General Aviation Safety: Additional FAA Efforts Could Help Identify and Mitigate Safety Risks

Published by the Government Accountability Office on 2012-10-04.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

               United States Government Accountability Office

GAO            Report to Congressional Committees

October 2012
               GENERAL AVIATION

               Additional FAA
               Efforts Could Help
               Identify and Mitigate
               Safety Risks

                                               October 2012

                                               GENERAL AVIATION SAFETY
                                               Additional FAA Efforts Could Help Identify and
                                               Mitigate Safety Risks
Highlights of GAO-13-36, a report to
congressional committees

Why GAO Did This Study                         What GAO Found
Although the U.S. aviation system is           The number of nonfatal and fatal general aviation accidents decreased from
one of the safest in the world,                1999 through 2011; more than 200 fatal accidents occurred in each of those
hundreds of fatalities occur each year         years. Airplanes—particularly single-engine piston airplanes—flying personal
in general aviation—which includes all         operations were most often involved in accidents. Most general aviation
forms of aviation except commercial            accidents are attributed to pilot error and involved a loss of aircraft control. Some
and military. The general aviation             segments of the industry experienced accidents disproportionately to their total
industry is composed of a diverse fleet        estimated annual flight hours. For example, among the airplane categories we
of over 220,000 aircraft that conduct a        reviewed, experimental amateur-built airplanes were involved in 21 percent of the
wide variety of operations—from
                                               fatal accidents but accounted for only 4 percent of the estimated annual flight
personal pleasure flights in small,
                                               hours. In another example, corporate operations were involved in about 1
piston aircraft to worldwide
professionally piloted corporate flights
                                               percent of fatal accidents while accounting for 14 percent of estimated annual
in turbine-powered aircraft. According         flight hours. We can draw some conclusions about general aviation accident
to 2011 National Transportation Safety         characteristics, but limitations in flight activity and other data preclude a confident
Board (NTSB) data, 92 percent of that          assessment of general aviation safety. The Federal Aviation Administration’s
year’s fatal accidents occurred in             (FAA) survey of general aviation operators, on which the agency bases its annual
general aviation. The majority of              flight-hour estimates, continues to suffer from methodological and conceptual
general aviation accidents are                 limitations, even with FAA’s efforts to improve it over the years. To obtain more
attributed to pilot error.                     reliable data, FAA has discussed requiring that flight-hour data be reported, such
                                               as during annual aircraft maintenance inspections. FAA has set a goal to reduce
GAO was asked to examine the (1)
                                               the fatal general aviation accident rate per 100,000 flight hours by 10 percent
characteristics of and trends in general
                                               from 2009 to 2018. However, given the diversity of the industry and shortcomings
aviation accidents from 1999 through
2011 and (2) recent actions taken by           in the flight activity data, this goal is not sufficient for achieving reductions in
FAA to improve general aviation                fatality rates among the riskier segments of general aviation. Further, achieving
safety. GAO analyzed NTSB accident             the goal could mask continuing safety issues in segments of the community.
data, reviewed government and                  FAA has embarked on several initiatives to meet its goal of reducing the fatal
industry studies and other documents,          general aviation accident rate by 2018. These include the renewal of the General
and interviewed FAA and NTSB                   Aviation Joint Steering Committee (GAJSC) with a data-driven approach and the
officials and industry stakeholders.
                                               implementation of the Flight Standards Service’s 5-year strategy. The GAJSC, a
What GAO Recommends                            government-industry partnership, focuses on analyzing general aviation accident
                                               data to develop effective intervention strategies. The 5-year strategy involves
GAO recommends, among other                    numerous initiatives under four focus areas: (1) risk management, (2) outreach
things, that FAA require the collection        and engagement, (3) training, and (4) safety promotion. The FAA Safety Team,
of general aviation aircraft flight-hour       which is composed of FAA staff and industry volunteers, will be responsible for
data in ways that minimize the impact          carrying out significant portions of the strategy. While the GAJSC’s efforts are
on the general aviation community, set
                                               modeled on an approach deemed successful in contributing to a reduction in fatal
safety improvement goals for individual
                                               commercial aviation accidents, the 5-year strategy has shortcomings that
general aviation industry segments,
and develop performance measures               jeopardize its potential for success. For example, the strategy lacks performance
for the significant activities underlying      measures for the significant activities that comprise it. Without a strong
the 5-year strategy. Department of             performance management structure, FAA will not be able to determine the
Transportation officials agreed to             success or failure of the significant activities that underlie the 5-year strategy.
consider GAO’s recommendations and
provided technical comments, which
GAO incorporated as appropriate.

View GAO-13-36. For more information,
contact Gerald L. Dillingham, Ph.D. at (202)
512-2834 or dillinghamg@gao.gov.

                                                                                         United States Government Accountability Office

Letter                                                                                     1
              Background                                                                   3
              General Aviation Accidents Decreased, but Some Segments Had
                Disproportionate Shares of Accidents                                       8
              FAA Has Key Initiatives Under Way to Improve General Aviation
                Safety, but One Has Several Shortcomings                                 24
              Conclusions                                                                33
              Recommendations for Executive Action                                       35
              Agency Comments                                                            36

Appendix I    Scope and Methodology                                                      37

Appendix II   GAO Contact and Staff Acknowledgments                                      39

              Table 1: Estimated Active Airplane Pilots and Selected
                       Requirements and Limitations for U.S. Pilot Certificates            6
              Table 2: Summary of General Aviation Accident Characteristics                8
              Table 3: Percentage of Fatal Accidents and Estimated Flight Hours
                       by Airplane Category and Operation (1999 to 2010)                 14
              Table 4: Aviation Industry Organizations Interviewed for This
                       Study                                                             38

              Figure 1: Types of General Aviation Aircraft                                 3
              Figure 2: General Aviation Accidents (1999 to 2011)                          9
              Figure 3: Type of Operation Flown by Airplanes in General
                       Aviation Accidents (1999 to 2011)                                 10
              Figure 4: Fatal General Aviation Accident Rates per 100,000 Flight
                       Hours (2000 to 2010)                                              23

              Page i                                        GAO-13-36 General Aviation Safety

ABS                        American Bonanza Society
AOPA                       Aircraft Owners and Pilots Association
CAST                       Commercial Aviation Safety Team
CGAR                       Center for General Aviation Research
DOT                        Department of Transportation
EAA                        Experimental Aircraft Association
E-AB                       Experimental amateur built aircraft
FAA                        Federal Aviation Administration
FAASTeam                   FAA Safety Team
GAJSC                      General Aviation Joint Steering Committee
GAMA                       General Aviation Manufacturers Association
IG                         inspector general
NASA                       National Aeronautics and Space Administration
NBAA                       National Business Aviation Association
NextGen                    Next Generation Air Transportation System
NTSB                       National Transportation Safety Board
SAFE                       Society of Aviation and Flight Educators
SAT                        safety analysis team
SMS                        safety management system
VFR                        visual flight rules

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Page ii                                                 GAO-13-36 General Aviation Safety
United States Government Accountability Office
Washington, DC 20548

                                   October 4, 2012

                                   The Honorable John D. Rockefeller IV
                                   The Honorable Kay Bailey Hutchison
                                   Ranking Member
                                   Committee on Commerce, Science, and Transportation
                                   United States Senate

                                   The Honorable John L. Mica
                                   The Honorable Nick J. Rahall, II
                                   Ranking Member
                                   Committee on Transportation and Infrastructure
                                   House of Representatives

                                   The Honorable Thomas E. Petri
                                   The Honorable Jerry F. Costello
                                   Ranking Member
                                   Subcommittee on Aviation
                                   Committee on Transportation and Infrastructure
                                   House of Representatives

                                   The U.S. aviation system is one of the safest in the world and a significant
                                   contributor to the nation’s economy. However, hundreds of fatalities occur
                                   each year in the sector known as general aviation, which includes all
                                   forms of aviation except commercial and military. According to National
                                   Transportation Safety Board (NTSB) data, 92 percent of all fatal aviation
                                   accidents 1 in 2011 occurred in general aviation. Each fatal general
                                   aviation accident typically involves a small number of casualties because
                                   of the smaller aircraft that are usually flown in general aviation.
                                   Nevertheless, these accidents can profoundly affect communities—as

                                    An aviation accident, as defined by 49 C.F.R. § 830.2, occurs when in the course of the
                                   operation of an aircraft—between the time anyone boards with the intention of flight and
                                   until the last person disembarks—any person suffers death or serious injury or the aircraft
                                   receives substantial damage. With certain exceptions, substantial damage means damage
                                   or failure that adversely affects the structural strength, performance, or flight
                                   characteristics of the aircraft, and that would normally require major repair or replacement
                                   of the affected component.

                                   Page 1                                                   GAO-13-36 General Aviation Safety
with the November 23, 2011, crash near Apache Junction, Arizona, that
killed six people, including a father and his three children who were going
to the father’s home for Thanksgiving—and the nation—as with the
August 9, 2010, crash near Aleknagik, Alaska, in which former Senator
Ted Stevens and four others perished and several others were seriously
injured. According to National Transportation Safety Board (NTSB) data,
the majority of general aviation accidents occurs because of an error on
the part of the pilot and often involves causes similar to or the same as
those identified in prior accidents. In June 2011, NTSB added “improve
general aviation safety” to its most wanted list of 10 critical changes
needed to reduce transportation accidents and save lives.

You asked us to examine general aviation safety in the U.S. This report
discusses the (1) characteristics of and trends in general aviation
accidents 2 from 1999 through 2011 and (2) recent actions taken by the
Federal Aviation Administration (FAA) to improve general aviation safety.
To address our objectives, we analyzed NTSB accident data, consulted
our prior work on general aviation safety trends as well as other related
work, 3 reviewed other government and industry documents, and
interviewed FAA and NTSB officials and industry stakeholders. We
conducted this performance audit from June 2011 to October 2012 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. See appendix I for more
information about our scope and methodology.

 We did not include incidents—defined as occurrences other than accidents associated
with the operation of aircraft which could have affected operational safety—in this study
because reporting of nonserious incidents is not mandatory. As such, there is not a
reliably comprehensive database of incidents to analyze.
 See GAO, General Aviation: Status of the Industry, Related Infrastructure, and Safety
Issues, GAO-01-916 (Washington, D.C.: Aug. 31, 2001); Initial Pilot Training: Better
Management Controls Are Needed to Improve FAA Oversight, GAO-12-117 (Washington,
D.C.: Nov. 4, 2011); and Aviation Safety: FAA Is Taking Steps to Improve Data, but
Challenges for Managing Safety Risks Remain, GAO-12-660T (Washington, D.C.: Apr.
25, 2012).

