the planned runway safety area improvements. An official from  an airport association said that even if sufficient airport improvement  funds are available for runway safety area improvements, all airports will  not be able to acquire the land needed to establish the safety areas. Eleven  of 14 experts we surveyed indicated that FAA’s use of airport  improvement funds to construct runway safety areas was very or  extremely effective in addressing runway overruns.
section_title: Lack of Coordination and Leadership, Technology Challenges, Lack of Data, and Human Factors Issues Impede Further Progress in Improving Runway Safety
paragraphs: Although FAA took many steps to address runway safety problems  involving incursions and overruns, especially since the number and rate of  incursions peaked in fiscal year 2001, its efforts have waned in recent  years, and the number and rate has remained steady. Additional measures  by FAA would enhance the coordination and leadership of runway safety  issues, technology, data collection and analysis, and human factors issues.
subsections: section_title: FAA’s Office of Runway Safety Is Not Carrying Out its Coordination and Leadership Functions
paragraphs: FAA is not following its order, issued in 2002, that directs the Office of  Runway Safety to coordinate and monitor activities throughout the agency  to ensure that runway safety goals are met. The absence of coordination  and national leadership impedes further progress on runway safety  because no single office is taking charge of assessing the causes of runway  safety problems and taking the steps needed to address those problems.  Under the FAA order, FAA’s Office of Runway Safety is to prepare a  national runway safety plan every 2 to 3 years and to provide updates as  needed. However, we found that the most recent national runway safety  plan, issued in 2002, is no longer being used and the status of its objectives  are not being tracked. FAA officials told us the national runway safety plan  has been replaced by the FAA Flight Plan, which is a high-level planning  document covering all of FAA’s programs. However, we agree with the  conclusion in a May 2007 audit report by the DOT Office of Inspector  General that replacing the national runway safety plan by the higher-level  FAA Flight Plan, with the goal of having each FAA office separately  include its runway safety initiatives in its own business plan, does not have  the same national focus and emphasis on runway safety that a national  plan for runway safety provides. In addition, although the Airports Office  and the Air Traffic Organization included runway safety objectives in their  business plans, the Office of Aviation Safety’s business plan for fiscal year  2007 did not include plans to reduce runway incursions. Moreover, the  lack of a comprehensive, targeted plan has resulted in uncoordinated  efforts that may not be the most effective.
In addition, although FAA hired a permanent director at the Senior  Executive Service (SES) level for the Office of Runway Safety in August  2007, the Office of Runway Safety did not have a permanent director for  the previous 2 years, resulting in a lack of national program leadership,  and its staff was reduced by about 45 percent over the last 4 years. Before  2004, the runway safety office had 66 full-time staff led by an SES-level  manager in headquarters, compared to about 37 full-time runway safety  staff led by a non-SES-level acting director as of May 2007. Moreover,  although contractors represented about 60 percent of the Office of  Runway Safety staff in 2004, funding for the office’s contract employees  was reduced from about $4 million in 2005 to about $2.5 million per year in  2007. An FAA official told us that because the Office of Runway Safety  relied heavily on contractors for staff, it lacked a career path for potential  managers in the field and at headquarters and lost expertise that the  contractors had developed when their contracts expired. In addition, as of  May 2007, the Office of Runway Safety no longer had as many full-time  detailees from other FAA offices with runway safety responsibilities,  including FAA’s Airports and Air Traffic Organization’s Terminal Service  offices, as it had in the past.
Several FAA officials and others said that the lack of leadership in the  Office of Runway Safety had negatively affected the program. A regional  runway safety program manager said, for example, that having had no  permanent director for the office resulted in a lack of direction from  headquarters, leaving regions to carry out runway safety efforts in  different ways. This situation prevents FAA from identifying systemwide  causes of runway safety problems that may require coordinated solutions.  Furthermore, an official currently working on the runway safety program  said that no quarterly performance review meetings were held between the  Acting Director of Runway Safety and the regional runway safety program  managers for over a year during 2006 and 2007. These meetings had been  held, for example, to discuss regional initiatives. Such sharing of  information between regions could help address runway safety issues  from a national perspective and implement changes systematically. FAA  research officials also told us that after having completed a study for the  Runway Safety Office, they could not find anyone to give it to in FAA  headquarters. The new permanent director of the Office of Runway Safety  indicated that the office plans to restart some initiatives, including  conducting quarterly runway safety performance reviews, starting in  December 2007. However, other plans for the office are still being  developed.
section_title: Technology Challenges Impede Progress in Improving Runway Safety
paragraphs: FAA has faced significant challenges in deploying and developing  technology for runway safety. Technology currently being installed, ASDE- X, has experienced cost increases and schedule delays from its original  baselines, and is encountering some operational difficulties. At the same  time, additional technology to prevent runway collisions is years away  from deployment. Because FAA relies heavily on technology as part of its  runway safety strategy to supplement a controller’s vision of the airfield,  these challenges impede progress in addressing runway safety.
FAA has revised its cost and schedule plans twice since 2001 to deploy  ASDE-X at 35 airports by 2011. The current program costs have increased  by about $125 million over the 2001 estimate, as FAA added nine airports  to its deployment schedule (see table 2). FAA currently estimates that the  total ASDE-X program cost will be about $806 million, including the cost  to operate and maintain the system through fiscal year 2030. This includes  facilities and equipment costs of about $550 million, which is  approximately $40 million more than what we reported in 2005, plus about  $257 million in operations and maintenance costs. As of August 2007,  ASDE-X was commissioned at 11 airports. Regarding their plans to  deploy ASDE-X to the remaining 24 airports by 2011, FAA officials said  that they had focused their efforts at the beginning of the program on  software development, which is nearly complete, and on system  enhancements, which have been completed, allowing them now to  concentrate on system deployment. In addition, FAA officials said in  November 2007 that ASDE-X deployment is ahead of the agency’s revised  2005 schedule and that costs have remained consistent with its revised  2005 cost estimate. Nonetheless, as discussed below, our concerns about  the schedule plans for ASDE-X remain.
Although it took about 4 years for ASDE-X to be commissioned at those 11  airports, FAA plans to deploy the system at the remaining 24 additional  airports in less than 4 years (see app. V). Furthermore, not all 11 ASDE-X  commissioned airports have key safety features of the system. For  example, as of August 2007, three of the ASDE-X commissioned airports  did not have safety logic, which generates a visible and audible alert to an  air traffic controller regarding a potential runway collision. Moreover, five  airports, including the three lacking safety logic, do not have a system  enhancement that allows ASDE-X to alert controllers of potential  collisions on intersecting runways or runways intersecting taxiways  during inclement weather (see table 3). Because of these issues, the DOT  Inspector General reported, and we agree, that the program is at risk of  not meeting its current cost and schedule plans to deliver ASDE-X systems  at 35 airports by 2011.
