Aviation Safety and Security: Challenges to Implementing the Recommendations of the White House Commission on Aviation Safety and Security

Published by the Government Accountability Office on 1997-03-05.

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

                   United States General Accounting Office

GAO                Testimony
                   Before the Subcommittee on Aviation, Committee on
                   Commerce, Science and Transportation, U.S. Senate

For Release
on Delivery
Expected at
                   AVIATION SAFETY AND
10 a.m. EST
Wednesday          SECURITY
March 5, 1997

                   Challenges to Implementing
                   the Recommendations of
                   the White House
                   Commission on Aviation
                   Safety and Security
                   Statement by Gerald L. Dillingham,
                   Associate Director, Transportation Issues,
                   Resources, Community, and Economic Development

                  Mr. Chairman and Members of the Subcommittee:

                  We appreciate the opportunity to share our views on the
                  recommendations contained in the recently released report of the White
                  House Commission on Aviation Safety and Security. The Commission’s 57
                  recommendations broadly cover safety, security, air traffic control, and
                  disaster response. As you know, 1996 was a bad year for aviation safety.
                  Last year, 380 people died in air accidents involving large U.S. air carriers,
                  the highest number in 11 years. The crashes of TWA Flight 800 off New
                  York and ValuJet Flight 592 in Florida accounted for most of those deaths.
                  Although the nation’s air transportation system remains the safest in the
                  world and the Federal Aviation Administration (FAA) the model for other
                  nations, these tragic events have served to raise the Congress’s, the
                  administration’s, the aviation industry’s, and the flying public’s
                  consciousness of the need to continuously increase the existing margin of

                  During the past several years, we have reported to the Congress on the
                  status of a wide range of programs and initiatives intended to expand that
                  margin of safety. Our testimony this morning, based on this prior work and
                  on an analysis of the Commission’s recommendations, will focus on the
                  implementation issues relating to three areas addressed by the
                  Commission: aviation safety, air traffic control modernization, and
                  aviation security.

                  We believe that the Commission’s recommendations are a good start
                  toward an evolutionary process of making real the Commission’s vision of
                  ensuring greater safety and security for passengers, restructuring the
                  relationships between the government and the industry, and maintaining
                  America’s position of global leadership in aviation. However, key
                  questions remain about how and when the recommendations will be
                  implemented, how much it will cost to implement them, and who will pay
                  the cost. Our message this morning focuses on the challenges that lie
                  ahead in taking the next steps to convert the Commission’s
                  recommendations from concepts to realities.

                  The Commission made 14 recommendations in the general area of aviation
Aviation Safety   safety. Foremost among these is establishing a national goal to reduce the
                  fatal accident rate by 80 percent within 10 years. This is a very challenging
                  goal, particularly in the light of the projected increases in the amount of
                  air traffic in the coming decade.

                  Page 1                               GAO/T-RCED-97-90 Aviation Safety and Security
We applaud the Commission’s adopting such a goal for accident reduction
and endorse many of its recommendations for improving safety. These
recommendations include, for example, expanding FAA’s inspection
program to cover not only aging aircraft’s structural integrity but also such
areas as electrical wiring, fuel lines, and pumps. A number of these
recommendations resonate with safety and efficiency improvements that
we and others, including FAA, have suggested over the years.1 However, we
believe that, as FAA tries to fundamentally reinvent itself as the
Commission contemplates through some of its recommendations, FAA and
the aviation industry will be challenged in three areas: (1) FAA’s
organizational culture and resource management, (2) FAA’s partnerships
with the airline industry, and (3) the costs of and sources of funding to
implement the recommendations.

A number of recent studies and the FAA itself have pointed to the
importance of culture in the agency’s operations. Last year, our review of
FAA’s organizational culture found that it had been an underlying cause of
the agency’s persistent acquisition problems, including substantial cost
overruns, lengthy schedule delays, and shortfalls in the performance of its
air traffic control modernization program.2 Furthermore, the lack of
continuity in FAA’s top management, including the Administrator and some
senior executive positions, has fostered an organizational culture that has
tended to avoid accountability, focus on the short term, and resist
fundamental improvements in the acquisitions process.

