The study of human factors examines how humans interact with machines and other people (pilots, air traffic controllers, or design and acquisition personnel) and determines whether procedures and regulations take into account human abilities and limitations. Identifying chances for human error can reduce the need for later replacing or modifying equipment and procedures. Human factors affect the operation of all of FAA’s functions, including research, the acquisition of equipment, and safety. FAA’s work on human factors focuses on such issues as whether equipment is designed to enhance operators’ performance and minimize errors and whether the procedures used by air traffic controllers promote safe operations. For example, much of the information conveyed to pilots by air traffic controllers has been standardized to minimize the possibility of misunderstanding. (See app. I for a more complete definition of human factors and examples of how human factors have affected safety in specific situations.) The Aviation Safety Research Act of 1988 directed FAA to augment its research on human factors and coordinate its work with that of NASA and Defense because the Congress believed that FAA did not have sufficient expertise in all areas of human factors. A report by the Office of Technology Assessment, cited in the House report on the act as the basis for the legislation, recommended that FAA allocate resources for developing its regulatory support staffs’ expertise in human factors and establish a focal point for human factors within the agency. In addition, the Congress has indicated through the budget process that research on human factors should be a priority in FAA’s overall research program. Figure 1 compares the congressional appropriations for FAA’s research on human factors with FAA’s funding requests. Key aspects of FAA’s human factors organization are the 1993 policy, the position of Chief Scientist, and the guidance on considering human factors in the acquisition process. The 1993 policy prescribes the roles and responsibilities of FAA’s assistant and associate administrators and program directors, as well as of the Human Factors Coordinating Committee (HFCC), including its chair, the Chief Scientist. The Chief Scientist also manages the Human Factors Division, which is housed in FAA’s Office of Aviation Research. (Fig. 2 illustrates the location of the Human Factors Division within FAA’s organizational structure.) On April 1, 1996, FAA changed its acquisition process and method of incorporating the consideration of human factors into that process. The creation of an Office of System Safety in 1995 may further affect the organizational structure for human factors. In October 1993, FAA issued an order for incorporating and coordinating the consideration of human factors throughout the agency. Under the order, assistant and associate administrators and program directors are responsible for, among other things, establishing formal procedures to ensure the systematic consideration of human factors within their organizations. However, FAA’s order does not prescribe the (1) methods for considering human factors, (2) minimal standards for incorporating human factors, or (3) requirements for seeking guidance on human factors from specialists that the administrators and directors are to follow. FAA officials in the three units where we held discussions—research and acquisitions, regulation and certification, and air traffic services—indicated that they have not fully established formal procedures for incorporating the consideration of human factors in their activities. FAA created the Human Factors Coordinating Committee in 1989 to facilitate the agency’s work on human factors and enhance the use of information on human factors. However, according to the Chief Scientist, the committee is not a decision-making body, even though its members are designated by the agency’s assistant and associate administrators and program directors. Instead, the Chief Scientist said, the committee is primarily a forum for exchanging information. As the committee’s chair, the Chief Scientist carries out most of the committee’s responsibilities. In addition to chairing the Human Factors Coordinating Committee, the Chief Scientist heads the Human Factors Division. This division is housed within the headquarters Office of Aviation Research, under the Associate Administrator for Research and Acquisitions. Among other things, the Human Factors Division develops policies on human factors that promote the productivity and safety of the national airspace system. The division is staffed by seven professional human factors specialists—six full-time and one part-time. According to its mission statement, the Human Factors Division seeks to provide scientific and technical support for FAA’s research on human factors in civil aviation and its applications in the agency’s programs for acquisitions, regulation and certification, and air traffic services. However, we found that the Human Factors Division’s ability to provide this support depends on the extent to which the associate administrators and program directors use the division. FAA does not require the division—or any other unit with scientific and technical expertise in human factors—to review the quality of the work on human factors performed by other FAA units or contractors. FAA does not require its administrators to seek guidance from human factors specialists, such as those in the Human Factors Division. Although the scope of our audit did not include a detailed examination of the application of human factors in acquisitions, we have previously found inadequate technical oversight in FAA’s management of acquisitions. For example, in a previous review