Recent serious runway incursions at airports with fully operational  runway safety technology reveal persistent problems with their alerting  functions. For example, air traffic controllers at eight airports with ASDE- 3/AMASS told us that the alerting function does not work well during  heavy precipitation and that they disable the alerting function during  inclement weather. As a result, air traffic controllers at those airports  with ASDE-3/AMASS do not have the benefit of an incursion alerting  system in poor weather conditions, when it may be most needed.  Furthermore, the ASDE-X commissioned airports are experiencing  problems with false alerts, which occur when the system incorrectly  predicts an impending collision, and false targets, which occur when the  system incorrectly identifies something on the airfield as an aircraft or  vehicle and could generate a false alert. (These problems are discussed in  more detail below.) Although FAA officials acknowledged that ASDE-X is  experiencing problems with false alerts, they said the system is operating  within specifications. An April 2007 FAA internal audit of the ASDE- 3/AMASS and ASDE-X safety logic systems concluded that the runway  safety logic system was not providing consistent information to  controllers, creating a lack of confidence in the system. Furthermore,  NTSB, after several investigations of incursions at airports equipped with  ASDE-3/AMASS, determined that the alerting process was ineffective  because the delay was too long before pilots would receive the alert  relayed by controllers. As a result, NTSB asked that FAA develop a system  that provides a direct warning to the cockpit.
Of the 11 ASDE-X commissioned airports, the control tower at the Seattle- Tacoma International Airport reported the most problems with false  targets. In addition, of the eight ASDE-X commissioned airports with the  alerting function, the control tower at the Hartsfield-Jackson Atlanta  International Airport reported the most problems with false alerts. When  an ASDE-3/AMASS or ASDE-X alert sounds, air traffic controllers are  required to instruct landing aircraft to follow a go-around procedure,  sending the aircraft back into the airspace for another landing attempt,  even if nothing is visible on the runway that could cause a collision. The  controllers said the effect of this practice is to increase air traffic and  flight times. Officials from the ASDE-X manufacturer said an elevated  number of false targets, on average, at the Seattle-Tacoma International  Airport is caused primarily by the location of the surface movement radar  relative to the airport facility structures, the movement area, and the  airport’s configuration. The location of these structures is determined by  FAA and the airports. Officials from the manufacturer also said ASDE-X at  the Hartsfield-Jackson Atlanta International Airport is experiencing an  elevated number of nuisance alerts, which are caused by real conditions  that are not safety threats, such as a vehicle on a runway, but landing  aircraft are far enough from the airport not to constitute a threat. They  said the nuisance alerts being experienced at the Hartsfield-Jackson  Atlanta International Airport are caused by the site-specific configuration  parameters of the system, and that they are working with air traffic  controllers, FAA engineers, and the ASDE-X program office to adjust the  parameters of the system to minimize the nuisance alerts while  maintaining the required performance. The officials noted the difference  between nuisance alerts and false alerts, which are issued after the system  detects potential threats that are not real. The officials said they examine  false alerts very closely with FAA and determine whether to make design  modifications to the system to ensure that they are minimized.
FAA ASDE-X program officials said that the problems with false alerts and  false targets are site-specific, rather than systemic issues, relating to the  location of sensors and radar towers. The officials said they are working to  address the problems by adjusting the sensitivity of the systems, which  they described as a time-consuming, continuous process with no single fix.  For example, they said that at the Seattle-Tacoma International Airport,  the system’s level of sensitivity was increased at the site’s request because  of its experience with heavy fog, and that a certain number of false targets  cannot be eliminated without sacrificing the sensitivity. At the same time,  FAA officials acknowledged that the location of the ASDE-X surface  movement radar at the Seattle-Tacoma International Airport has affected  system performance much more than originally anticipated. FAA also  noted that all radar systems experience false targets as a function of  detection and that the majority of false targets at the Seattle airport  occurred on taxiways near the terminal. They also said that new software  being deployed at airports starting in September 2007 would help address  the problems involving false alerts and that with the addition of the new  software, ASDE-X is operating under system requirements not to generate  more than two false alerts within 24 hours. This software enhancement  was deployed at the Hartsfield-Jackson Atlanta International Airport in  September 2007, and FAA program officials said they believe it has  resulted in improved ASDE-X system performance. We were not able to  confirm this information.
Only 3 of 17 experts we surveyed indicated that FAA’s deployment of  ASDE-3/AMASS was very effective, and 4 of 17 experts said that ASDE-X  was very or extremely effective in addressing runway incursions. One  expert, for example, said that ASDE-X appears to be a great technology to  aid controllers, but is not trustworthy at this point because the rate of false  alerts is somewhat high. In addition, this expert said that because ASDE-X  has been deployed only to a few airports, it is not doing much to address  runway incursions within the national airspace system as a whole. Another  expert said that ASDE-X and runway status lights would greatly enhance  both pilot and air traffic controller awareness, particularly at complex  airports.
Most airports in the United States have no runway safety technology to  supplement a controller’s vision of the airfield and will not have such  technology even after FAA completes its plan to deploy ASDE-X at 35  major airports. FAA’s original plans called for 34 airports to receive ASDE- 3/AMASS and 35 airports to receive ASDE-X. In total, 59 airports were to  receive either technology, but this number was reduced to 44 in August  2006 after FAA canceled plans to deploy ASDE-X at 15 of the originally  scheduled airports. The 35 major airports to receive ASDE-X handle 70  percent of the enplanements at U.S. airports but represent only 6 percent  of all U.S. commercial airports, leaving most airports without this type of  technology. Six of 12 experts who indicated that they had knowledge of or  experience with the deployment of ASDE-X indicated that, considering the  benefits and problems with ASDE-X, including false alerts and false  targets, deployment of the system at the remaining 27 airports by 2011  should be kept as planned, 4 said that deployment should be accelerated,  and 2 said that deployment should be slowed down. One expert, for  example, who indicated that the deployment of ASDE-X should be kept as  planned, said that the problems with the system will be worked out as the  system is deployed.
FAA is testing additional runway safety technology, but these systems are  still years from being deployed in the United States. Runway status lights,  which warn pilots when runways are unsafe to enter or cross, have had  positive preliminary test evaluations, but need a surface surveillance  system such as ASDE-3/AMASS or ASDE-X to operate. FAA officials  expect to decide in 2007 whether to deploy runway status lights at the 35  ASDE-X airports at an estimated cost of $300 million but do not expect to  make a final investment decision on another runway safety lighting  technology, the Final Approach Runway Occupancy Signal, which  provides a visible warning to aircraft on approach, for another 2 years. In  addition, an FAA official said the agency is still exploring the capabilities  of the low cost surface surveillance system and does not yet have a  deployment schedule. Only 2 of the experts we surveyed indicated that  FAA’s testing of the low cost surface surveillance system was very  effective in addressing runway incursions. FAA announced in March 2007  that it was changing the certification process to enable the use of  electronic flight bags (electronic display systems that give pilots a variety  of aviation data such as aircraft operating manuals and navigational  charts) and airport moving maps, which can show an aircraft’s position  on an airfield, but a system that shows the location of other aircraft on the  airfield is still under development. In addition, although officials from the  Hartsfield-Jackson Atlanta International Airport cited the benefit of  reducing aircraft runway crossings from using the airport’s new perimeter  taxiway, FAA officials said that few U.S. airports have the space to  construct perimeter taxiways and noted that they are expensive to  construct.
section_title: Lack of Runway Incident Data Impedes Causal Analysis
paragraphs: In addition to its technological challenges, FAA lacks reliable runway  safety data and the mechanisms to ensure that the data are complete.  FAA’s tabulation of the number of incursions does not reflect the actual  number of incidents that occur. FAA only counts incursions that occur at  airports with air traffic control towers, so the actual number of incursions,  including those that occurred at airports without air traffic control towers,  is higher than FAA reports. In addition, FAA’s information on incursions  that occurred at towered airports may not be complete, according to some  experts we surveyed. For example, one expert said that the airline  industry’s reporting of runway incursions is higher than FAA’s data and  that most or all air carriers are aware of significant events that controllers  failed to report. Although the airline industry provides data to FAA on  safety incidents that may involve runway incursions, the information lacks  sufficient specificity for FAA to use in its tabulation of incursions.