Page 2                                                   GAO-13-36 General Aviation Safety
                                          General aviation is characterized by a diverse fleet of aircraft flown for a
Background                                variety of purposes. In 2010, FAA estimated that there were more than
                                          220,000 aircraft in the active general aviation fleet, comprising more than
                                          90 percent of the U.S. civil aircraft fleet. Included among these aircraft are
                                          airplanes, balloons, unmanned aircraft systems, gliders, and helicopters.
                                          (See fig. 1.) Airplanes comprise the vast majority—almost 80 percent—of
                                          the general aviation fleet. According to a 2009 FAA study, general
                                          aviation airplanes have an average age of 40 years. 4 In addition, most are
                                          single-engine piston, such as the Beechcraft Bonanza, Cessna 172, and
                                          Piper Archer.

Figure 1: Types of General Aviation Aircraft

                                          FAA designates a small, but growing, portion of the general aviation fleet
                                          as “experimental.” These include aircraft used for racing and research as
                                          well as exhibition aircraft, such as former military aircraft known as

                                           FAA, Part 23—Small Airplane Certification Process Study, July 2009.

                                          Page 3                                                GAO-13-36 General Aviation Safety
warbirds. The largest group of experimental aircraft—and the fastest
growing segment of the general aviation fleet, according to FAA—is
defined by FAA as “experimental-amateur built” (E-AB). Individuals build
E-AB aircraft either from kits sold by manufacturers or from their own
designs. E-AB aircraft can contain previously untested systems, including
engines not designed for aircraft use, and modifications of airframes,
controls, and instrumentation. The E-AB fleet is diverse, ranging from
open-framework designs with no cabin structure to small, pressurized
airplanes able to fly long distances. The majority are simple craft used
primarily for short personal flights. The expertise of the builders varies, as
does the experience of the pilots and the availability of training for
transitioning to the aircraft. 5 Following a successful inspection of the
aircraft and documentation review, FAA issues a special airworthiness
certificate in the experimental category to the aircraft’s builder and
assigns operating limitations in two phases specifying how and where the
aircraft can be flown. 6 Phase I is the required flight test period, in which
the builder determines the aircraft’s airspeed and altitude capabilities and
develops a flight manual. Phase II refers to normal operations after the
flight testing is completed.

General aviation aircraft can be used for a wide variety of operations,
although about 78 percent of general aviation operations fall under one of
four types:

•   personal (e.g., a pilot taking his family on a sightseeing trip);
•   business (e.g., a pilot flying herself to a meeting);
•   corporate (e.g., a professionally-piloted aircraft transporting corporate
    employees around the globe); and
•   instructional (e.g., a student flying with a certified flight instructor).

 In order to qualify for an experimental certificate for an amateur-built aircraft, the builder
must fabricate and assemble a major portion—or 51 percent—of it. The builder can hire
others to complete the remainder of the tasks.
 In addition to those granted to experimental aircraft, there are several other categories of
“special” airworthiness certificates. (14 C.F.R. § 21.175(b)). Included among these are two
certificate categories for light sport aircraft, which are simple, small, lightweight (less than
1,320 pounds for land-based aircraft), low-performance aircraft. The experimental light
sport aircraft category includes kit-built versions and special light-sport aircraft that are re-
certificated as experimental. The special light-sport aircraft category is for light sport
aircraft manufactured according to an industry consensus standard rather than a type
certificate. 14 C.F.R. § 1.1.

Page 4                                                      GAO-13-36 General Aviation Safety
These operations are conducted from the more than 2,950 public use
general aviation airports (which primarily serve general aviation aircraft)
as well as from thousands of other airports (including those that support
commercial air service) and landing facilities (e.g., heliports). General
aviation flights operate under various federal aviation regulations. 7 For
purposes of this report, our definition of general aviation includes flights
operated under part 91 general operation and flight rules.

Pilots, including those flying general aviation operations, earn one or
more of the six basic types of pilot certification—(1) student, (2) sport, (3)
recreational, (4) private, (5) commercial, and (6) airline transport. To
obtain any of these certificates, individuals must typically successfully
complete pilot training at any of the approximately 3,400 collegiate, flight-
instructor, or vocational pilot schools 8 and pass an FAA knowledge test
as well as a practical test, which consists of a flight test and an oral
examination. These tests are typically administered by designated pilot
examiners, who are individuals authorized to conduct various pilot-
certification-related activities on behalf of FAA. Pilots may also earn
additional authorizations—referred to as ratings—that define the
conditions or specific aircraft in which a pilot certificate may be used. In
addition, FAA, to further define conditions or specific aircraft not covered
by ratings, may issue endorsements. To be considered active, a pilot
must also hold a valid medical certificate. 9 FAA estimated that as of
December 31, 2011, there were approximately 580,800 active pilots
holding one of those six airplane pilot certificates. 10 Table 1 provides

 Federal Aviation Regulations under which general aviation operations are flown include
14 C.F.R. part 91 (general operating and flight rules), part 125 (privately operated aircraft
with seating capacity of 20 or more or maximum payload capacity of 6,000 lbs. or more),
part 133 (rotorcraft external load operations), and part 137 (agricultural operations). FAA
includes some part 135 operations (on-demand) as well as parts 133 and137 and public
aircraft in its tracking of the general aviation fatal accident rate.
 GAO-12-117. Our definition of flight-instructor based schools includes individual flight
 Medical certificates are issued by FAA-designated aviation medical examiners following a
physical examination of the applicant. The class of medical certificate required and the
length of validity depend on the operation that pilot is flying and the age of the pilot. For
pilots exercising sport pilot privileges, a valid U.S. driver’s license is required in place of a
medical certificate.
  There are separate certifications for rotorcraft (helicopter) and glider pilots. These
certifications are not included in this estimate.

Page 5                                                      GAO-13-36 General Aviation Safety
                                         more information about the estimated number of active airplane pilots and
                                         selected pilot certificate requirements and limitations.

Table 1: Estimated Active Airplane Pilots and Selected Requirements and Limitations for U.S. Pilot Certificates

                       Estimated                       Selected requirements                                      Selected limitations
                       number of                                                                                                Allowed to carry
                  active pilots as                     Minimum total                                                            property for
Certificate         of December      Minimum             prerequisite                                   Allowed to carry        compensation
type                    31, 2011          age            flight hours          Prior certifications     passengers?             or hire?
Student                  118,657             16                        0       None                     No                      No
                                                   c                                                          d
Sport                       4,066             17                      20       Student certificate      Yes                     No
Recreational                                                                   Student or sport         Yes                     No
                              227              17                     30       certificate
Private                                                                        Student, sport, or         Yes                   No
                         194,441              17                      40       certificate
Commercial               120,865               18                   250        Private certificate      Yes                     Yes
Airline                                                                        Commercial               Yes                     Yes
transport pilot                                                                certificate with an
                         142,511               23                1,500         instrument rating
                                         Sources: FAA and 14 C.F.R. part 61.
                                             Pilots with rotorcraft-only certificates are excluded.
                                             Student pilots must be at least 14 to operate a glider or balloon.
                                          Private and sport pilots seeking certificates to fly a glider or balloon are eligible to do so at age 16.
                                             Recreational and sport pilots may carry no more than one passenger.

                                         Various offices within FAA are responsible for ensuring general aviation
                                         safety, most notably the Flight Standards Service, Aircraft Certification
                                         Service, Office of Accident Investigation and Prevention, and Office of
                                         Runway Safety. According to FAA, the agency’s fiscal year 2011 budget
                                         submission included nearly $203 million for activities within the Aviation
                                         Safety organization related to the top priority of reducing the general
                                         aviation fatal accident rate. FAA’s responsibilities include administering
                                         aircraft and pilot certification, conducting safety oversight of pilot training
                                         and general aviation operations, and taking enforcement actions against
                                         pilots and others who violate federal aviation regulations and safety
                                         standards. FAA also collects general aviation fleet and flight activity data
                                         through an annual survey and supports the NTSB by gathering
                                         information about general aviation accidents. According to NTSB officials,
                                         FAA collects information on the vast majority of general aviation

                                         Page 6                                                               GAO-13-36 General Aviation Safety
NTSB is responsible for all aviation accident investigations—using the
information gathered by FAA and its own investigators—and for
determining the probable cause of accidents. NTSB uses a coding
system of aircraft accident categories and associated phases of flight that
are useful in describing the characteristics and circumstances of aviation
accidents. For ease of interpretation and to categorize similar events,
NTSB identifies one event as the “defining event” of the accident, which
generally describes the type of accident that occurred—hard landing,
midair collision, or fuel exhaustion, for example. In addition, NTSB
identifies the causes of an accident and the contributing factors, which
describe situations or circumstances central to the accident cause. Just
as accidents often include a series of events, the reason those events led
to an accident may reflect a combination of multiple causes and
contributing factors. For this reason, a single accident report can include
multiple cause and contributing factor codes. NTSB also collects
descriptive information about the environmental conditions, aircraft, and
people involved in aviation accidents. It captures its findings and
descriptive information in its Aviation Accident Database. NTSB
calculates general aviation accident and fatality rates, which it does using
its own accident data and FAA’s annual estimates of general aviation
flight activity. NTSB may also recommend regulatory and other changes
to FAA and the aviation industry based on the results of its investigations
and any studies it conducts.

The U.S. general aviation industry includes a number of trade groups,
“type clubs,” 11 and other organizations that actively promote the
importance of safety and, in many cases, offer educational opportunities
to pilots. Many of the groups also work with FAA on advisory and
rulemaking committees. Prominent trade organizations include the
Aircraft Owners and Pilots Association (AOPA), the Experimental Aircraft
Association (EAA), the General Aviation Manufacturers Association
(GAMA), and the National Business Aviation Association (NBAA). The
Society of Aviation and Flight Educators (SAFE) and the National
Association of Flight Instructors represent certified flight instructors and
other aviation educators. The American Bonanza Society (ABS), the
Cirrus Owners and Pilots Association, and the Lancair Owners and

  Type clubs are organizations formed around a particular type of aircraft. Type clubs may
host discussion forums, publish magazines, and keep libraries of technical information.
Some type clubs have also developed specialized training courses and voluntary
inspection programs for various systems or entire aircraft types.

