Airline travel is one of the safest modes of public transportation in the United States. The current level of airline safety has been achieved, in part, because the airline industry and government regulatory agencies have implemented rigorous pilot training and evaluation programs. The major airlines have training programs for pilots that focus on, among other things, maintaining flying skills, qualifying to fly new types of aircraft, and acquiring skills in dealing with emergencies. FAA’s original regulations for the airlines’ general training programs—referred to in this report as part 121—spell out the number of hours of training required in particular areas, such as the time spent practicing emergency procedures. Effective for 1996, FAA instituted a requirement for CRM training under part 121 that states the following: “After March 19, 1998, no certificate holder may use a person as a flight crewmember, and after March 19, 1999, no certificate holder may use a person as a flight attendant or aircraft dispatcher unless that person has completed approved crew resource management or dispatcher resource management initial training, as applicable, with that certificate holder or with another certificate holder.” FAA believes that this training should improve flight crews’ performance. As an alternative to training under these regulations, airlines may apply to participate in AQP. Eight of the 10 major airlines have applied to, and been approved for participation in, AQP. Unlike traditional part 121 training, AQP specifies the criteria for the required level of performance in certain types of maneuvers, rather than hours of training, and it integrates CRM training with technical flying skills. The airlines are expected to fully implement AQP over a period of time, up to 8 years. Full implementation means that the airlines have trained their pilots for each type of aircraft they fly. Training, however, occurs only after the airline has gone through three other stages: (1) getting approval to participate in the program, (2) developing a training curriculum, and (3) training instructors. Continuing crew training, the last stage, is to occur annually. Responsibility for AQP and traditional part 121 training rests with different FAA branches. The AQP Branch within the Office of Flight Standards Services oversees AQP, and the Branch expects to transfer many of its oversight responsibilities to inspectors in the field as each airline fully implements its AQP. The administration of traditional part 121 training is divided between the Air Carrier Training Branch, which sets training requirements, and the flight standards inspectors in the field, who are responsible for overseeing the training. FAA’s inspectors periodically review and approve airlines’ curricula and training materials and observe training. CRM is a “human factors” approach for improving aviation safety by preventing or managing pilots’ errors. Human factors refers to a multidisciplinary effort to develop information about human capabilities and limitations and to apply this information to equipment, systems, facilities, procedures, jobs, environments, training, staffing, and personnel management for safe and effective human performance. Under this approach, pilots are trained to recognize potential mistakes in judgment or actions and to compensate for them to prevent accidents and incidents. For example, in training for initial departure, CRM training has the captain practice briefing the crew about the actions to be taken if the takeoff must be aborted because of an emergency. CRM also teaches the crew to question orders when they believe they have information that indicates these orders are inappropriate. Similarly, CRM training teaches the crew to anticipate problems and make decisions that take these anticipated problems into account. About 30 percent of the 169 accidents and 18 percent of the 3,901 incidents that occurred from 1983 through 1995 were caused at least in part by pilots’ performance, according to our analysis of the National Transportation Safety Board’s (NTSB) and FAA’s data. Furthermore, the accident data indicate that nearly one-third of the accidents occurred because the pilots either did not follow, or did not correctly follow, CRM principles. The most frequently occurring accidents and incidents included collisions on the ground with objects and other airplanes, flights through turbulent weather that resulted in injuries, and deviations from flight paths that had the potential to cause an in-flight collision. On the ground, pilot performance was associated most frequently with airplanes colliding with vehicles, buildings, other equipment, or animals. This was the case for both accidents (32 percent) and incidents (34 percent). Figure 1 shows the types of accidents and incidents on the ground reported from 1983 through 1995. Loss of control on ground NTSB cited 62 events associated with pilots’ performance in 169 accidents. FAA cited 446 events associated with pilots’ performance in 3,901 incident reports. In the air, pilot performance was most frequently associated with injuries to passengers and flight attendants during turbulent weather—41 percent of accidents and 12 percent of incidents. Figure 2 shows the types of accidents and incidents in the air that were reported. In addition to the accidents and incidents discussed above, FAA