Furthermore, although FAA requires errors that may result in incursions  to be reported, the information collected does not always contain  complete data on the causes and circumstances involved. Without more  complete data, FAA cannot conduct in-depth analyses to ensure that the  most effective corrective measures that address the causal factors are  being implemented. An FAA program to obtain detailed information about  the circumstances regarding runway incursions by administering  questionnaires to pilots involved in incursions—the Runway Incursion  Information and Evaluation Program—could help to identify root causes  of pilot deviations and provides a mechanism to obtain information that  may not otherwise be reported. However, only 19 percent of pilots  involved in runway incursions and surface incidents participated in the  program during 2004 through 2006, and FAA did not provide any evidence  that it analyzed the data that were collected.
Certain FAA efforts that are in the early stages have the potential to  improve runway safety data. For example, FAA plans to start a  nonpunitive, confidential, voluntary reporting program for air traffic  controllers, similar to the Aviation Safety Action Program as part of the  FAA safety management system. The program will enable air traffic  controllers to report anything that they perceive could contribute to safety  risks in the national airspace system. The benefit of such program is that  the information obtained might not be reported otherwise, and could  increase the amount of data collected on the causes and circumstances of  runway incursions. Many industry stakeholders such as the National Air  Traffic Controllers Association, the Air Transport Association, the Air Line  Pilots Association, and the Air Safety Foundation, support establishing  such a program, which could also help reduce any underreporting of  incidents. FAA has been working on establishing such a program since  2004, and indicated at a runway incursion meeting with the aviation  community in August 2007 that it would implement a short-term runway  safety plan that included implementing such a voluntary self-reporting  program. According to FAA, it signed a partnership agreement with the  National Air Traffic Controllers Association regarding the program in  October 2007; however, the agency did not indicate when the plan would  be implemented.
We also found that FAA’s categorization of the severity of runway  incursions involves a level of subjectivity, raising questions about the  accuracy of the data. An internal FAA audit of 2006 runway incursion data  found that the subjectivity of the severity classifications has the potential  to affect the accuracy of the classifications. The audit found that incursion  severity classifications were subjective and partially incomplete. In  addition, 18 percent of the incursion severity classifications for 2006 were  found not to be in compliance with FAA severity classification  requirements or could not be classified accurately. The audit also found  that since August 31, 2006, the Office of Runway Safety has been using a  computer program called Runway Incursion Severity Classification to  calculate initial assessments of severity. FAA indicated that use of the  computer program ensures consistent ratings based on available data.  However, most of the information regarding incursions, which is entered  into the computer model, is based on observations of incidents, rather  than instrument readings, because many airports do not have the  technology needed to collect such information or the information is not  available to FAA, according to agency officials. Observations regarding  matters such as how close two aircraft came to colliding on a runway may  be less accurate than instrument readings and, therefore, raise questions  about the accuracy of the severity assessments. These findings were  supported by the experts we surveyed. The majority of the experts who  responded to a question about the accuracy of FAA’s incursion severity  classifications indicated that, based on their knowledge of specific  incidents, FAA classified the incidents as being less severe than they  actually were.
Furthermore, FAA does not have complete information on ASDE-3/AMASS  and ASDE-X system abnormalities, which could be used to analyze the  performance of the systems’ alerting functions. An internal FAA audit  concluded that 54 percent of all alerts—false and real—from the ASDE- 3/AMASS and ASDE-X systems and 40 percent of instances when the  systems’ alerting functions were disabled were not recorded. The audit  also found no evidence of alerting standards for the runway safety logic  systems, which limits the systems’ capability of assessing risks and  providing timely alerts to air traffic controllers.
We also found that FAA does not systematically collect data on the  number of runway overruns that do not result in damage or injury that  could be used for analytical purposes to study trends and causes of these  incidents. FAA officials said it would be useful to collect such data  because it would help them tailor standards to what has actually occurred,  for example, how far an aircraft overran a runway before stopping.
section_title: Controller Fatigue Continues to Be a Runway Safety Concern
paragraphs: Air traffic controller fatigue continues to be a human factors issue  affecting runway safety. In April 2007, for example, NTSB recommended  that FAA mitigate concerns about air traffic controller fatigue by (1)  working with the National Air Traffic Controllers Association to revise  controller work-scheduling policies and practices so controllers would  have enough sleep and to modify shift rotations to minimize disrupted  sleep patterns for controllers, and (2) developing a fatigue awareness and  countermeasures training program for controllers and for the personnel  involved in scheduling their work. In supporting its recommendation,  NTSB cited four instances from 2001 through 2006 when tired controllers  made errors while performing their duties that resulted in serious  incursions. NTSB said that although FAA regulations and policies place  limits on controller work schedules, for example, by requiring that  controllers be provided at least one full 24-hour day off per week, they do  not adequately consider the potential effect of work scheduling on fatigue  and performance. FAA officials said they were analyzing NTSB’s  recommendations on air traffic controller fatigue but that implementing  them would require renegotiating the agency’s contract with the union  representing the controllers.
According to FAA data, as of May 2007, at least 20 percent of the  controllers at 25 air traffic control facilities, including towers at several  major airports, were working 6-day weeks, which could cause fatigue.  FAA officials said that it may take 2 to 3 years before controller overtime  can be reduced at some facilities, as the agency acts to replace retiring  controllers. In the meantime, the agency officials indicated that they had  no plan to mitigate the effects of air traffic controller fatigue.
While FAA has taken some actions to address controller fatigue, problems  have been identified with some efforts. For example, an FAA human  factors initiative, the National Air Traffic Professional Program, is aimed at  identifying how controllers’ performance can be affected by factors such  as fatigue and distraction. The program consists of training designed to  sharpen and maintain controllers’ mental skills most closely associated  with visual attention and scanning. However, the DOT Inspector General  reported in May 2007 that the program had not been implemented at  towers where visual attention and scanning are key factors in preventing  runway incursions. Although FAA has taken some steps to address human  factors issues through the educational initiatives that were discussed  earlier, progress on addressing runway safety will be impeded until the  human factors issues involving fatigue are addressed.
section_title: FAA Has Not Implemented NTSB’s Runway Safety Recommendations
paragraphs: FAA has not implemented any of NTSB’s six runway incursion prevention  recommendations, made in 2000, that FAA  require all airports with scheduled passenger service to deploy a ground  movement safety system that will prevent runway incursions and provide a  direct warning capability to flight crews; require that all runway crossings be authorized by specific air traffic  control clearance;  require that, when aircraft need to cross multiple runways, air traffic  controllers issue an explicit crossing instruction for each runway;   discontinue the practice of allowing departing aircraft to hold on active  runways at night or at any time when visibility conditions preclude  arriving aircraft from seeing traffic on the runway in time to initiate a safe  go-around maneuver;   adopt an ICAO landing clearance procedure that forbids multiple landing  clearances for the same runway; and require the use of ICAO phraseology for airport surface operations, and  periodically emphasize to controllers the need to use this phraseology and  to speak at reasonable rates when communicating with flight crews.