Similarly, a 1996 report issued by the Aviation Foundation and the
Institute of Public Policy stated that the recent actions taken to reorganize
FAA have done nothing to change the long-term structural problems that
plague the organization.3 The study concluded that FAA does not have the
characteristics to learn and that its culture does not recognize or serve any
client other than itself.

As FAA’s own 1996 report entitled Challenge 2000 points out, it will take
several years to overcome the many cultural barriers at FAA, determine the

 For example, see Aviation Safety: New Airlines Illustrate Long-Standing Problems in FAA’s Inspection
Program (GAO/RCED-97-2, Oct. 17, 1996); Aviation Safety: Targeting and Training of FAA’s Safety
Inspector Workforce (GAO/T-RCED-96-26, Apr. 30, 1996); and Aircraft Maintenance: FAA Needs to
Follow Through on Plans to Ensure the Safety of Aging Aircraft (GAO/RCED-93-91, Feb. 26, 1993).
 Aviation Acquisition: A Comprehensive Strategy Is Needed for Cultural Change at FAA
(GAO/RCED-96-159, Aug. 22, 1996).
  Why Can’t the Federal Aviation Administration Learn? Creating a Learning Culture at the FAA, the
Aviation Foundation, Falls Church, Virginia and the Institute of Public Policy, George Mason
University, Fairfax, Virginia (July 10, 1996).

Page 2                                          GAO/T-RCED-97-90 Aviation Safety and Security
skill mix of the workforce of the 21st century, and recruit the necessary
talent in a resource-constrained environment.4 In the light of these studies’
results, we would caution that the organizational and cultural changes
envisioned by the Commission may require years of concerted effort by all
parties concerned.

In connection with resource management, FAA’s fiscal year 1998 budget
request reveals some difficult choices that may have to be made among
safety-related programs. For example, FAA proposes increasing its safety
inspection workforce by 273 persons while decreasing some programs for
airport surface safety, including a program designed to reduce runway
incursions. The National Transportation Safety Board has repeatedly
included runway incursions on its annual lists of its “most wanted” critical
safety recommendations. FAA’s budget request includes a reduction in the
Runway Incursion program from $6 million in fiscal year 1997 to less than
$3 million in fiscal year 1998. Although FAA set a goal in 1993 to improve
surface safety by reducing runway incursions by 80 percent by the year
2000 from the 1990 high of 281, the results have been uneven; there were
186 runway incursions in 1993 and 246 in 1995. As was shown by the
November 1994 runway collision in St. Louis, Missouri, between a
commercial carrier and a private plane, such incidents can have fatal
consequences—2 people lost their lives. It is unclear what progress will be
made in this area, given the proposed budget cuts.

Similarly, we have reported since 1987 that the availability of complete,
accurate, and reliable FAA data is critical to expanding the margin of
safety.5 However, funding for FAA’s National Aviation Safety Data Analysis
Center, a facility designed to enhance aviation safety by the rigorous
analysis of integrated data from many aviation-related databases, is slated
to be reduced from $3.7 million in fiscal year 1997 to $2 million in fiscal
year 1998.

The Commission’s report stresses that safety improvements cannot
depend solely on FAA’s hands-on inspections but must also rely on
partnerships with the aviation industry in such areas as self-monitoring
and certification. Several programs for the airlines’ self-disclosure of
safety problems have already contributed to identifying and resolving

  Challenge 2000: Recommendations for Future Aviation Safety Regulation, prepared for FAA’s Office
of Policy, Planning, and International Aviation by Booz•Allen & Hamilton, Inc. (Apr. 1996).
  Aviation Safety: Data Problems Threaten FAA Strides on Safety Analysis System (GAO/AIMD-95-27,
Feb. 8, 1995); Department of Transportation: Enhancing Policy and Program Effectiveness Through
Improved Management (GAO/RCED-87-3, Apr. 13, 1987).