Page 7                                                  GAO-13-36 General Aviation Safety
                                        Builders Organization are examples of the several general aviation type

                                        Our analysis of NTSB accident data showed that the annual number of
General Aviation                        general aviation accidents generally decreased for 1999 through 2011.
Accidents Decreased,                    We also identified several characteristics of accidents with respect to the
                                        types of operations and the causes of the accidents. These
but Some Segments                       characteristics were largely consistent with observations made during our
Had Disproportionate                    last review of general aviation safety in 2001. 12 To better understand
Shares of Accidents                     these characteristics, where possible, we sought to measure their
                                        occurrence in numbers of accidents in relation to their overall occurrence
                                        in, for instance, total flight hours or pilot certifications as estimated by
                                        FAA. In doing so, we identified some accident characteristics that, based
                                        on our analysis, appear to occur disproportionately. However, we also
                                        identified methodological and conceptual limitations with the activity
                                        data—particularly the General Aviation and Part 135 Activity Survey that
                                        FAA uses to estimate annual flight hours and the number of active
                                        aircraft—that we discuss later in this section. See table 2 for a summary
                                        of the characteristics of general aviation accidents according to our
                                        analysis of the NTSB accident data.

Table 2: Summary of General Aviation Accident Characteristics

 Analysis                                                           Fatal accidents                  Nonfatal accidents
 Percentage change in general aviation accidents                    -24%                             -29%
 Most common operation flown in general aviation                    Personal                         Personal
 Most common type of airplane in general aviation                   Single-engine piston             Single-engine piston
 Most common defining event in general aviation                     Loss of control in flight        Loss of engine power (total
 accidents                                                                                           or partial)
 Proportion of pilots in general aviation accidents who             70%                              59%
 were a cause of the accident
 Percentage of pilots in general aviation accidents with            44%                              43%
 fewer than 100 hours in the accident aircraft make and
                                        Source: GAO analysis of NTSB data.


                                        Page 8                                                     GAO-13-36 General Aviation Safety
General Aviation Accidents               From 1999 through 2011, nonfatal accidents involving general aviation
Decreased from 1999 to                   airplanes generally decreased, falling 29 percent, from 1,265 in 1999 to
2011                                     902 in 2011. 13 Fatal accidents generally decreased as well, falling 24
                                         percent. Figure 2 indicates the number of fatal and nonfatal accidents for
                                         each year we reviewed. During this period of time, though the majority
                                         (approximately 56 percent) of all accidents resulted in no injuries, there
                                         were more than 200 fatal accidents each year.

Figure 2: General Aviation Accidents (1999 to 2011)

                                         Note: All accidents occurred in the 50 states and involved an airplane flying under Part 91.

                                           As previously mentioned, we limited our data analysis for this report to accidents
                                         involving airplanes flying under Part 91. These aircraft accounted for 88 percent of all
                                         general aviation accidents from 1999 through 2011.

                                         Page 9                                                          GAO-13-36 General Aviation Safety
Most General Aviation     From 1999 through 2011, personal operations accounted for 73 percent
Accidents Involved        of airplanes in nonfatal general aviation accidents and 77 percent of
Personal Operations and   airplanes in fatal general aviation accidents. (See fig. 3.) This is not a new
                          phenomenon. As we reported about accidents occurring in 1998,
Single-Engine Piston      personal operations accounted for more than 75 percent of fatal general
Aircraft                  aviation accidents.

                          Figure 3: Type of Operation Flown by Airplanes in General Aviation Accidents (1999
                          to 2011)

                          From 1999 through 2011, airplanes flying instructional operations were
                          the second most often involved in accidents. However, instructional
                          operations were also the operation with the smallest proportion of fatal
                          accidents. According to our analysis, almost 38 percent of accidents that
                          occurred during instructional flying involved hard landings or loss of
                          control while the aircraft was on the ground. These types of events are
                          less likely to cause fatalities than other types of events. It is also possible
                          that the presence of a certified flight instructor onboard to share the

                          Page 10                                            GAO-13-36 General Aviation Safety
management of the cockpit and other tasks may have contributed to the
lower fatality rate for instructional operations.

Corporate operations, in which a professional pilot flies an aircraft owned
by a business or corporation, was the least common type of operation to
be involved in general aviation accidents. Corporate operations
accounted for less than 1 percent of fatal general aviation accidents and
less than 0.5 percent of nonfatal accidents. From 2008 through 2011,
there were no fatal accidents involving corporate airplanes, giving
corporate operations an accident record similar to that of commercial air
carriers. Again, this is not a new phenomenon. As we reported in 2001,
the low number of accidents involving corporate operations is attributable
to a number of factors, including the pilot’s training, experience, and
participation in ongoing training to maintain and improve their skills, as
well as the safety equipment that is typically installed on corporate

According to a representative of the NBAA, an organization representing
companies that rely on general aviation aircraft to conduct business, most
corporate operations also benefit from advanced technologies, including
avionics that provide synthetic vision and terrain displays; auto-throttle,
which helps maintain airspeed; and fuel gauges that are built to the
standards required for commercial airliners. Further, airplanes used for
corporate purposes are often powered by turbine engines and may be
subject to additional safety requirements. 14 Flying for corporate purposes
can also differ from other types of flying. Whereas a pilot flying for fun
may perform several take-offs and landings and practice maneuvers, a
corporate flight likely includes a single take off and landing, with the
majority of time spent en route—one of the phases of flight when the
fewest fatal accidents occur.

Regarding the type of aircraft involved in general aviation accidents,
single-engine piston airplanes accounted for almost 76 percent of
airplanes in nonfatal general aviation accidents and 60 percent of
airplanes in fatal accidents. 15 Single-engine piston airplanes are the most
common type of aircraft in the general aviation fleet and, according to

  Large and turbine-powered multiengine airplanes have additional equipment and
operating requirements as described in 14 C.F.R. Pts. 91 Subpart F and 61.
 These numbers exclude single-engine piston airplanes that are classified as E-ABs.

Page 11                                               GAO-13-36 General Aviation Safety
stakeholders, the type of aircraft most commonly flown by pilots holding
private pilot certifications and flying for personal reasons. According to
AOPA, mechanical failures cause relatively few accidents, indicating that
the frequency with which single-engine piston airplanes are in accidents
is not necessarily a reflection of the safety of the aircraft.

E-ABs were the second most common airplane involved in general
aviation accidents. From 1999 through 2011, E-AB aircraft accounted for
14 percent of airplanes in nonfatal general aviation accidents and
approximately 21 percent in fatal accidents. According to EAA, the
organization that represents experimental and amateur-built aircraft
owners, E-AB airplanes were also the fastest growing type of aircraft in
the general aviation fleet in recent years. In 2011, there were
approximately 33,000 registered E-AB aircraft, a 10 percent increase from
3 years earlier. AOPA’s 2010 Nall Report—an annual safety report that
provides perspectives on the previous year’s general aviation accidents—
indicated that the physical characteristics and the manner in which these
aircraft are used expose E-AB aircraft pilots to greater risk and make
accidents less survivable. 16

In 2012, NTSB completed a safety study of E-AB aircraft that included the
use of an EAA survey of E-AB pilots. 17 Among other findings, NTSB
concluded that the flight test period—the first 50 hours of flight—is
uniquely challenging for most E-AB pilots because they must learn to
manage the handling characteristics of an unfamiliar aircraft while also
managing the challenges of the flight test environment, including
instrumentation that is not yet calibrated, controls that may need
adjustments, and possible malfunctions or adverse handling
characteristics. NTSB added that the E-AB safety record could be
improved by providing pilots with additional training resources and,
accordingly, made several recommendations to FAA and EAA regarding
flight training and testing.

  Air Safety Institute, The 2010 Joseph T. Nall Report of Accident Trends and Factors,
Frederick, MD. As previously noted, most E-ABs are simple aircraft that may incorporate
previously untested systems and modified airframes and instruments. They are also used
primarily for short personal flights, which means more take-offs and landings.
 NTSB, The Safety of Experimental Amateur-Built Aircraft, NTSB/SS-12/01, Washington,
D.C.: May 22, 2012.

Page 12                                               GAO-13-36 General Aviation Safety
Some Industry Segments   To better understand the above observations about the airplanes involved
Experienced Fatal        in and the types of operations flown during general aviation accidents, we
Accidents                compared the proportions of fatal accidents by airplane category and
                         operation type to their shares of FAA estimated flight hours for 1999
Disproportionately to    through 2010. 18 For this analysis, we considered 5 airplane categories:
Their Estimated Annual   (1) non-E-AB, single-engine piston; (2) non-E-AB, multi-engine piston; (3)
Flight Hours             non-E-AB, turbine engine; (4) E-ABs, 19 regardless of engine type; and (5)
                         others. As designated, there is no overlap in this categorization. If there
                         were no relationship between accidents and airplane category, then we
                         would expect each airplane category to be involved in accidents in
                         proportion to its share of overall flight activity; for example, we would
                         expect an airplane category that comprised 50 percent of general aviation
                         flight hours to also comprise 50 percent of accidents. We found this to be
                         the case with the single-engine piston airplane. Though the single-engine
                         piston airplane is most often involved in fatal general aviation accidents,
                         its share of fatal accidents (60 percent) was slightly less than its share of
                         general aviation flight hours (65 percent). By comparison, E-ABs
                         comprised 21 percent of fatal accidents, but only 4 percent of estimated
                         flight hours. With regard to type of operation, we found that 77 percent of
                         fatal accidents occurred during personal operations, but only 40 percent
                         of the estimated flight hours involved personal operations. (See table 3.)

                          2010 is the most recent year for which estimated flight hours are available.
                           We understand that E-ABs are not, strictly speaking, an airplane type but that they
                         represent a type of airworthiness certificate.

                         Page 13                                                 GAO-13-36 General Aviation Safety
                          Table 3: Percentage of Fatal Accidents and Estimated Flight Hours by Airplane
                          Category and Operation (1999 to 2010)

                                                                            Percentage of fatal        Percentage of flight
                                                                                    accidents                       hours
                           Airplane category
                                      Single-engine piston                                     60                           65
                                      Multi-engine piston                                      12                           10
                                      Turbine                                                   6                           19
                                      E-AB                                                     21                           4
                                      Other                                                      0                          2
                                       Personal                                                 77                          40
                                       Instructional                                             7                          18
                                       Business                                                  5                          14
                                       Corporate                                                 1                          14
                                       Other                                                   10                           13
                          Source: GAO analysis of NTSB and FAA data.