Since NTSB made these recommendations 7 years ago, FAA has made  some efforts to address them, but NTSB has not accepted FAA’s  responses. Regarding NTSB’s recommendation that a direct incursion  warning capability be developed for flight crews, FAA indicated in 2006  that, among other efforts, it had successfully completed promising initial  field tests of runway status lights at the Dallas-Ft. Worth International  Airport but that additional tests would be needed to determine if the  system could be deployed to airports throughout the country. An NTSB  official told us that the board would need to evaluate the runway status  lights system before it could determine whether the system would satisfy  this recommendation. Regarding NTSB’s recommendations that FAA  change certain air traffic control procedures, FAA said that implementing  the recommendations could possibly transfer the risk to another segment  of the operation by increasing pilot and controller workload and radio  frequency congestion, and causing unexpected and unnecessary go-around  procedures. However, NTSB disagreed, indicating that it remained  concerned about situations where pilots may be lost, or believed they have  received permission to move to different positions other than those that  air traffic controllers intended and that air traffic controllers should not  clear aircraft to land on runways that are occupied by other aircraft.
Regarding NTSB’s recommendation that FAA adopt ICAO phraseology,  FAA indicated in 2004 that adopting certain ICAO phraseology would  create inconsistency and nonstandardization throughout the national  airspace system. However, NTSB noted that by not adopting the ICAO  phraseology, FAA has not harmonized its phraseology with the rest of the  world. Two of our survey respondents also suggested that FAA adopt  ICAO phraseology in communications between the air traffic controllers  and pilots. In August 2007, FAA announced that it plans to assess whether  it needs to change the phraseology of taxi clearances given by controllers  to better align with ICAO standards, among other planned actions.
section_title: FAA Has Opportunities to Improve Runway Safety
paragraphs: The results of our survey of experts indicated that the actions that FAA  could take with the greatest potential to prevent runway incursions,  considering costs, technological feasibility, and operational changes, were  measures to provide information or alerts directly to pilots (see table 4).  For example, the actions that FAA could take with the most potential were  lighting systems that guide pilots as they taxi at the airport and technology  that provides enhanced situational awareness on the airfield and alerts of  potential incursions.
Our survey respondents and international aviation safety experts also said  that certain runway safety procedures in other countries have the  potential, if adopted, to improve runway safety in the United States.  International aviation organization officials said that there is some benefit  to having air traffic controllers clear aircraft to holding points—a practice  being followed at some airports outside of the United States—rather than  directly to runways but that it would increase already-busy radio  communications between pilots and the air traffic control tower. In  addition, some experts suggested that because of the safety risks involved,  FAA should stop using land and hold short procedures, which are mainly  used in the United States and involve instructing landing aircraft to land  and hold on their runway before crossing an intersection or another  runway. Officials from an international aviation organization said that U.S.  carriers are generally comfortable with land and hold procedures and  understand that they are necessary to manage the large volume of traffic at  certain airports. However, they added that the procedures would be  greatly improved if they could be agreed upon and promulgated  internationally. An expert also suggested that FAA consider deploying  progressive taxiway lights that activate as aircraft taxi to or from the  runway to help keep aircraft from making wrong turns or entering the  runway environment. However, other experts said that progressive  taxiway lights are difficult to see in the daytime.
Recognizing the need for additional actions to improve runway safety, on  August 15, 2007, FAA met with the aviation community and agreed on a  short-term plan, which included some measures that our experts had also  recommended. The participants decided to take the following actions  during the subsequent 60 days: (1) conduct safety reviews at the airports  where runway incursions and wrong runway departures are the greatest  concern, (2) disseminate runway safety information and training across  the entire aviation industry, (3) accelerate the deployment of improved  airport signage and markings at the top 75 airports, and (4) review cockpit  and air traffic control procedures, which could include changing cockpit  procedures to minimize pilot activities and distractions while an aircraft is  moving on the ground and to make air traffic control procedures more  precise. On October 22, 2007, FAA announced that among the actions  taken, (1) safety reviews at 20 airports had been completed, (2) 104 of 112  air carriers provided pilots with simulator and other training incorporating  runway scenarios, (3) runway markings had been upgraded at 52 of 75  medium- and large-sized airports, and (4) 101 of 112 air carriers had  reviewed cockpit procedures to identify and develop a plan to address  pilot distractions when taxiing to runways. In addition, FAA indicated that  it had completed analyzing air traffic control procedures regarding taxi  clearances and found that more explicit taxi instructions were needed.
The experts we surveyed also provided suggestions to prevent runway  overruns. They said the actions that FAA could take with the greatest  potential, considering costs, technological feasibility, and operational  changes, included improving communication of runway conditions and  weather to flight crews and encouraging improvements in and use of  runway condition and friction measurements (data regarding the slickness  of a runway). Regarding overseas practices to help prevent overruns, some  survey respondents said that more detailed information about runway  conditions is provided to pilots in some other countries, which could be  communicated to pilots in the United States as they prepare to land.  Furthermore, on October 4, 2007, NTSB recommended that FAA require  pilots to conduct landing distance assessments before every landing on the  basis of existing aircraft performance data, actual conditions, and  incorporating a minimum 15 percent safety margin. FAA has not yet  responded to this recommendation.
section_title: Progress in Addressing Ramp Safety Is Affected by a Lack of Data and Standards, but the Industry Is Taking Action to Address these Issues
paragraphs: The aviation industry has made efforts in recent years to address the  incidence of ramp accidents. However, these efforts have been hindered  by a lack of data on the nature, extent, and cost of ramp accidents and the  absence of industrywide ground handling standards. In response, the  federal government and the aviation industry have undertaken additional  steps to collect data and develop standards as a means of understanding  the problem and reducing the number of accidents.
subsections: section_title: Lack of Complete Accident Data Hinders Efforts to Address Ramp Safety
paragraphs: We found no source of comprehensive data on airport ramp accidents.  Various aviation entities collect ramp accident data, but they are not  complete enough to be useful for industrywide analyses, and, in many  cases, the entities were not willing for competitive reasons to publicly  disclose the data. Many industry stakeholders indicated to us that they  lack complete ramp accident data. Without such data, it will be difficult  for the aviation industry to understand the nature, extent, and cost of  ramp accidents and to allocate appropriate resources and methods to  improve ramp safety.