of FAA’s modernization program, we found that not following the technical principles of the human factors discipline in designing equipment delayed some projects. Instead of relying on the discipline’s objective criteria for measuring the performance of alternative designs, FAA consulted users’ preferences, only to find that its efforts were misdirected because different groups of users had different preferences. Recent legislative and organizational changes may affect how the formal consideration of human factors is incorporated in the acquisition process and may strengthen the application of human factors in operations, such as safety. Several offices under the Associate Administrator for Research and Acquisitions are responsible for developing and acquiring new systems, such as air traffic control equipment. According to staff in the Human Factors Division, applying considerations of human factors increases a product’s or a process’s performance and efficiency while decreasing developmental, operational, and maintenance costs over the lifetime of the product or process. To develop and deploy equipment more efficiently, in 1995, FAA adopted a new management approach that relies on integrated product teams,whose members include end-users, contractors, and all other parties responsible for developing or procuring new equipment or processes. As a first step in ensuring that human factors are considered in acquisitions, the Human Factors Division developed a requirement in FAA’s 1993 acquisition policy that all new acquisition projects include a human factors plan. Such a plan was to (1) describe how considerations of human factors should be applied and (2) document how a piece of equipment or a process should perform when operated as expected by the end-users. However, on April 1, 1996, in response to new legislation exempting FAA from most federal procurement statutes, FAA implemented the Federal Aviation Administration Acquisition Management System, which superseded FAA’s 1993 acquisition policy. According to the initial guidance provided for this new system, human factors may be formally considered at an earlier stage in the acquisition process than previously, but this early consideration is not required. Furthermore, the extent to which human factors should be considered is not specified in the system’s guidance, nor is a separate plan for human factors required. There is no requirement for integrated product teams to obtain recommendations from human factors specialists. According to some FAA human factors specialists, considering human factors is key to improving the safety of aviation operations. In 1990, the FAA Administrator testified before the Congress that the agency’s objective in aviation safety is zero accidents. The following year, the Administrator testified that human error was the most serious impediment to FAA’s achieving that goal. He said that FAA planned to accentuate its consideration of human factors in all of its programs, from training to procurement. To help reach its goal of zero accidents in aviation operations, FAA, in 1995, created a staff Office for System Safety. This office is headed by the Assistant Administrator for System Safety, who reports directly to the FAA Administrator. The objective of this office is to proactively determine potential sources of accidents and prevent them from occurring. The Assistant Administrator for this office has indicated that human factors will be an important part of his office’s work. Although the Human Factors Division administers FAA’s research on human factors, some of which is directly concerned with safety, its staff are not involved in some applications of human factors to safety. For example, the Office of Regulation and Certification—responsible for aircraft certification, safety inspections, and flight operational safety—plans to strengthen its emphasis on human factors by hiring at least one specialist, rather than rely on the specialists in the Human Factors Division. According to the Associate Administrator for Regulation and Certification, the specialists in the Human Factors Division do not have the expertise needed to apply considerations of human factors to developing requirements for regulation and certification. The Human Factors Division is responsible for identifying aviation-related issues in research on human factors and for allocating and coordinating FAA’s resources for internal and external research on human factors. To identify aviation-related issues in research on human factors, the Human Factors Division consults with FAA units and other members of the aviation community. To develop its initial objectives for research on human factors, FAA participated in a task force in April 1989, sponsored by the Air Transport Association of America. This task force identified a number of significant research topics, which FAA incorporated into the National Plan for Civil Aviation Human Factors. This plan—developed by the Human Factors Division in conjunction with the Department of Defense, NASA, industry, and academia—includes a framework that categorizes research on the basis of five priorities, or “thrusts,” and provides guidelines for initiating and managing research on human factors in aviation. (See app. II for a description of each priority and a listing of the ongoing projects under each.) Besides participating in the task force, the Human Factors Division has worked with the aviation community to develop research issues by participating in conferences and workshops. In comparing FAA’s processes to the aviation community’s, we found that FAA not only looks to the aviation community but the aviation community also often looks to FAA to focus attention on particular research issues.