                          Note: For the purpose of this analysis, we used 5 categories of airplanes: (1) non-E-AB, single-engine
                          piston; (2) non-E-AB, multi-engine piston; (3) non-E-AB, turbine engine; (4) E-ABs regardless of
                          engine type; and (5) others. Given this designation, there is no overlap among the categories. 2010 is
                          the most recent year for which estimated flight hours are available. Percentages may not total 100
                          percent due to rounding.

Loss of Control Was the   Loss of control in flight—the unintended departure of an aircraft from
Most Common Type of       controlled flight, airspeed, or altitude—was the most common defining
Fatal General Aviation    event in fatal general aviation accidents. Loss of control can occur
                          because of aircraft malfunction, human performance, and other causes.
Accident                  During the period we examined, 1,036 fatal accidents (31 percent) were
                          categorized as loss of control in flight. This was the most common event
                          in a fatal accident for 3 of the 4 types of general aviation operations—
                          personal, instructional, and business operations—and for all types of
                          airplanes. FAA and the industry recently completed a review of a
                          subgroup of fatal loss of control accidents and will be developing detailed
                          implementation plans for the intervention strategies.

                          Page 14                                                        GAO-13-36 General Aviation Safety
Pilot Error Was a Cause of    According to our analysis of NTSB data, the pilot was a cause in more
Most Accidents, but           than 60 percent of the general aviation accidents from 2008 through
Targeting Mitigations Is      2010. 20 The pilot’s actions, decision making, or cockpit management was
                              a cause for 70 percent of the airplanes in fatal accidents and 59 percent
Difficult because of a Lack
                              in nonfatal accidents. NTSB and other experts view aviation accidents as
of Pilot Data                 a sequence of events with multiple causes and contributing factors. Of the
                              2,801 general aviation accidents that occurred from 2008 through 2010
                              for which a causal determination was made, 71 percent were determined
                              to have multiple causes. In approximately 34 percent of fatal accidents
                              involving airplanes, the cause was a combination of the pilot’s actions and
                              the failure to properly attain or maintain a performance parameter—e.g.,
                              airspeed and altitude.

                              Many of the pilots involved in general aviation accidents had low levels of
                              experience in the accident airplane make and model, which some
                              stakeholders and experts with whom we spoke believed can contribute to
                              pilot error. In its review of general aviation accidents from 2005, NTSB
                              found that 40 percent involved pilots with 100 hours or less in the
                              accident airplane make and model. In its review of general aviation
                              accidents from 2007 through 2009, NTSB also found that, for pilots in
                              accidents who were flying personal operations, a relatively small portion
                              of their total hours flown had been in the type of airplane involved in the
                              accident. Our analysis found that, in the accidents where flight hours were
                              available, many pilots had a low number of hours flying in the accident
                              airplane make and model. 21 Approximately 43 percent of pilots in nonfatal
                              accidents had fewer than 100 hours as the pilot in that make and model
                              of airplane; for fatal accidents that figure was approximately 44 percent of
                              pilots. However, without comparable information on flying hours or
                              habits—such as how many different types of airplanes the pilot has
                              flown—of pilots who are not in accidents, we cannot draw conclusions
                              about the effect of pilot flight hours on accidents. For example, if about 40

                                In 2007, NTSB undertook an effort to align its categories of accident causes with
                              internationally recognized standards. As such, in 2008 NTSB created a new organizational
                              structure for this information within its database. According to an expert at NTSB, it would
                              be inappropriate to try to apply the new cause coding to accidents investigated before the
                              changes were made. As a result, our analysis of the accident causes only includes those
                              that are classified under the new structure.
                                In some instances, there was more than one pilot associated with an airplane. Since we
                              were unable to determine from the data which pilot was in control of the aircraft at the time
                              of the incident, we included data on all pilots involved in the accident in this and
                              subsequent analyses regarding pilot characteristics or experience.

                              Page 15                                                   GAO-13-36 General Aviation Safety
percent of all pilots had fewer than 100 hours in any given airplane make
and model, then we could expect the results of the above analysis even if
pilot flight hours in the airplane make and model had no relation to
accidents. We discuss the implications of the lack of this and other data
later in this section.

To further explore the relationship between pilot flight hours and
accidents, we looked at the portion of pilots with fewer than 100 hours in
the accident airplane make and model where the pilot was determined to
be a cause of the accident and compared it to the portion of pilots with
more than 100 hours in the accident airplane make and model. We then
did the same using pilot certification levels. Our analysis of accidents from
2008 through 2010 found that private pilots with fewer than 100 hours of
experience in the accident airplane make and model were a cause of fatal
and nonfatal general aviation accidents at similar rates as pilots with more
than 100 hours of experience and with higher pilot certifications. For fatal
accidents, 73 percent of pilots with fewer than 100 hours of experience in
the accident airplane make and model were a cause as compared to 76
percent of pilots with more than 100 hours of experience. In nonfatal
accidents, those portions were 63 and 64 percent, respectively. With
regard to pilot certification levels, we found that in nonfatal accidents,
private pilots were a cause more often (68 percent) than other types of
pilots (percentages ranging from 52 to 58 percent); but in fatal accidents,
similar proportions of private and commercial pilots were found to be a
cause (75 percent and 80 percent, respectively). 22

Although some experts may believe that lack of experience can contribute
to pilot error and accidents, the above suggests that this might not
necessarily be the case. However, we do not have enough information to
draw any real conclusions because FAA lacks certain key information
about pilots that could help identify the root causes of accidents and,
thus, risk mitigation opportunities. First, FAA’s estimate of the number of
active pilots is an imperfect measure because, according to FAA’s
definition, an active pilot is a certificated pilot who holds a valid medical
certificate. However, depending on the type of operation the pilot is flying
and the pilot’s certification level, age, and health condition, the medical
certificate is valid for between 6 and 60 months. The designation as

  Forty-three percent of pilots with airline transport pilot certificates that were involved in
fatal accidents were determined to be a cause of the accident.

Page 16                                                     GAO-13-36 General Aviation Safety
active is also not an indication of whether the pilot has actually flown in
the previous year. Second, though pilots report total flight hours as part of
their medical certificate application, a pilot’s experience in different makes
and models of aircraft—which is not collected—is also relevant as there
are risks associated with operating an unfamiliar airplane. As described
above, this information would be necessary to draw conclusions about the
effect of pilot flight hours on accidents. Third, though pilot flight hours are
to be reported as part of the accident report, investigators are not always
able to obtain this information for accident pilots as the logbooks in which
it is recorded are sometimes destroyed in accidents. Of the 3,257 pilots
involved in an accident from 2008 through 2010, pilot flight hours in the
accident airplane make and model was missing for 514, or 16 percent of
them. Missing data can compromise the validity of analyses that seek to
examine the relationship between pilot experience and the causes of
general aviation accidents.

In addition, FAA does not maintain information about where pilots were
trained or whether noncommercial pilots participate in any recurrent
training programs other than its WINGS pilot proficiency program 23—
information that would facilitate analyses of the relationship between pilot
training and the causes of general aviation accidents and that could help
identify shortcomings in current pilot training programs. Private pilots are
not required to participate in recurrent training, though they must
successfully complete a biennial review of their skills and knowledge by a
designated pilot examiner or a certified flight instructor. In recent years,
as pilot training has been identified as a contributing factor in high profile
accidents, 24 there has been a renewed focus on the sources and amount
of pilot training and on altering the training paradigm. 25 FAA has been

  The WINGS pilot proficiency program is an internet-based program open to any active
pilot; it focuses on activities and tasks that address the causal factors of accidents.
  The investigation of the February 2009 Colgan Air crash near Buffalo, New York,
identified aspects of training as safety issues associated with the crash.
  We and others, including SAFE, have previously found that the current pilot -training
paradigm focuses on rote memorization and on the execution of stick and rudder skills
and does not emphasize the importance of cockpit management, which can prevent
accidents, according to stakeholders. For instance, according to FAA and other
stakeholders, the regulations regarding ground school and flight training, as well as the
test standards for a commercial pilot certificate, generally emphasize the mastery of
maneuvers and individual tasks to determine competence. The emphasis is on the
development of motor skills to satisfactorily accomplish individual maneuvers—whereas
only limited emphasis is placed on aeronautical decision making.

Page 17                                                  GAO-13-36 General Aviation Safety
                             required to take steps to maintain qualification and performance data on
                             airline pilots, 26 but there has been no decision about whether recurrent
                             training will be included in the database, and no such effort has been
                             undertaken with regard to the remaining pilot population. Without more
                             information about the training of general aviation pilots—and not just
                             those who are in accidents—FAA’s efforts to identify and target risk areas
                             and populations is impeded.

Flight Activity Data         FAA estimates of general aviation annual flight hours—a measure key to
Limitations Impede FAA’s     NTSB’s calculation of general aviation accident and fatality rates and
Ability to Assess General    NTSB’s and FAA’s assessments of the safety of general aviation—may
                             not be reliable because of methodological and conceptual limitations with
Aviation Safety and Target   the survey used to gather flight activity data. Since 1978, FAA has used a
Risk Mitigation Efforts      survey of aircraft owners to estimate annual general aviation flight hours.
                             The survey was redesigned in 1999, and FAA has modified it since then,
                             on its own volition and in response to NTSB recommendations, to
                             improve the survey’s ability to capture activity trends. Changes include
                             sampling 100 percent of certain subpopulations of general aviation
                             aircraft owners who were previously underrepresented in the random
                             sample response—such as owners of turbine engine, rotorcraft, and
                             Alaska-based aircraft—and revising the process for collecting information
                             from owners of multiple aircraft. FAA and NTSB believe these changes
                             have improved the reliability of the survey’s estimates, but some
                             conceptual and methodological limitations persist.