We found that data on ramp fatalities was more readily available than data  on nonfatal injuries and accidents without injuries. We reviewed FAA,  NTSB, and OSHA ramp fatality data from 2001 through 2006 and  determined that these agencies investigated 29 fatal ramp accidents during  that time. (See fig. 12.) These accidents occurred at airports of various  sizes—from large hubs to small general aviation airports. No airport  experienced more than 2 fatalities during this time period. (See app. VI.)  Of the 29 fatalities, 17 were ground workers, 8 were passengers, and 4  were pilots. The ramp fatalities generally occurred when these employees  were struck by objects (such as vehicles), were crushed, or fell. Most  aviation safety officials told us that ramp accidents represent little or no  danger to passengers, although a potential danger exists if, for example,  damage to an aircraft is left unreported. Of the 8 passengers who were  killed in ramp accidents from 2001 through 2006, 5 were struck by  propellers. Although we obtained data on fatal accidents, it is difficult to  determine the true nature and extent of all ramp accidents, including those  that result in injuries, because OSHA, the primary source of ramp fatality  data, does not collect or report data on occupational injuries other than  fatalities that occur in ramp areas. Furthermore, because FAA and NTSB  only investigate certain ramp accidents, as discussed earlier, they do not  have complete ramp accident data.
section_title: Lack of Standards for Ramp Operations Could Hinder Safety
paragraphs: We found no federal or industrywide standards for ramp operations. Each  airport authority has its own rules and regulations, which may be based on  local ordinances or state laws. In the United States, airlines typically  control the ramp areas, and each operates its ramps with its own specific  set of policies and procedures. In addition, in recent years, more airlines  have been contracting out some or all of these services, and often one  ground handling company services the aircraft of several airlines at an  airport. In this situation, ground handling companies must carry out their  duties in accordance with each airline’s policies and procedures, and,  because there is no standard for ramp operations, this could lead to  confusion about operating procedures and safety rules and increases the  likelihood of accidents.
section_title: The Federal Government and the Aviation Industry Are Taking Some Measures to Address Ramp Safety
paragraphs: FAA, OSHA, airports, and airlines are taking various measures to address  ramp accidents. According to experts we surveyed, three of the four most  effective actions are being taken by airlines, for example, by setting safety  targets and using ramp towers (see table 5).
The federal government has generally taken an indirect role in addressing  ramp safety. Since August 2000, FAA and OSHA have operated under a  memorandum of understanding that gives FAA responsibility for  investigating occupational accidents involving flight attendants; in the  memorandum, OSHA agreed to continue its enforcement efforts on behalf  of other aviation employees, such as ramp workers. However, neither  agency has developed a plan or policy to reduce ramp accidents and  address ramp safety in a strategic, coordinated manner. FAA’s primary  tool for enhancing ramp safety is the promotion of a safety management  system for aviation service and airport operators through advisory  circulars issued in 2006 and 2007. FAA defines a safety management  system as the application of a systematic, proactive approach to  identifying and mitigating safety risks. The use of safety management  systems increases the likelihood that safety problems would be detected  and corrected before they result in an accident. However, advisory  circulars are voluntary in nature. Although FAA expects to issue a Notice  of Proposed Rulemaking in 2008, which would make this guidance  mandatory for airport operators, rulemakings often take years to  complete.
According to an official with the Air Transport Association, a trade  organization representing the airline industry, the safety management  system concept invites FAA’s acceptance of the continuous improvement  process adopted by the carrier and its airport stakeholders. The official  added that measuring the effectiveness of mitigation efforts is an essential  part of safety management systems. However, only two of the experts we  surveyed indicated that FAA’s issuance of advisory circulars on safety  management systems for airport operators and aviation service providers  was very effective in addressing ramp accidents. One expert said that  FAA’s issuance of an advisory circular does not prompt change, but is a  way to reduce the agency’s inspection workload. However, another expert  said that when safety management systems are required, airports and air  carriers will assume a larger role in oversight, data collection, and safety  assurance.
OSHA uses industry participation in its voluntary programs to promote  ramp safety while also conducting workplace inspections and taking  enforcement actions when needed. Twelve airlines and the National  Safety Council, a nonprofit, nongovernmental, public service organization  dedicated to protecting life and promoting health, maintained a national  alliance addressing ergonomic issues associated with customer checked  baggage handling with OSHA from November 2002 to November 2006. This  alliance resulted in several tools for enhancing ramp safety, including an  OSHA e-Tool on baggage handling safety and an OSHA Web page detailing  the agency’s assistance for the airline industry. The Air Transport  Association has initiated discussions with OSHA about forming an alliance  to address ramp vehicle safety. Three of 13 experts we surveyed indicated  that airlines entering into safety alliances with OSHA to address ramp  accidents was very or extremely effective. One expert, for example, said  that OSHA safety alliances are an extremely effective way for air carriers  to develop mitigation strategies in concert with OSHA. However, another  expert said that airlines entering into alliances with OSHA have no real  effect on ramp safety because OSHA’s focus is on preventing personal  injury, not aircraft damage.
OSHA’s workplace inspections—which are initiated in response to  fatalities or serious injuries, such as amputations, complaints, or data  indicating that an industry is experiencing a high rate of illness or injury— may result in OSHA proposing that the employer be fined. For example, on  July 25, 2007, OSHA proposed fines totaling about $72,500 against an  airline for alleged violations of workplace safety standards in its ramp area  at one airport. According to OSHA safety enforcement officials, proposed  fines are intended to serve as a deterrent to unsafe practices in the  workplace and are sometimes reduced after the employers take corrective  actions, show good faith, or have a favorable safety history. However, as  we reported in 2005 on FAA’s safety enforcement efforts, reductions in  proposed fines may weaken any deterrent effect that would be expected  from sanctions. Only 2 of 13 experts we surveyed indicated that OSHA’s  safety enforcement actions were very effective in addressing ramp  accidents.
Several airport officials we interviewed had initiated efforts to improve  ramp safety at their airports, even though their ramp areas are typically  under the control of one or more airlines. For example, a Massachusetts  Port Authority official said that ramp accidents at the Boston Logan  International Airport were reduced by 50 percent during a 6-month period  during 2004 and 2005 after they implemented a ramp safety program. Other  airport officials said they had used their local Runway Safety Action  Teams as forums or initiated their own efforts for addressing ramp safety  issues. In addition, the Seattle-Tacoma International Airport uses a ramp  tower and ASDE-X surface movement radar to monitor ramp activities. Of  15 survey respondents, 4 experts indicated that the use of Runway Safety  Action Teams was very or extremely effective in addressing ramp  accidents, and 2 indicated that surface surveillance technology was very  effective. One expert indicated that Runway Safety Action Teams are an  extremely important venue that can involve all airport stakeholders in a  collaborative process to identify hazards, perform a risk assessment, and  develop mitigation strategies and measure their effectiveness. Of 15 survey  respondents, 2 experts indicated that airports’ use of ramp towers was  very or extremely effective in addressing ramp accidents, and 3 indicated  that airlines’ use of ramp towers was very effective. One expert said that  ramp towers improve operational safety but that all operations are still not  completely visible.