Page 3                                         GAO/T-RCED-97-90 Aviation Safety and Security
some of these types of problems.6 For example, one airline’s program for
reporting pilot events or observations—a joint effort by the airline, the
pilot union, and FAA—has identified safety-related problems, the vast
majority of which would not have been detected by relying solely on FAA
surveillance. The discovery of these problems has resulted in safety
improvements to aircraft, to the procedures followed by flight crews, and
to air traffic patterns. As the Commission has recognized, however, such
information will not be provided if its disclosure threatens jobs or results
in punitive actions. However, FAA’s role in some broader partnerships with
industry has also raised some questions. For example, FAA’s cooperative
process working with Boeing on the 777 aircraft helped enable the
manufacturer to meet the planned certification date, but FAA was also
criticized by some FAA engineers and inspectors for providing inadequate
testing of the aircraft’s design.

In the case of self-disclosure programs, decisions will have to be made on
which aviation entities are best suited to such partnership programs, how
to monitor these programs and make effective use of the data they offer,
how to balance the pressure for public disclosure against the need to
protect such information, and how to standardize and share such
information across the aviation industry. With broader cooperation
between FAA and the aviation industry, the Congress and FAA need to be on
guard that the movement toward partnerships does not compromise the
agency’s principal role as the industry’s regulator.

Finally, it is important to point out that the costs associated with achieving
the accident reduction goal and who should pay for these costs have not
yet been determined. In accordance with the Commission’s call for more
government-industry partnerships, government, the industry, and the
traveling public would likely share in these costs. For example, FAA’s
partnership programs involve significant costs for both the agency and the
industry. In the case of equipping the cargo holds of passenger aircraft
with smoke detectors, the cost would fall initially on the industry, while
the costs associated with the recommendation that children under the age
of 2 be required to have their own seats on airplanes would fall more
directly on the traveling public.

Regardless of who bears the cost of the proposed improvements, the
Commission has correctly recognized that additional safety improvements
may sometimes be difficult to justify under the benefit-cost criteria applied

 Examples of ongoing or recent partnership programs include the American Airlines Safety Action
Program for pilots as well as the USAir Inc. Altitude Awareness Program and the Alaska Airlines
Altitude Awareness Program.

Page 4                                         GAO/T-RCED-97-90 Aviation Safety and Security
                      to regulatory activities. The Commission recommended that cost not
                      always be the determining factor or basis for deciding whether to put new
                      aviation safety and security rules into effect. Specifically, the Commission
                      notes that the potential reduction in the fatal accident rate merits a careful
                      weighing of the options for improving safety in terms of the benefits that
                      go beyond those traditionally considered in benefit-cost analyses.
                      However, we also believe that it is important to recognize that the
                      recommendation (1) represents a significant departure from traditional
                      processes, (2) could result in significant cost increases for relatively
                      modest increases in the safety margin, and (3) could rest on a limited
                      empirical justification. In effect, this recommendation may increase the
                      number of instances in which the primary factor determining whether or
                      not to go forward with a safety or security improvement is what might be
                      referred to as a public policy imperative rather than the result of a
                      benefit-cost analysis. One instance of such a decision is the Commission’s
                      recommendation to eliminate the exemption in the Federal Aviation
                      Regulations that allows children under 2 to travel without the benefit of an
                      FAA-approved restraint.

                      The Commission also reviewed the modernization of the air traffic control
Air Traffic Control   (ATC) system. FAA is in the midst of a $34 billion dollar, mission-critical
Modernization         capital investment program to modernize aging ATC equipment. This
                      program includes over 100 projects involving new radars, automated data
                      processing, and navigation, surveillance, and communications equipment.
                      We believe this modernization is also important for attaining the next level
                      of safety by replacing aging equipment and providing controllers and pilots
                      with enhanced communication and better information.

                      Recognizing that new technology, such as satellite-based navigation and
                      new computers in ATC facilities and in aircraft cockpits, offers tremendous
                      advances in safety, efficiency, and cost-effectiveness for users of the ATC
                      system and for FAA, the Commission recommended accelerating the
                      deployment of this new technology. According to FAA’s current plan, many
                      of these elements would not be in place until the year 2012 and beyond.
                      However, the Commission has recommended that these technologies be in
                      place and operational by the year 2005—7 years ahead of FAA’s planned
                      schedule. The Commission’s goal is commendable, but given FAA’s past
                      problems in developing new ATC technology and the technical challenges
                      that lie ahead, there is little evidence that this goal can be achieved.