                             First, as with all surveys that rely on self-reported data, there is the risk
                             that respondents will not be able to accurately recall and report
                             information, introducing error and perhaps bias into the survey’s
                             estimates. The general aviation survey, which is usually open from March
                             through August each year, asks respondents to estimate the number of

                               The Airline Safety and Federal Aviation Administration Extension Act of 2010 (Pub. L.
                             No. 111–216, § 203, 124 Stat. 2348, 2352 (2010)) required that FAA develop a centralized
                             pilot records database that air carriers must access to review pilot qualifications and past
                             performance data before hiring pilots. According to the Department of Transportation
                             Inspector General (IG), FAA met the act’s initial milestone in developing a centralized
                             electronic pilot-records database that will include records previously maintained by air
                             carriers. However, the IG indicated that FAA needs to address the level of detail that
                             should be captured from air carrier pilot-training records—such as determining whether
                             recurrent flight training will be included, how to transition from the current practices to the
                             new database without disrupting information flow, and how to ensure the reliability of data.

                             Page 18                                                    GAO-13-36 General Aviation Safety
hours flown during the previous calendar year. Depending on funding
availability, the survey has opened later or for shorter periods of time.
This year, because of contracting-related delays in bringing the survey
consultant on board, aircraft owners did not receive the first request for
information about 2011 flight hours until August 2012. According to
NTSB, accuracy depends on the record-keeping habits and memories of
aircraft owners, and in some cases, the aircraft owners’ ability to obtain
needed information from pilots who fly their aircraft. Though some portion
of aircraft owners may record each flight in their logbooks, to which they
can refer to complete the survey, logging each flight is not mandatory. To
the extent aircraft owners rely on their recollection of flight hours flown in
the previous year, long delays such as the one occurring this year are
likely to further degrade the resulting information.

Second, the survey has long suffered from low response rates, and this
shortcoming, combined with limited information about the population, can
call into question any estimates based on the survey’s results. Since the
current method for calculating the response rate was implemented in
2004, the overall response rate has ranged from 43 and 47 percent
annually through 2010. The primary problem with low response rates is
that they can lead to biased estimates if survey respondents and
nonrespondents differ with regard to the variables of interest—in this
case, annual flight hours. According to guidance from the Office of
Management and Budget, agencies should plan to conduct item-level
bias analyses if the expected response rate of the survey is below 70
percent and to consider the anticipated response rate in the decision to
proceed with the survey. In 2011, the survey contractor completed a
nonresponse analysis and concluded that there was no evidence of
significant bias. 27 However, relatively little is known about the aircraft
owners who do not respond and, as a result, the contractor and we
concluded that the sample is not rich enough in information to understand
the differences between the two groups. For instance, there may be

  Most surveys experience some degree of nonresponse, which gives rise to the concern
that the respondents might differ from nonrespondents in such a way that the results of
the survey might be biased. When response rates are low, researchers often conduct a
nonresponse bias analysis, in which respondents and nonrespondents are compared
using information that is available about the nonrespondents. In this case, little information
was available about the nonrespondents, and the contractor was only able to compare
respondents and nonrespondents with respect to aircraft type and aircraft age. Lack of
information about other characteristics of nonrespondents made it impossible to test for
other possible differences between the two groups.

Page 19                                                   GAO-13-36 General Aviation Safety
certain characteristics of owners that are associated with flying habits,
such as the owner’s age or certification level. 28 Though a low response
rate does not necessarily imply bias, it does raise the possibility for it.
Further, the ability to detect any such bias is limited by what is known
about those who do not respond. Given these conditions, bias remains a
serious concern.

An alternative data collection method implemented in 2004 for owners of
multiple aircraft may also introduce bias to the survey’s flight-hour
estimates. In an effort to improve response rates among owners of
multiple aircraft who were less likely to respond because of the burden of
multiple forms, the survey administrators developed a modified data
collection procedure for these owners. This includes sending out a form
and calling these owners to verify receipt of the survey and encouraging
participation. Survey staff also collect essential data—including the
number of hours flown—during these phone calls. This alternative method
accounted for data for approximately 23 percent of the aircraft owners
responding to the survey that estimated 2010 flight hours. These efforts
may have improved response rates, but these owners, the aircraft they
own, and their use of the aircraft likely differ from owners of a single
aircraft. By encouraging responses from a particular set of owners, survey
estimates may be biased.

Flight hours account for what stakeholders refer to as “exposure” or how
often particular types of operations or aircraft are flown. FAA’s flight hour
estimates can provide a general sense of the relationship between hours
and accidents. However, the methodological and conceptual limitations
we have identified call the estimates’ precision into question. As a result,
these estimates may not be sufficient for drawing conclusions about small
changes in accident rates over time—including FAA’s progress toward its
goal to reduce the fatal general aviation accident rate per 100,000 flight
hours by 10 percent over 10 years. Implementing alternative means of
collecting flight hour data, such as requiring the reporting of aircraft
engine-revolution or run-time data, could supplement or replace the data
generated through the survey and add rigor to FAA’s flight-hour

  Hypothetically speaking, perhaps older owners fly more than younger ones and are also
more likely to respond to the survey. Even if the survey collected information about age,
there is no corresponding information available for nonrespondents. As a result, the
survey contractor would have no way of detecting that older owners are responding at a
higher rate and biasing the flight-hour estimates upward.

Page 20                                                GAO-13-36 General Aviation Safety
estimates. Moreover, more precise flight-hour data could allow FAA to
better target its safety efforts at subpopulations within the general aviation
community. This could include reviewing an industry segment’s
characteristics, such as the number of fatal accidents relative to its
portion of estimated flight hours and setting a measurable goal for
improving safety within that segment. Though FAA has attempted to
address the disproportionate number of fatalities within the E-AB
community by developing an advisory circular to encourage transition
training for pilots, it has not set a specific goal for reducing fatal accidents
in that segment. 29

FAA and NTSB, to their credit, have recognized that flight-hour estimates
derived from the general aviation survey are imperfect. FAA has
discussed ways to improve its flight-hour data, including requiring general
aviation owners to report flight hours (in the form of engine-revolution or
run-time data) directly to FAA during aircraft registration renewals or at
the annual aircraft maintenance check. However, collecting data from
these alternative sources has not progressed beyond internal
discussions. In addition, organizations representing pilots have generally
been opposed to suggestions for increased data collection, which they
view as potential impediments to flying. According to these groups,
general aviation pilots typically would prefer to avoid additional regulation
or federal involvement.

In 2005, NTSB explored using alternative approaches to determining
annual general aviation activity, approaches that involved using other
measures as proxies for hours flown—including the number of active
pilots and fuel consumption. However, there are shortcomings to each of
these options. As discussed previously, active pilots are defined as those
who have current medical certifications; this is not related to whether the
pilot actually flew in a given year. And while aviation gas consumption
could be a proxy measure for piston engine aircraft activity, some piston-
engine aircraft are used for operations other than general aviation.
Further, jet fuel consumption cannot reasonably be used as a proxy for
the general aviation activity of turbine engine aircraft because of the many
types of operations (e.g., air taxi, air ambulance, etc.) flown by these

 AC-90-109, Airmen Transition to Experimental or Unfamiliar Airplanes, Mar. 30. 2011.

Page 21                                               GAO-13-36 General Aviation Safety
FAA’s Singular Goal to      In 2008, FAA set a goal to reduce the fatal general aviation accident rate
Reduce the Fatal Accident   by 10 percent—from a baseline of 1.12 fatal accidents per 100,000 flight
Rate May Mask Problems      hours to 1 fatal accident per 100,000 flight hours—over 10 years, from
                            2009 to 2018. 30 This single long-term safety goal may mask problems in
in Certain Segments of
                            certain segments of the community. The goal stemmed from FAA’s desire
General Aviation            to have a target for its general aviation safety improvement efforts that
                            accounted for changes in flight activity over time. According to FAA
                            officials, they were looking for a goal that was achievable and
                            represented an improved level of safety. FAA did not meet the annual
                            targets for the goal in 2009 and 2010 and, according to projections of
                            flight activity, it does not appear FAA will meet its target in 2011. 31

                            This singular goal is applied to an industry that is diverse in aircraft types
                            and operations—some of which experience accidents at a higher rate
                            than others. General aviation airplanes differ significantly in size and
                            performance, ranging from single-seat E-AB airplanes to large corporate
                            jets. The types of flying and pilot experience also vary by segment. Some
                            private pilots may only fly a few times each year, while some corporate
                            pilots may keep a schedule similar to that of a commercial airline pilot. In
                            addition, given the expense of flying and maintaining an airplane,
                            downturns in the economy can decrease activity in some segments of
                            general aviation. Changes in flight activity in certain segments of the
                            industry could mask or minimize problems in others and contribute to a
                            rate that does not accurately reflect the trends in the individual segments.
                            (See fig. 4.) For instance, total general aviation flight hours have
                            decreased since the most recent recession, but some segments have
                            declined at a faster rate than others. Personal flying hours in 2010 were 4
                            percent lower than they were in 2008; corporate flying hours, by
                            comparison, were almost 15 percent lower in 2010 than in 2008.
                            Historically, corporate flying has been one of the safest types of general
                            aviation operations. From 1999 through 2010, corporate airplane
                            operations accounted for just 1 percent of fatal general aviation accidents
                            but 14 percent of flight hours. And from 2008 through 2011, there were no

                              Prior to 2009, FAA set an annual goal of the number of fatal general aviation accidents
                            not to exceed. Critics of this approach noted that this goal did not account for exposure
                            and that accident numbers would decrease if general aviation activity decreased. In
                            response to these concerns, FAA shifted to a rate-based goal.
                              The results of the survey used to estimate general aviation flight hours are generally
                            released in the fall for the previous calendar year. The 2011 estimates have not yet been

                            Page 22                                                 GAO-13-36 General Aviation Safety
fatal accidents involving corporate airplane operations. As a result,
changes in corporate flight activity could result in changes in the overall
fatal accident rate that are not necessarily a reflection of changes in
safety but rather a reflection of the changing composition of general
aviation flight activity. In addition, as previously discussed, the rate is
based on estimates of annual general aviation flight hours that may not
be reliable.

Figure 4: Fatal General Aviation Accident Rates per 100,000 Flight Hours (2000 to

There has been some discussion within FAA and industry about
implementing separate goals for each segment of general aviation.
According to one stakeholder we interviewed, the types of operations—
even among fixed-wing aircraft—differ enough to warrant such a
disaggregation. He explained that an hour flown during a corporate
operation, during which an advanced aircraft flies from point to point with
a significant portion of the time spent en route, is quite different from a

Page 23                                             GAO-13-36 General Aviation Safety
                        pilot flying for pleasure and practicing maneuvers and take-offs and
                        landings—the phase of flight when most accidents occur. However, other
                        stakeholders we interviewed maintained that they all fly under the same
                        operating rules, so it is proper to consider the safety of general aviation
                        as a whole. Given the significant dissimilarities among the various general
                        aviation sectors, along with the varied accident and fatality rates, setting
                        separate safety improvement goals would allow FAA to take a more risk-
                        based approach and target its resources and safety improvement efforts
                        to the unique characteristics of and risks posed by each sector.