We spoke with officials from two U.S. airlines about measures they were  taking to improve ramp safety. One of those airlines is using and the other  plans to use a Web-based surface surveillance system at certain hubs to  track the movements of ground vehicles and aircraft. Although the airline’s  purpose for purchasing the system was for greater efficiencies in its  ground operations, an official from that airline said he believed that  increased safety was an additional benefit of the system because it  significantly improved situational awareness. Although not specifically  tracked, the airline believes it has had fewer ground accidents and  incidents since implementing the system. Officials at another airline said  they were addressing ramp safety further by incorporating a safety  management system into the ramp procedures in the airline’s operations  manual, including specific ground safety training as a component of  recurrent training required annually. In addition, the airline has  established annual goals for reducing employee injuries and ground  damage. The airline reported the setting of a goal appears effective and  has resulted in a significant decrease in employee injuries and ground  damage over the prior year. Officials from this airline also said that the  airline had formed a safety action team to share best practices with its  ground handling partners and to review their safety performance, resulting  in an incident rate for the airline’s partners that has been greatly reduced  in the last two years and continues to improve. The experts we surveyed  had mixed views on the effectiveness of airlines setting safety targets for  reducing injuries in ramp areas in addressing ramp accidents. Four of 15  experts indicated that it was very effective, 6 said it was moderately  effective, and 5 indicated it was slightly or not at all effective. One expert  said that airlines have set safety targets for reducing injuries in ramp areas  for years and failed to achieve discernable results.
Aviation industry groups also have efforts under way to address the lack  of data for ramp accidents as well as the lack of standards for ramp  operations. In 2003, the Flight Safety Foundation, an international  nonprofit membership organization that researches and promotes aviation  safety, started the Ground Accident Prevention Program to “analyze  equipment damage and human injuries and develop methods of preventing  such accidents.” The program is now in its third phase, in which it will  identify and encourage technical solutions to ramp safety problems along  with continued data collection and analysis. Next year, the International  Air Transport Association, an international airline association, plans to  start a safety audit program of ground handling companies with the aim of  improving operational safety by establishing a “worldwide ground  operational safety benchmark and standard.” The program will be  available to all ground service providers, who, after successfully  completing the audit, will be placed on a registry for an agreed-upon  period. In addition, the National Air Transportation Association, which  represents companies that own, operate, and service aircraft primarily for  the general aviation community, has launched an industry-wide effort to  collect ramp incident data and has goals of identifying best practices,  reducing insurance claims, and lowering insurance costs. The Airports  Council International, an organization that represents airports worldwide,  publishes the Airside Safety Handbook as one component of its efforts to  help airports operate more safely. Finally, the Air Transport Association  collects, aggregates, and shares ground incident damage and injury data to  its members. The data are reviewed at the association’s quarterly Ground  Safety Committee meetings and form a basis for assessing risk, developing  mitigation strategies, and measuring effectiveness. According to the  association, airlines freely share best practices concerning safety and  many airlines perform ground servicing of aircraft (fuel, potable water,  baggage handling, etc.) for one another.
section_title: Additional Measures May Improve Ramp Safety
paragraphs: The results of our survey of experts indicated that the actions that FAA,  OSHA, airports, or airlines could take with greatest potential of preventing  ramp accidents, considering costs, technological feasibility, and  operational changes, included promoting a safety culture, standardizing  airport ramp markings, improving or increasing training of ramp workers,  increasing the supervision of ramp workers, and developing safer  equipment designs (see table 6).
One expert said that as part of an improved safety culture—which experts  in our survey indicated was the most effective action to address ramp  accidents—management must recognize the connection between the  occurrence of ramp incidents and accidents and its demand for quick  aircraft turnaround times. Turnaround times are an important cost factor  for airlines. Another expert said that standardizing ramp markings would  be beneficial because the markings can be confusing for pilots. One of the  experts indicated, however, that while improving and increasing the  training of ramp workers would be beneficial, high job turnover among  ramp employees is also part of the problem. Furthermore, a report  prepared by an aviation industry group in 2004 cited inadequate training  and high turnover of ramp workers, particularly aircraft fuelers, as  contributing factors in ramp accidents. The report also indicated that low  wages contributed to high rates of employee turnover. One of the experts  we surveyed indicated that poor pay attracts a group of ramp workers that  exhibit high turnover rates, language issues, and work ethic challenges.  Similarly, in reports that we issued before the September 11, 2001, terrorist  attacks, we cited high turnover and low wages among airport security  screeners as factors affecting the effectiveness of performing their  security duties.
Some aviation industry officials and experts said that ramp safety in the  United States might be improved through the use of new technology. One  example is a ground pop-up system to handle aircraft fueling and other  ramp services, which is used at airports in Zhuhai, China, and Stockholm,  Sweden. An expert said that a ground pop-up system reduces ramp  congestion and the chance of vehicle collisions and injuries. In addition,  some aviation officials said that new baggage loading technology could  help make the ramp environment safer for ramp workers. New baggage  loading technologies include the sliding carpet and RampSnake®.  However, an international aviation safety official said that although these  new baggage loading devices could improve working conditions and effort  required by baggage loaders, it is not readily apparent how such devices  could help prevent ramp accidents. This official also noted the high cost of  a ground pop-up system and that it is inflexible to accommodate changed  aircraft parking arrangements and different aircraft types. The potential  effectiveness of safer designs of ramp equipment was supported by the  experts we surveyed, the majority of whom said that developing safer  designs of ramp equipment had great or very great potential in addressing  ramp accidents. An International Air Transport Association official also  indicated that high-density airports outside of the United States typically  have a higher degree of control and coordination between the ramp and  air traffic controllers, which can contribute to safety.
Aviation industry stakeholders expressed diverse views about whether the  federal government should increase ramp safety oversight and if so, which  agency should carry out that increased oversight. Officials from a union  representing ramp workers favored increased FAA and OSHA oversight of  ramp operations because they felt this would lead to more and better  training for ramp workers, the implementation of standardized  procedures, and a focus on ramp safety equal to that provided to runway  safety. However, an airport association official said that increasing FAA’s  oversight in the ramp area would not be the best use of the agency’s  resources because the safety risks are greater on the airfield, where an  aircraft collision could result in many fatalities. In addition, a Flight Safety  Foundation official said that additional FAA ramp safety oversight is not  needed because FAA’s focus is on passenger safety and that the agency  would have difficulty identifying additional resources to oversee ramps.  An author of reports on ramp accidents issued by an aviation industry  group said that OSHA should do more to regulate safety on the ramp  because, in his view, FAA lacks knowledge of industrial safety issues.  However, an airline association official said that increased OSHA oversight  of ramp operations would have little potential until OSHA develops  national standards and appropriate regulations for airport ramp  operations. This airline association official also said that the lack of a  voluntary disclosure reporting program for OSHA-regulated incidents  impedes improving safety in the ramp area. OSHA officials, however, said  that very few industries have their own workplace safety standards, and  that the agency is devoting the appropriate amount of resources for  inspecting airport ramps because its safety inspections overall are selected  largely on the basis of injury and illness data and complaints. However,  they were not able to identify how many inspections of ramp areas were  prompted by data. FAA officials said that they do not have responsibility  for ramp safety and that their jurisdiction is limited to the movement  areas. They also noted that ramp areas are normally under the jurisdiction  of state and local authorities but that ultimately the airport operator has  responsibility for ramp safety unless the area is leased to an air carrier or  fixed-base operator.
section_title: Conclusions
paragraphs: FAA took a number of actions to address runway safety since the number  and rate of incursions reached a peak in fiscal year 2001. However, as  runway safety incidents declined, FAA’s runway safety efforts  subsequently waned. During that period of decreased attention, the  number and rate of incursions remained relatively constant and at a level  higher than any time during the 1990s. Moreover, preliminary data for  fiscal year 2007 indicate the overall incursion rate increased to a level  nearly as high as the 2001 peak. In addition, serious incursions, where  collisions were narrowly or barely avoided, continue to occur—about 30  per year since fiscal year 2002—suggesting a high risk of a catastrophic  runway collision occurring in the United States. Furthermore, in recent  years, FAA’s Office of Runway Safety has not been fulfilling its mission to  coordinate and lead the agency’s runway safety efforts. The absence of  national leadership and a current national runway safety plan impede  further progress on runway safety because no single office is taking charge  of assessing the causes of runway safety problems. This situation has  resulted in uncoordinated runway safety efforts by individual FAA offices.  FAA recently hired a runway safety director, which is a good first step.  However, other plans for the program are still being developed, and it is  too early to know if the office will provide sustained attention to runway  safety problems.