maintains data separately for those occasions on which pilots failed to comply with the air traffic controller’s instructions—such as not staying on the directed flight path and/or entering a runway without clearance. Of the 1,471 unauthorized maneuvers from 1987 through 1995, 80 percent occurred in the air, and most of these (73 percent) occurred when pilots did not maintain their assigned altitude levels. The unauthorized pilot maneuvers on the ground were most often (69 percent) associated with pilots’ moving airplanes onto runways without authorization from the air traffic control tower. These types of incidents have the potential to cause accidents. For example, the December 1990 crash at the Detroit Metropolitan Airport occurred when an airplane taxied onto a runway being used for takeoff by another airplane and collided with that airplane. Twelve people died. The first plane had not gotten permission from the control tower to enter this runway, as it should have. Figure 3 shows the most frequently reported unauthorized pilot maneuvers in the air and on the ground. In our analysis of accidents, we found deficiencies in the airline pilots’ use of CRM in nearly one-third of all accidents involving pilots’ performance. Moreover, we found CRM deficiencies in half of the serious accidents in which there was at least one fatality. About 46 percent of these CRM deficiencies involved a lack of coordination among members of the cockpit crew, as well as the captain’s failure to assign tasks to other crew members and to effectively supervise the crew. Generally, these CRM deficiencies illustrated the importance of effective communication. For example, in the Charlotte, North Carolina, crash in July 1994, communication among crew members did not occur, according to NTSB’s accident investigation report. NTSB believes that the captain, who was not flying the aircraft at the time and could not see the ground because of poor visibility, became disoriented and commanded the first officer, “down, push it down,” even though they were encountering windshear, which is a sudden change in wind direction. The first officer did not question the order, as he should have, according to NTSB, because the windshear was creating an unstable situation; the plane could not recover from the sudden downward shift in direction caused by following the captain’s order. The plane crashed nose down into the ground, and 37 people died. Similarly, in a June 1984 accident in Detroit, Michigan, a lack of communication between the crew and air traffic controllers during a landing in a severe thunderstorm contributed to the accident, according to the NTSB report. The crew did not request clarification about the weather conditions or change its course of action to take these conditions into account. The winds associated with the storm forced the plane down precipitously, causing an emergency landing without the landing gear’s being fully extended. The plane skidded off the runway, causing serious damage to the aircraft and an emergency evacuation of the passengers. NTSB reported that the lack of CRM practices was a probable cause of the accident. The National Aeronautics and Space Administration reported similar results in its analysis of pilot reports submitted to its voluntary reporting system. Nearly half of the reports cited deficiencies in the pilots’ use of CRM principles; about 53 percent of the CRM deficiencies concerned coordination among members, assignment of tasks, and crew supervision. For AQP training, FAA has specified the process airlines need to follow to develop and implement a curriculum that integrates CRM concepts with technical flying skills, but FAA’s guidance for CRM training under part 121 does not have the same degree of specificity. As a result, inspectors overseeing training under part 121 do not have standards they can use to evaluate airlines’ CRM training curriculum and the delivery of that training. Generally, inspectors could not use the guidance provided under AQP to evaluate part 121 training for the CRM curriculum because the curricula developed under the two programs differ significantly. As a result, airlines continue to need specific guidance for CRM under part 121—both those airlines that have opted not to enter AQP as well those that will continue to train at least some of their crews under part 121 until they have fully implemented AQP, which could take up to 8 years. Once an airline elects to participate in AQP, it must follow SFAR 58 (the AQP regulation) for developing a formal curriculum—including assessing the skills pilots need to safely operate the aircraft they fly, developing curriculum objectives for teaching those skills, having measurable criteria for evaluating whether the pilots have achieved those objectives, and developing materials to teach those objectives. FAA must approve this curriculum. Furthermore, AQP requires all airlines to train their pilots in simulators so that they gain experience with a number of emergency situations. Finally, airlines must submit data to FAA demonstrating that their crews have mastered the skills they need to fly for those airlines. In developing its AQP curriculum, an airline is required to integrate CRM training into every aspect of its crews’ training. As a result, the pilots trained under AQP are assessed on CRM principles as well as on technical flying skills.