                        FAA has embarked on key initiatives to achieve its goal of a 10-percent
FAA Has Key             reduction in the fatal general aviation accident rate per 100,000 flight
Initiatives Under Way   hours by 2018. One is the long-standing General Aviation Joint Steering
                        Committee (GAJSC), which is led by the Office of Accident Investigation
to Improve General      and Prevention. More recently, FAA announced a 5-year strategy to
Aviation Safety, but    improve general aviation safety that was developed by the General
One Has Several         Aviation and Commercial Division of the Flight Standards Service.
                        Although both initiatives work toward the overall goal of reducing general
Shortcomings            aviation fatalities, the GAJSC is using a data-driven approach to identify
                        risks in general aviation operations and propose mitigations, while the 5-
                        year strategy is composed of a wide variety of activities under four focus

FAA Renewed the GAJSC   In January 2011, FAA renewed the GAJSC, 32 a joint FAA effort with the
in Early 2011           general aviation industry, 33 the National Aeronautics and Space
                        Administration (NASA), and NTSB that in 1998 was part of the Safer

                          The GAJSC’s early efforts focused on enhancing aeronautical decision making,
                        promoting runway safety, and reducing weather-related accidents, and its work was
                        conducted through three subgroups—personal/sport aviation, technically advanced
                        aircraft/automation, and turbine aircraft operations. In addition, the General Aviation Data
                        Improvement Team oversaw the annual general aviation activity survey and analyzed
                        accident data. Early GAJSC work resulted in the development of guidance and training,
                        such as the Air Safety Foundation’s WeatherWise Safety Seminar. The GAJSC, according
                        to FAA officials, has floundered in the past but still produced good information and
                        contributed to enhanced safety; however, its prior efforts were topic driven and based
                        more on expert opinion than on data analysis.
                         Industry members of the GAJSC include AOPA, EAA, GAMA, and NBAA.

                        Page 24                                                  GAO-13-36 General Aviation Safety
Skies Initiative. 34 Utilizing the model of the Commercial Aviation Safety
Team (CAST), the GAJSC’s goal is to focus limited government and
industry resources on data-driven risk reductions and solutions to general
aviation safety issues. 35 The GAJSC consists of a steering committee that
provides, among other things, strategic guidance and membership
outreach. It also consists of a safety analysis team (SAT), which
determines future areas of study and charters safety studies, among
other things. GAJSC officials indicated that they would charter working
groups as issues for study were identified.

The first working group of the renewed GAJSC focused on loss of control
in approach and landing accidents. This area was selected because,
according to analyses of NTSB accident data for fatal airplane accidents
that occurred from 2001 through 2011and for which NTSB had completed
its investigation, 36 loss of control was the number one causal factor. The
working group divided into three subgroups—reciprocating non-E-AB
aircraft, turbine engine aircraft, and E-AB aircraft—and agreed upon a
sample of 30 accidents to be analyzed by each. 37 Despite issues such as
a lack of data and the consistency of member participation, the working
group developed 83 intervention strategies. These strategies were used
to develop the 27 safety enhancements that were presented to the
GAJSC for approval. The GAJSC approved 23 of the safety
enhancements. The next steps will include developing detailed
implementation plans for each of the strategies, with the SAT conducting
resource/benefit evaluations of each plan. The SAT then will determine
which are the most effective solutions, draft a master strategic plan, and
submit the plan to the GAJSC for approval. Implementation is expected to
begin upon approval. During implementation, the SAT will be responsible

  Safer Skies, which FAA announced in 1998, was a major initiative to reduce the number
of fatal aviation accidents per million flight hours by 2007.
  CAST is a joint government-industry effort to reduce the commercial aviation fatality risk
in the United States using an integrated, data-driven strategy. According to CAST, its
work—along with new aircraft, regulations, and other activities—reduced the commercial
aviation fatal accident rate by 83 percent from 1998 to 2008 and is an important aspect of
FAA’s efforts to improve aviation safety by sharing and analyzing data.
   These accident flights were conducted under 14 C.F.R. Pts. 91, 137, and 135
(unscheduled). The analysis also included public use flights and flights with an unknown
flight operation code.
  Because of a lack of accidents, the turbine engine group analyzed 28 accidents and 2
serious incidents.

Page 25                                                  GAO-13-36 General Aviation Safety
                           for tracking implementation schedules and levels, tracking the
                           effectiveness of the intervention strategies, and recommending areas for
                           future study. We believe that with the GAJSC’s renewal and adoption of
                           CAST-like methods, it has the potential to contribute to a reduction in
                           general aviation accidents and fatalities over the long term.

FAA Launched a 5-Year      In March 2011, FAA announced its 5-year strategy to improve general
Strategy in 2011 to Help   aviation safety. This initiative is a complementary effort to the work of the
Reduce the Fatal General   GAJSC. FAA described the strategy as a nonregulatory approach
                           conducted in partnership with the general aviation community and
Aviation Accident Rate     coordinated across FAA lines of business. The strategy has four focus
                           areas—(1) risk management, (2) safety promotion, (3) outreach and
                           engagement, and (4) training—and includes a 2-year review and the
                           development of validation metrics as each phase of the plan is

Risk Management            FAA initially planned to concentrate its risk management efforts in three
                           areas: (1) the top 10 causes and contributing factors in fatal general
                           aviation accidents—initiated in coordination with the GAJSC, (2) E-AB
                           aircraft, and (3) agricultural operations, which comprise one segment of
                           the general aviation sector. 38 To begin this effort, an FAA team identified
                           the top ten causes of fatal general aviation accidents as well as the
                           leading contributing factors, and provided the information to the GAJSC.
                           The GAJSC, as previously discussed, is using the results of the data
                           analysis to focus its efforts on loss-of-control accidents during approach
                           and landing.

Safety Promotion           For the safety promotion aspect of its 5-year strategy, FAA relies on the
                           FAA Safety Team (FAASTeam). Created in September 2004 as the
                           education and outreach arm of FAA, 39 the FAASTeam consists of 154
                           FAA employees in eight regional field offices, along with 32 groups and
                           2,500 individual members from the general aviation industry. In 2011,
                           FAA refocused the FAASTeam—from national and international
                           activities—to promote general aviation safety and technical proficiency

                             However, because most of the agricultural accidents reviewed were survivable and two
                           industry groups focused on helicopter safety already had strong safety programs in place,
                           FAA decided to forgo concentration on the agricultural sector of general aviation.
                            FAA Order 8000.83.

                           Page 26                                                 GAO-13-36 General Aviation Safety
                          through a host of nationwide seminars and contact with pilots at airports.
                          A significant part of the FAASTeam’s new focus is the annual FAA safety
                          standdown—a series of nationwide meetings that highlight issues of
                          concern for general aviation and include industry and GAJSC member
                          participation. The 2012 standdown focused on loss of control, the focus of
                          a GAJSC working group, from three different perspectives: (1) preflight
                          mistakes, (2) aeronautical decision making, and (3) handling a loss of
                          control. In addition, the FAASTeam is conducting workshops for certified
                          flight instructors to increase the quality of training offered to general
                          aviation pilots. The FAASTeam has also been examining intervention
                          strategies by working directly with designated pilot examiners to promote
                          its educational opportunities to all applicants for practical tests.

Outreach and Engagement   In its outreach and engagement efforts for the 5-year strategy, FAA has
                          briefed aviation associations, type clubs, and flight instructors, and, with
                          the assistance of the Aviation Accreditation Board International, 40 held a
                          symposium on flight training with academia in July 2011. FAA has also
                          reached out to major aviation insurance providers. As a result of these
                          and other efforts, FAA reports that it has strengthened its links with
                          aviation associations while also improving its outreach efforts to type

Training                  The training portion of FAA’s 5-year strategy includes chartering an
                          aviation rulemaking committee 41on pilot testing standards and training,
                          expanding its focus on certified flight instructors, and revamping the
                          WINGS pilot proficiency program. In September 2011, FAA announced
                          the establishment of an aviation rulemaking committee to address
                          concerns from AOPA, SAFE, 42 and others about the testing and training

                            The Aviation Accreditation Board International is a nonprofit organization that sets
                          standards for all aerospace programs taught in colleges and universities worldwide.
                            An aviation rulemaking committee is an informal committee established through the FAA
                          Administrator to allow industry's participation in providing recommendations to the
                          rulemaking process. Participants are invited by FAA to the designated rulemaking
                            As a result of its May 2011 pilot training reform symposium, SAFE made six broad
                          recommendations addressing safety, industry growth, doctrine, standards, curricula, and
                          aviation educators. For example, SAFE recommended that FAA doctrine and standards
                          be revised to implement scenario-based training, risk management, and other higher order
                          pilot skills.

                          Page 27                                                  GAO-13-36 General Aviation Safety
                           standards for pilots. 43 The rulemaking committee focused on the certified
                           flight instructor, private pilot, instrument rating, and commercial pilot
                           certificates. It made nine recommendations to FAA to enhance the pilot-
                           testing and pilot-training processes. The recommendations included
                           establishing a stakeholder body to assist in the development of
                           knowledge test questions and handbook content as well as transitioning
                           to a single testing standard document for the knowledge test. FAA
                           concurred with most of the rulemaking committee’s recommendations.

                           To increase its focus on certified flight instructors, FAA is reviewing
                           certified flight instructor recurrent training and renewal requirements. FAA
                           also updated the advisory circular on flight instructor courses and
                           published it in September 2011. 44

                           The FAASTeam’s voluntary WINGS pilot proficiency program is being
                           revamped to encourage more participation. 45 An FAA-established industry
                           group has been surveying pilots to determine what changes need to be
                           made to the WINGS program. Once the survey is completed, the resulting
                           data will be analyzed and recommendations for changes will be made by
                           the end of fiscal year 2012. FAA officials anticipate implementing changes
                           to the program as funding becomes available in fiscal year 2013.