FAA’s runway safety program also lacks certain data on the causes and  circumstances of incursions and overruns. FAA has planned since 2004 to  develop a voluntary reporting system for air traffic controllers, which  would increase the amount of data available on runway incursions, but it  is not clear when such a program will be established. Without additional  data, FAA cannot conduct additional analysis of the causes and  circumstances of runway incidents to ensure that the most effective  corrective measures that address the causal factors are used. In addition,  the fact that air traffic controllers at some of the nation’s busiest airports  are regularly working 6-day weeks due to staffing shortages raises  questions about the extent to which regularly working overtime may cause  fatigue, which NTSB has cited as a contributing factor in air traffic control  errors. Furthermore, the nature and scope of ramp accidents are  unknown. FAA is not working with the aviation industry and OSHA to help  collect and analyze ramp accident data, which could identify the causes  and circumstances of ramp accidents, and identify corrective actions.  Without such data, FAA and the aviation industry will be hindered in  understanding the nature and extent of ramp accidents, which would help  identify measures to improve ramp safety.
section_title: Recommendations
paragraphs: To advance efforts to improve runway safety, we recommend that the  Secretary of Transportation direct the FAA Administrator to take the  following five actions:  Implement the FAA order establishing the Office of Runway Safety to lead  the agency’s runway safety efforts, including preparing a new national  runway safety plan. The plan should include goals to improve runway  safety; near- and longer-term actions designed to reduce the severity,  number, and rate of runway incursions; timeframes and resources needed  for those actions; and a continuous evaluative process to track  performance towards those goals. The plan should also address the  increased runway safety risk associated with the expected increased  volume of air traffic.
Develop an implementation schedule for establishing a nonpunitive  voluntary safety reporting program for air traffic controllers.
Develop and implement a plan to collect data on runway overruns that do  not result in damage or injury for analyses of trends and causes such as  the locations, circumstances, and types of aircraft involved in such  incidents.
Develop a mitigation plan for addressing controller overtime that  considers options such as shift changes and incentives to attract  controllers to facilities with high volumes of air traffic and high rates of  controller overtime.
Work with the aviation industry and OSHA to develop a mechanism to  collect and analyze data on ramp accidents and, if the analysis shows it is  warranted, develop a strategic plan aimed at reducing accidents involving  workers, passengers, and aircraft in the ramp area. The plan should  include a discussion of roles and responsibilities, performance measures,  data collection and analysis, and milestones, and consider ramp safety  practices being followed in other countries.
section_title: Agency Comments
paragraphs: We provided DOT and the Department of Labor with drafts of this report  for their review and comment. FAA agreed to consider the report’s  recommendations and provided technical corrections and clarifications,  which we incorporated as appropriate. The Department of Labor had no  comments but provided a technical correction, which we incorporated.
As arranged with your offices, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after the  date of this letter. At that time, we will send copies of this report to  interested congressional committees and to the Secretary of  Transportation and the Secretary of Labor. We will make copies available  to others upon request. In addition, this report will be available at no  charge on our Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  on (202) 512-2834 or at dillinghamg@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. Key contributors to this report are listed in  appendix VII.
section_title: Appendix I: Objective, Scope, and Methodology
paragraphs: Our objective was to review how well the Federal Aviation Administration  (FAA) and others are addressing runway and ramp safety issues. To  accomplish this, we established the following questions: (1) What progress  is being made in addressing runway safety, and what additional measures,  if any, could be taken? and (2) What factors affect progress in improving  ramp safety and what is being done by FAA and others to address those  factors?
For background information on runway and ramp safety issues, we  reviewed reports prepared by FAA, the National Transportation Safety  Board (NTSB), the Department of Transportation’s (DOT) Inspector  General, and others; FAA orders, advisory circulars, and regulations; and  applicable laws. We also determined the roles and responsibilities  involving runway and ramp safety of FAA, NTSB, the Occupational Safety  and Health Administration (OSHA), airports, and airlines. Regarding  runway incursions, we obtained data on the number and rates of  incursions from fiscal year 1998 through fiscal year 2007 and reviewed  NTSB accident reports on incursions that resulted in collisions during that  time. We also obtained runway incursion data from fiscal year 2001  through fiscal year 2006 broken down by severity, error types, and  frequency of incursions involving general aviation and commercial  aircraft. Regarding runway overruns, we collected data on overruns that  NTSB investigated from fiscal year 2001 through fiscal year 2006.  Regarding ramp accidents, we obtained information on ramp accident  fatalities that were investigated by FAA, NTSB, and OSHA from 2001  through 2006. Based on interviews with officials knowledgeable about the  data contained in this report, we determined that runway and ramp safety  data were sufficiently reliable for the types of analyses that we performed  for this report such as trends in runway incursions, the incidence of  fatalities in airport ramp areas, and frequency of air traffic controller  overtime.
To determine what progress is being made in addressing runway safety  and what additional measures could be taken, we reviewed the status of  FAA’s implementation of objectives contained its 2002 national runway  safety plan and the status of the runway safety recommendations that  NTSB made to FAA. We also evaluated FAA’s compliance with orders  establishing the agency’s runway safety and runway safety area programs;  FAA’s collection and analysis of runway safety data, including the process  that the agency follows to assess the severity of runway incursions; and  findings made by FAA’s Air Traffic Safety Oversight Service on the  agency’s runway incursion severity classification process and runway  safety technology. We also looked at how taxiways affect runway safety.
To help identify the causes of runway incursions and measures being  taken to prevent them, we interviewed FAA and airport officials at five  airports that have experienced more runway incursions than other airports  in recent years. Because technology is a major part of FAA’s strategy to  improve runway safety, we discussed the agency’s efforts to develop and  deploy technology with program officials, visited five airports where new  technology was being tested and used to observe their operation, reviewed  data on the systems’ performance, and interviewed FAA air traffic  controllers and managers and aviation industry officials about their views  on the effectiveness of the technology. In addition, we reviewed the  implementation status of Public Law No. 109-115, which requires  commercial service airports to bring their runway safety areas into  compliance with FAA standards by 2015. We also interviewed officials  from FAA’s William J. Hughes Technical Center, DOT’s Volpe National  Transportation Systems Center, and the National Aeronautics and Space  Administration’s Ames Research Center about their runway safety  research projects. In addition, we interviewed officials from international  aviation organizations about runway safety practices and technologies  being used overseas that could be used in the United States.