                      Page 5                               GAO/T-RCED-97-90 Aviation Safety and Security
We have chronicled FAA’s efforts to modernize the air traffic control
system for the past decade. Because of the modernization effort’s size,
complexity, cost, and past problems, we designated it as a high-risk
information technology initiative in 1995 and again in 1997.7 Many of FAA’s
modernization projects have been plagued by cost-overruns, schedule
delays, and shortfalls in performance that have delayed important safety
and efficiency benefits. We reported last year that the agency’s culture was
an underlying cause of FAA’s acquisition problems. FAA’s acquisitions were
impaired because employees acted in ways that did not reflect a strong
commitment to, among other things, the focus on and the accountability to
the modernization mission.8 More recently, we have identified other
important factors that have contributed to FAA’s difficulty in modernizing
the ATC system. For example, FAA’s lack of effective cost-estimating and
-accounting practices forces it to make billion-dollar investment decisions
without reliable information. Also, the absence of a complete systems
architecture, or overall blueprint, to guide the development and evolution
of the many interrelated ATC systems forces FAA to spend time and money
to overcome system incompatibilities.9

We agree with the Commission’s recommendations to integrate the
airports’ capacity needs into the ATC modernization effort and to enhance
the accuracy, availability, and reliability of the Global Positioning System.
However, we have two concerns about accelerating the entire
modernization effort that focus on the complexities of the technology and
the integrity of FAA’s acquisition process. First, the complexity of
developing and acquiring new ATC technology—both hardware and
software—must be recognized. The Commission contends that new ATC
technology to meet FAA’s requirements is available “off-the-shelf.”
However, FAA has found that significant additional development efforts
have been needed to meet the agency’s requirements for virtually all major
acquisitions over the past decade. More recently, two new major contracts
for systems—the Standard Terminal Automation Replacement System and

High-Risk Series: An Overview (GAO/HR-95-1, Feb. 1995); and High-Risk Series: Information
Management and Technology (GAO/HR-97-9, Feb. 1997).
 Aviation Acquisition: A Comprehensive Strategy Is Needed for Cultural Change at FAA
(GAO/RCED-96-159, Aug. 1996).
 Air Traffic Control: Improved Cost Information Needed to Make Billion Dollar Modernization
Investment Decisions (GAO/AIMD-97-20, Jan. 1997); and Air Traffic Control: Complete and Enforced
Architecture Needed for FAA Systems Modernization (GAO/AIMD-97-30, Feb. 1997).

Page 6                                         GAO/T-RCED-97-90 Aviation Safety and Security
                    the Wide Area Augmentation System—called for considerable
                    development efforts.10

                    Second, requiring FAA to spend at an accelerated rate could prove to be
                    inconsistent with the principles of the agency’s new Acquisition
                    Management System, established on April 1, 1996, in response to the
                    legislation freeing it from most federal procurement laws and regulations.11
                     FAA’s acquisition management system calls for FAA to go through a
                    disciplined process of (1) defining its mission needs, (2) analyzing
                    alternative technological and operational approaches to meeting those
                    needs, and (3) selecting only the most cost-effective solutions. Until FAA
                    goes through this analytical and decision-making process, it is premature
                    to predict what new technology FAA should acquire. For example, FAA itself
                    points out that while satellite communications that link the
                    communication and navigation functions offer tremendous potential
                    benefits, the technology is not yet mature enough for civil
                    aviation—significant development is needed to determine the
                    requirements and operational concepts of the technology. In this
                    particular case, accelerating the ATC modernization too much could
                    increase the risk that FAA will make poor investment decisions. Overall,
                    our message in this area is one of caution—accelerating the entire
                    modernization effort will have to overcome a long history of problems that
                    FAA’s new acquisition management system was designed to address and a
                    number of obstacles.