The 5-Year Strategy Has    FAA’s 5-year strategy to improve general aviation safety suffers from
Significant Shortcomings   several shortcomings that hinder its potential for success. First, senior
                           FAA officials acknowledged that there are no specific performance goals
                           or measures 46 for the activities under the 5-year strategy. The officials
                           said that because the goal of the initiative, as a whole, is to change
                           general aviation culture, the strategy’s success will be measured through
                           changes in the general aviation fatal accident rate. They also indicated
                           that they are developing validation metrics as each phase of the plan is

                            We reported on pilot training in November 2011. See GAO-12-117.
                            AC 61-83G, Nationally Scheduled FAA-Approved Industry-Conducted Flight Instructor
                           Refresher Course, Sept. 30, 2011.
                             Pilots who participate in and satisfactorily complete a current phase of the WINGS
                           program can credit satisfactory completion to meet the biennial flight review requirements
                           of 14 C.F.R. § 61.56(e).
                             Performance measurement is the ongoing monitoring of accomplishments, particularly
                           progress toward established goals.

                           Page 28                                                 GAO-13-36 General Aviation Safety
implemented. However, successful results-oriented organizations
measure their performance at each organizational level by developing
performance measures. Without performance goals or measures for the
individual initiatives implemented under the 5-year strategy, FAA will not
be able to evaluate the success or failure of those activities, regardless of
whether the fatal accident rate is reduced. Further, FAA has yet to meet
its annual target for the general aviation fatal accident rate goal and may
not meet the overall goal by 2018. Therefore, it is even more crucial that
FAA determine whether these activities have been successful.

Second, the strategy was developed without the initial input of significant
stakeholders—the GAJSC and the general aviation industry. Successful
agencies we have studied based their strategic planning, to a large
extent, on the interests and expectations of their stakeholders, and
stakeholder involvement is important to ensure that agencies’ efforts and
resources are targeted at the highest priorities. 47 According to officials
from the GAJSC and the general aviation industry groups we contacted,
although they were briefed on the strategy, they were not consulted in its
development and were surprised by the announcement of the strategy.
General aviation industry trade groups, type clubs, and other
organizations are active in promoting a safety culture and continuous
education among their members. For example, AOPA offers numerous
seminars each year to educate the pilot community, and EAA offers
advisory programs for experimental aircraft builders and pilots. Further,
many initiatives are joint efforts of FAA and the industry. Involving
stakeholders in strategic planning efforts can help create a basic
understanding among the stakeholders of the competing demands that
confront most agencies, the limited resources available to them, and how
those demands and resources require careful and continuous balancing.
FAA officials have indicated that their initial publication of the strategy
served as a “straw man” for obtaining industry’s input and that there has
been industry acceptance of the strategy as demonstrated by various
industry groups’ development of plans and programs supporting the
strategy. However, a lack of industry input into the development and
announcement of the strategy jeopardizes its prospects for acceptance
and success. This may be indicated in the current perspective of two

 GAO, Executive Guide: Effectively Implementing the Government Performance and
Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1996).

Page 29                                            GAO-13-36 General Aviation Safety
                            industry groups—which is that the best use of industry resources to
                            improve general aviation safety is through the work of the GAJSC.

                            Third, the FAASTeam, which will be the main vehicle for promoting the 5-
                            year strategy to the industry, lacks the confidence of two significant
                            general aviation industry stakeholders we interviewed, and its
                            reorganization has not been completed. These industry stakeholders
                            indicated that there is inconsistency in the focus of the FAASTeam. One
                            stakeholder noted that industry “struggles to understand the role of the
                            FAASTeam,” and the other stated that the FAASTeam is “well
                            intentioned, but unfocused.” In addition, FAA initially planned to
                            reorganize the FAASTeam to reduce the number of volunteers to a strong
                            core group and to include a national FAASTeam located in Washington,
                            D.C. However, a senior FAA official recently indicated that the
                            restructuring of the FAASTeam is in flux and that the plan to reduce the
                            number of volunteers to a strong core group does not begin until 2013.
                            We believe that until there is a strong performance management
                            structure, input and buy-in from industry, and a respected and organized
                            FAASTeam, the effectiveness of the 5-year strategy will be in jeopardy.

FAA Has Other Initiatives   •   Formed a rulemaking committee to recommend revisions to the small
Under Way That Could            airplane airworthiness standards: In August 2011, FAA chartered a
                                rulemaking committee to reorganize part 23—which promulgates
Also Contribute to              airworthiness standards for small airplanes—according to airplane
Improved General Aviation       performance and complexity criteria as opposed to the traditional
Safety                          criteria of airplane weight and propulsion. The goals of this rulemaking
                                committee include increasing safety and decreasing certification
                                costs. Co-chaired by the manager of FAA’s Small Airplane
                                Directorate, the rulemaking committee includes members
                                representing other sections of the Aircraft Certification and Flight
                                Standards Services as well as members from industry groups,
                                manufacturers, and foreign aviation authorities. The committee is
                                expected to complete its work by the summer of 2013.

                            •   Encouraging adoption of a safety management system (SMS): In
                                guidance issued in April 2011, FAA encouraged general aviation

                            Page 30                                        GAO-13-36 General Aviation Safety
    business and corporate operators to develop and implement SMS. 48
    FAA has also supported NBAA’s promotion of single-pilot resource
    management, an SMS tool that teaches pilots to manage all available
    resources to ensure a successful flight. However, as we noted
    previously, personal operations continue to comprise the highest
    proportion of general aviation accidents, and as our current analysis
    shows, the majority is caused by pilot error. Therefore, it seems that
    FAA’s focus on business operators is misplaced. A senior FAA official
    admitted that though FAA has incorporated some parts of single-pilot
    resource management into the practical test standards and flight
    reviews, it had not yet focused on SMS for general aviation operators.
    He contended that SMS is a challenge that necessitates a strong
    outreach effort showing that general aviation can benefit from it.

•   Providing funding to develop a system for reporting aircraft issues:
    FAA’s Small Airplane Directorate has sponsored a project by Wichita
    State University to develop type club service information-sharing
    systems. The goal of the project is to share information among a
    targeted population of general aviation aircraft owners to prevent
    accidents and improve safety. Wichita State has collaborated with a
    large, well-organized type club, ABS, to develop the first reporting
    system. The ABS system will be accessed through the club’s web
    site, and a moderator will review and approve entries. Once the
    system is in place, ABS will control the data that are generated, and
    FAA will not have direct access to the data. According to Wichita
    State officials, the intent is for aircraft owners to sort through the
    information reported to determine whether their own aircraft have
    similar problems and, if so, report them to the system. There are
    currently no plans to evaluate the results of the system.

•   Funding university research on general aviation issues: FAA’s Center
    for General Aviation Research (CGAR) was formed in 2001 to

  An SMS is a data-driven, risk-based safety approach that involves establishing the
necessary organizational structures, accountabilities, policies, and procedures. We
published a report in September 2012 on our assessment of FAA’s shift to SMS. See
Aviation Safety: Additional FAA Efforts Could Enhance Safety Risk Management,
GAO-12-898 (Washington, D.C.: Sept. 12, 2012).

Page 31                                                GAO-13-36 General Aviation Safety
     supplement FAA’s general aviation safety research. 49 Researchers
     from the six universities that comprise CGAR are studying and
     proposing solutions for a variety of general aviation issues—including
     the lack of robust general aviation activity data, flight risk analysis,
     and flight data monitoring. CGAR is awarded funding through a
     biannual process in which FAA offices identify and prioritize a list of
     projects, and the FAA Technical Center awards the projects to CGAR
     or other research entities and conducts project oversight. According to
     FAA officials, CGAR is an attractive choice for research projects
     because it is required to match FAA project awards dollar-for-dollar
     with funds from other sources. CGAR has been awarded about $20
     million since its inception. However, CGAR officials have noted that
     their efforts are hindered by changing leadership within FAA, the
     uncertainty of FAA funding, the need for more FAA sponsors, and the
     matching requirement.

•    Provided new technology to reduce accidents in Alaska: The
     Capstone and Weather Camera programs in Alaska have contributed
     to increased aviation safety in that state because its dependence on
     aviation and unusual weather conditions make it more susceptible to
     fatal aviation accidents than other states. In 1999, FAA, in conjunction
     with the industry and the State of Alaska, established Capstone to
     improve aviation safety and efficiency by putting cost-effective new
     avionics equipment (e.g., Global Positioning System) into aircraft and
     on the ground. Capstone was also intended to demonstrate certain
     capabilities for potential use in the rest of the national airspace
     system. The demonstration areas lacked radar, and most of the air
     carrier operations were limited to visual flight rules (VFR). 50 Capstone
     began in Southwest and Western Alaska and was successful in
     reducing those areas’ aircraft accidents by 40 percent. Since fiscal

  The following universities comprise CGAR: Embry-Riddle Aeronautical University
(administrator), University of Alaska, University of North Dakota, and Wichita State
University. Florida A&M and Middle Tennessee State Universities are affiliates. FAA
announced on September 27, 2012, that it had selected a team of universities to lead a
new Center of Excellence for general aviation since CGAR has nearly completed its 10-
year term. The new group, called the Partnership to Enhance General Aviation Safety,
Accessibility and Sustainability (PEGASAS), will be led by Purdue, Ohio State, and
Georgia Tech. The core team will also include the Florida Institute of Technology, Iowa
State University, and Texas A&M. There are an additional 10 affiliate universities.
  Visual flight rules govern the procedures for conducting flight under visual conditions, as
opposed to instrument flight rules, which govern the procedures for conducting flights
using instruments.

Page 32                                                   GAO-13-36 General Aviation Safety
                                year 2007, the Weather Camera Program has funded the
                                procurement and installation of 182 weather camera sites in Alaska.
                                The cameras provide near real time video images of sky conditions at
                                airports, mountain passes, and strategic VFR locations, such as high-
                                use air routes, to enhance pilots’ situational awareness. According to
                                FAA, this new capability is providing measurable reductions in
                                weather-related VFR accidents in Alaska. FAA’s goal is to install a
                                total of 221 weather camera sites.