To determine the factors affecting progress in improving ramp safety and  what is being done by FAA and others to address those factors, we  interviewed officials from FAA, airports, and aviation industry  organizations; members of the Airport Operations Safety Panel, an aviation  industry group that issued reports on ramp accidents in 2004 and 2005;  union officials representing ramp workers and pilots; and other individuals  knowledgeable about ramp safety. In addition, we interviewed OSHA  officials about the agency’s industry alliance program and enforcement  efforts. We also interviewed officials from international aviation  organizations about ramp safety practices and technologies being used  overseas that could be used in the United States.
Table 7 lists the organizations that we visited or contacted regarding  runway and ramp safety.
We conducted our work from October 2006 through November 2007 in  accordance with generally accepted government auditing standards.
section_title: Appendix II: Survey Methodology
paragraphs: We administered a 2-phase Web-based survey to gather the professional  views of experts on runway incursions, runway overruns, and ramp safety.  The structured survey questions ensured that all individuals had the  opportunity to provide information in response to the same questions and  enabled us to quantify the results. Moreover, the iterative nature of the 2- phase survey provided the experts with the opportunity to identify future  actions that could be taken to prevent incursions, overruns, and ramp  accidents and then to evaluate the potential of the future actions that they  and the other experts identified.
We contracted with the National Academy of Sciences to identify experts  to participate in our survey. Using criteria to ensure adequate  representation across the criteria that we had specified, the National  Academy identified 19 experts and we identified ten. The criteria ensured  that we achieved    balance in terms of the type and depth of expertise (i.e., pilots, airline  officials, aircraft manufacturing officials, association representatives,  academics, foreign civil aviation authorities, unions representing airlines,  air traffic controllers, ramp workers, Federal Aviation Administration  (FAA) maintenance and safety inspectors, professors and researchers  involved in aviation safety);   balance of knowledge across relevant content areas (i.e., effectiveness of  measures being used to address runway incursions, overruns, and ramp  accidents; technology research, testing, and use; FAA air traffic control  practices and procedures; international aviation safety practices, human  factors issues; general aviation; airports; and ground operations); and   balance in representing relevant organizations (i.e., academia, business,  government, and professional organizations).
The survey responses represent the professional views of the experts.  Their expertise can be derived from formal education, professional  experience, or both. The experts were identified by the National Academy  and us as individuals who are recognized by others who work in the same  subject matter area as having knowledge that is greater in scope or depth  than that of most people working in the area.
We recognize that it is likely that no one individual possessed complete  knowledge in each of the content areas addressed in the survey: runway  incursions, runway overruns, and ramp accidents. However, through our  selection criteria, we attempted to identify a set of individuals who, when  their responses were considered in the aggregate, could be viewed as  representing the breadth of knowledge in each of the areas addressed in  the survey.
We identified the information to collect in our surveys based on our  congressional request, Internet and literature searches, professional  conferences we attended, and background interviews. A social science  survey specialist collaborated with staff with subject matter expertise on  the development of the surveys.
We developed a 2-phase Web-based survey. The first survey contained  open-ended questions asking respondents to identify the primary causes of  runway incursions, runway overruns, and ramp accidents; overseas  practices and technologies that could be used in the United States; and  future actions, including the development of new technology that FAA  could take in the future to prevent incursions, overruns, and ramp  accidents. The responses to the questions on future actions were analyzed  and coded into categories that were then used as the basis for the  questions on future actions in the second survey. A reviewer checked the  resulting categories and coded responses and, where interpretations  differed, agreement was reached between the initial coder and the  reviewer. As an extra step to check the completeness of the list of future  actions that was generated by the experts we corroborated the list with  other evidence we had collected as a part of our study and found that  many of the same actions the experts identified were also identified  through our other study efforts.
The same set of respondents was also sent the second survey. As  mentioned above, the second survey contained closed-ended questions  asking respondents to evaluate the potential of the future actions that  could be taken to prevent runway incursions, runway overruns, and ramp  accidents. Other closed-ended questions addressed the effectiveness of  specific actions that FAA and others are taking to address runway  incursions, runway overruns, and ramp accidents; the accuracy of FAA  reporting on runway incursions that have occurred since January 1, 2001;  and whether the deployment schedule of the Airport Surface Detection  Equipment, Model-X (ASDE-X) at 27 additional airports by 2011 should be  kept as planned or changed, considering some of the benefits and  problems associated with the system.
Both surveys were pretested to ensure that the questions appropriately  addressed the topics, were clearly stated, easy to comprehend, unbiased,  and did not place undue burden on respondents. We also evaluated the  usability of the Web-based surveys. Based on the pretest results, we made  necessary changes to the surveys prior to implementation.
We administered the Web-based surveys between June and September  2007. We used e-mail to inform the respondents of the survey  administration, and provided them with the Web link for the survey and  their log-in name and password. In the e-mail message, we informed  respondents that our report will not contain individual survey responses;  instead, it would present the aggregated results of all participants. To  maximize the response rate, we sent follow up e-mail reminders and  followed up by telephone as necessary to encourage survey participation.
The first survey was sent to 27 experts. Two experts did not respond and  were not included in the second survey. As a result, 25 of 27 experts  responded to the first survey for a response rate of 93 percent.
The second survey was sent to the 25 experts who responded to the first  survey. Twenty-two of the 25 experts responded for a response rate of 88  percent.
The number of responses varied for each of the survey content areas— runway incursions, runway overruns, and ramp accidents—because we  asked the experts to answer questions only within their areas of expertise.  In addition, the number of responses may vary by question because we do  not report the number of experts who responded “Don’t know” or “No  basis to judge.” We report the survey results in terms of actions that are  most effective or future actions that have the most potential. For tables 1  and 6, the actions that we report as being the most effective or having the  most potential were the ones that a majority of respondents indicated  were very or extremely effective for the effectiveness questions or great or  very great potential for the questions asking about potential. For table 4,  the actions that we report as having the most potential reflect the ones  that a majority of experts indicated as having great potential or very great  potential. Although other actions also received a majority of positive  responses, this table reports the ones that received the highest number of  positive responses. For table 5, the actions that we report received the  highest number of responses indicating that they were very effective or  extremely effective. However, none of these actions received a majority of  positive responses.
The first survey, which was administered via the Web, included 12  questions shown in figure 13.
The second phase of the survey was also administered via the Web and is  reproduced as a graphic image on the following pages.
section_title: Appendix III: Serious Incursions Involving Commercial Aircraft
section_title: Appendix IV: Status of the National Runway Safety Plan Objectives
section_title: Appendix V: Airports with Surface Surveillance Technology
section_title: Appendix VI: Airports Where Ramp Accident Fatalities Occurred
subsections: section_title: Cincinnati/Northern Kentucky International
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, Teresa Spisak (Assistant  Director), Ashley Alley, Nancy Boardman, Colin Fallon, Evan Gilman, Bob  Homan, Dave Hooper, Richard Hung, Rosa Leung, Sara Ann Moessbauer,  Josh Ormond, and Pamela Vines made key contributions to this report.