Technology and Equipment   According to FAA, new technologies such as inflatable restraints (air
May Also Help Improve      bags), ballistic parachutes, weather in the cockpit, angle-of-attack
General Aviation Safety    indicators, and terrain avoidance equipment could significantly reduce
                           general aviation fatalities. Angle of attack indicators and inflatable
                           restraints have the greatest likelihood of significantly improving safety.
                           Angle-of-attack indicators provide the pilot with a visual aid to prevent
                           loss of control of the aircraft. Previously, cost and complexity of indicators
                           limited their use to the military and commercial aircraft. FAA has
                           streamlined the approval of angle-of-attack indicators for general aviation
                           aircraft and is working to promote the retrofit of the existing fleet. FAA is
                           also streamlining the certification and installation of inflatable restraints
                           with the goal of making all general aviation aircraft eligible for
                           installation. 51 Further, FAA is working with manufacturers to define
                           equipage requirements and support the Next Generation Air
                           Transportation System (NextGen)—a new satellite-based air traffic
                           management system that by 2025 will replace the current radar-based
                           system—by streamlining the certification and installation of NextGen
                           technologies. Some industry experts told us, however, that there might
                           not be future opportunities to significantly improve general aviation safety
                           with the aid of technology since most accidents are still attributed to pilot

                           To further reduce the number of fatal general aviation accidents, FAA
Conclusions                needs to effectively target its accident mitigations, as it is attempting to do
                           through the GAJSC. The agency’s ability to do so, however, is limited by

                             In a January 2011 report, NTSB concluded that aviation airbags can mitigate occupant
                           injuries in severe but survivable crashes in which the principal direction of force is
                           longitudinal. NTSB made several recommendations to FAA to enhance the safety of and
                           information about airbag use in aircraft. See NTSB, Airbag Performance in General
                           Aviation Restraint Systems, NTSB/SS-11/01, Washington, D.C.: Jan. 11, 2011.

                           Page 33                                               GAO-13-36 General Aviation Safety
a lack of pilot data. For instance, FAA does not maintain certain key
information about general aviation pilots, including how many are actively
flying each year and whether they participate in recurrent training other
than FAA’s own WINGS program. Without this information, FAA cannot
determine the potential effect of the various sources and types of training
on pilot behavior, competency, and the likelihood of an accident. The lack
of pilot data also makes it difficult to identify the root causes of accidents
attributed to pilot error and determine appropriate risk mitigation

The annual survey FAA uses for collecting general aviation flight-activity
data suffers from significant limitations—limitations that call into question
the resulting activity estimates FAA produces as well as the accident
rates calculated by NTSB. Though FAA has improved the survey over the
years, our concerns remain because the survey continues to experience
response rates below 50 percent and relies on the record-keeping habits
and memories of survey respondents who sometimes have to recall
details that occurred more than 12 months earlier. Further, other methods
for obtaining general aviation flight-activity data have encountered
resistance from the industry. Without a more accurate reporting of general
aviation flight activity, such as requiring the reporting of flight hours at
certain intervals—e.g., during registration renewals or annual
maintenance inspections—FAA lacks assurance that it is basing its policy
decisions on a true measure of general aviation trends, and NTSB lacks
assurance that its calculations of accident and fatality rates accurately
represent the state of general aviation safety.

Given the diversity of the general aviation community—illustrated, for
example by the wide variety of aircraft in the fleet and the varying nonfatal
and fatal accident rates among the general aviation segments, the
adoption of a singular agency goal–-a 10 percent reduction in the general
aviation fatal accident rate per 100,000 flight hours by 2018 is not the
most effective risk-based tool for achieving general aviation safety gains.
The goal does not take into account the variety of general aviation
operations or the risks associated with each. For example, one hour flown
during a personal operation is not the same as one hour flown during a
corporate operation. Also, economic conditions affect each segment
differently, making it difficult to discern if a change in the accident rate is
an indication of a change in the safety of the industry. If the goal is
reached, the overall success might mask ongoing safety issues in one or
more segments of the community.

Page 34                                          GAO-13-36 General Aviation Safety
                      FAA officials have indicated that the success of the 5-year strategy—
                      which is composed of numerous initiatives—will be measured through
                      changes in the general aviation fatal accident rate. However, successful
                      results-oriented organizations measure their performance at each
                      organizational level by developing performance measures. For this
                      reason, we think it is important for FAA to develop performance measures
                      for the significant initiatives underlying the 5-year strategy. This is
                      important because if FAA does not measure the performance of the
                      significant underlying initiatives, it will not be able to determine whether
                      the initiatives were effective in their own right. In addition, in order for the
                      FAASTeam to be successful in its promotion of the 5-year strategy, it
                      must be well respected within the general aviation community. We are not
                      making a recommendation regarding the FAASTeam at this time since
                      plans for restructuring it are in flux and its volunteer force realignment is
                      not scheduled to begin until 2013.

                      To enhance FAA’s efforts to improve general aviation safety, we
Recommendations for   recommend that the Secretary of Transportation direct the FAA
Executive Action      Administrator to take the following four actions:

                      •   To expand the data available for root cause analyses of general
                          aviation accidents and other purposes, collect and maintain data on
                          each certificated pilot’s recurrent training, and update the data at
                          regular intervals.

                      •   Improve measures of general aviation activity by requiring the
                          collection of the number of hours that general aviation aircraft fly over
                          a period of time (flight hours). FAA should explore ways to do this that
                          minimize the impact on the general aviation community, such as by
                          collecting the data at regular events (e.g., during registration renewals
                          or at annual maintenance inspections) that are already required.

                      •   To ensure that ongoing safety issues are addressed, set specific
                          general aviation safety improvement goals—such as targets for fatal
                          accident reductions—for individual industry segments using a data-
                          driven, risk management approach.

                      •   To determine whether the programs and activities underlying the 5-
                          year strategy are successful and if additional actions are needed,
                          develop performance measures for each significant program and
                          activity underlying the 5-year strategy.

                      Page 35                                          GAO-13-36 General Aviation Safety
                  We provided the Department of Transportation (DOT) with a draft of this
Agency Comments   report for review and comment. DOT officials agreed to consider our
                  recommendations and provided technical comments, which we
                  incorporated as appropriate.

                  We are sending copies of this report to the appropriate congressional
                  committees, the Secretary of Transportation, the Chairman of NTSB, and
                  interested parties. In addition, this report is available at no charge on the
                  GAO Web site at http://www.gao.gov.

                  If you or your staff members 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 II.

                  Gerald L. Dillingham, Ph.D.
                  Director, Physical Infrastructure Issues

                  Page 36                                         GAO-13-36 General Aviation Safety
Appendix I: Scope and Methodology
             Appendix I: Scope and Methodology

             Our objective was to conduct a comprehensive review of general aviation
             safety. To do so, we addressed the following questions: (1) what are the
             characteristics and trends in general aviation accidents from 1999 to 2011
             and (2) what actions have been taken by the Federal Aviation
             Administration (FAA) to improve general aviation safety?

             To identify the characteristics of and trends in general aviation accidents,
             we conducted a data analysis using the National Transportation Safety
             Board’s (NTSB) Aviation Accident Database. We limited our analysis to
             accidents involving airplanes operating under Part 91 of the Federal
             Aviation Regulations that occurred from January 1, 1999, through
             December 31, 2011, in the U.S. We excluded accidents that occurred in
             U.S. territories, possessions, and international waters. To assess the
             reliability of the NTSB data, we reviewed documentation on data
             collection efforts and quality assurance processes, talked to
             knowledgeable NTSB officials about the data, and checked the data for
             completeness and reasonableness. We determined that these data were
             sufficiently reliable for the descriptive and comparative analyses used in
             this report. To supplement our analysis of the NTSB accident data, we
             also analyzed FAA’s general aviation flight-hour estimates for 1999
             through 2010 and estimated active pilot data for 2011. To assess the
             reliability of these data, we reviewed documentation on data collection
             efforts and quality assurance processes and talked to knowledgeable
             FAA officials. In assessing the reliability of the flight-hour estimates, we
             also spoke with the contractors responsible for executing the survey that
             yielded these estimates, the General Aviation and Part 135 Survey. We
             determined that the flight-hour data and the active pilot data were
             sufficiently reliable for the purposes of this engagement. Specifically,
             these data elements were sufficiently reliable to provide meaningful
             context for the numbers and characteristics of accidents that we report.
             However, we also determined that because of the methodological
             limitations identified—a low response rate and the potential for
             nonresponse bias—the flight-hour estimates developed from the General
             Aviation and Part 135 Survey may not have the precision necessary to
             measure small changes in the general aviation accident rate over time.

             To identify actions FAA and others have taken to improve general
             aviation safety, we reviewed our prior reports as well as documents and
             reports from FAA, NTSB, NASA, and general aviation industry trade and
             other groups, including the Aircraft Owners and Pilots Association
             (AOPA), the Experimental Aircraft Association (EAA), and the Society of
             Aviation and Flight Educators (SAFE); FAA orders, notices, advisory
             circulars; and applicable laws and regulations. We also determined the

             Page 37                                         GAO-13-36 General Aviation Safety
Appendix I: Scope and Methodology

roles and responsibilities of FAA and NTSB in collecting and reporting
general aviation safety data. In addition to interviewing officials from the
various FAA offices and divisions responsible for general aviation safety,
we interviewed aviation experts affiliated with various aviation industry
organizations. (See table 4.)

Table 4: Aviation Industry Organizations Interviewed for This Study

Aviation technology developer
Educational organization
Society of Aviation and Flight Educators (SAFE)
Employee organization
Professional Aviation Safety Specialists (PASS)
Trade groups
Aviation Insurance Association (AIA)
Aircraft Owners and Pilots Association (AOPA)
Experimental Aircraft Association (EAA)
General Aviation Manufacturer’s Association (GAMA)
National Business Aviation Association (NBAA)
Embry-Riddle Aeronautical University
Wichita State University
Source: GAO.

To obtain additional insight into the general aviation industry, we attended
the September 2011 AOPA Aviation Summit in Hartford, Connecticut; the
March 2012 Annual FAA Aviation Forecast Conference in Washington,
D.C.; the February 2012 Northwest Aviation Conference in Puyallup,
Washington; and the June 2012 NTSB General Aviation Forum in
Washington, D.C.

Page 38                                              GAO-13-36 General Aviation Safety
Appendix II: GAO Contact and Staff
                  Appendix II: GAO Contact and Staff


                  Gerald L. Dillingham, Ph.D., (202) 512-2834 or dillinghamg@gao.gov
GAO Contact
                  In addition to the contact named above, the following individuals made
Staff             important contributions to this report: H. Brandon Haller, Assistant
Acknowledgments   Director; Pamela Vines; Jessica Wintfeld; Russ Burnett; Bert Japikse;
                  Delwen Jones; Josh Ormond; and Jeff Tessin.

                  Page 39                                      GAO-13-36 General Aviation Safety
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