                    Aviation security is another component of ensuring the safety of
Aviation Security   passengers. It rests on a careful mix of intelligence information,
                    procedures, technology, and security personnel. The Commission strongly
                    presented aviation security as a national security priority and
                    recommended that the federal government commit greater resources to
                    improving it. Many of the Commission’s 31 recommendations on security

                     The Standard Terminal Automation Replacement System project is expected to replace the aging
                    computers and related equipment used at the FAA facilities that track aircraft in the airspaces
                    surrounding airports. The Wide Area Augmentation System project is refining the use of the Global
                    Positioning System to meet the requirements of civil aviation.
                      Public Law 104-50, section 348.

                    Page 7                                          GAO/T-RCED-97-90 Aviation Safety and Security
are similar to those that we have made in previous reports.12 For example,
the Commission urged FAA to deploy commercially available systems for
detecting explosives in checked baggage at U.S. airports while also
continuing to develop, evaluate, and certify such equipment. Similarly, the
Commission echoed our recommendation that the government and the
industry focus their safety and security research on the human factors
associated with using new devices, especially on how operators will work
with new technology. The Committee’s recommendations address a
number of long-standing vulnerabilities in the nation’s air transportation
system, such as (1) the screening of checked and carry-on baggage, mail,
and cargo and (2) unauthorized individuals gaining access to an airport’s
critical areas. Many of the 20 initial security recommendations that the
Commission made on September 9, 1996, are already being implemented
by the airlines or by government agencies.

We found, however, that in the past FAA has had difficulty in meeting some
of the time frames for implementing the safety improvements
recommended by GAO and the Department of Transportation (DOT)
Inspector General.13 Similarly, in the security area, FAA has also had
problems meeting the implementation time frames. For example, FAA is
just beginning to purchase explosives-detection systems to deploy at U.S.
airports, although the Aviation Security Improvement Act of 1990 set an
ambitious goal for FAA to have such equipment in place by November 1993.
This delay was due primarily to the technical problems slowing the
development and approval of the explosives-detection devices. But we
also found that FAA did not develop an implementation strategy to set
milestones and realistic expectations or to identify the resources to guide
the implementation efforts. It is important that FAA sustain the momentum
generated by the Commission’s report and move forward systematically to
implement its recommendations.

Finally, although the Commission concluded that many of its proposals
will require additional funding, it did not specifically recommend funding
levels for new security initiatives over the long term. Instead, the
Commission recommended that the federal government devote at least

 See, for example, Aviation Security: Additional Actions Needed to Meet Domestic and International
Challenges (GAO/RCED-94-38, Jan. 27, 1994); Aviation Security: Development of New Security
Technology Has Not Met Expectations (GAO/RCED-94-142, May 19, 1994); Aviation Security:
Technology’s Role in Addressing Vulnerabilities (GAO/T-RCED/NSIAD-96-262, Sept. 19, 1996); Aviation
Security: Immediate Action Needed to Improve Security (GAO/T-RCED/NSIAD-96-237, Aug. 1, 1996);
and Aviation Security: Urgent Issues Need to be Addressed (GAO/T-RCED/NSIAD-96-251, Sept. 11,
 Aviation Safety: FAA Generally Agrees With but Is Slow in Implementing Safety Recommendations
(GAO/RCED-96-193, Sept. 23, 1996).

Page 8                                         GAO/T-RCED-97-90 Aviation Safety and Security
           $100 million annually to meet security capital requirements—leaving the
           decision on how to fund the remaining security costs to the National Civil
           Aviation Review Commission. The National Civil Aviation Review
           Commission is charged with looking at FAA funding issues, and we do not
           want to preempt its report and recommendations. But, for example, the
           $144.2 million appropriated by the Congress in 1997 for new security
           technology represents a fraction of the estimated billions of dollars
           required to enhance the security of air travel. To improve aviation security,
           the Congress, the administration, and the aviation industry need to agree
           on what to do and who will pay for it—and then to take action.

           In closing, Mr. Chairman, we face a turning point. The public’s concern
           about aviation safety and security has been heightened. The Congress and
           the administration have a renewed commitment to addressing this urgent
           national concern. The Commission’s work is a good start toward an
           evolutionary process of reaching agreement on the goals and steps to
           improve aviation safety and security. To guide the implementation of the
           Commission’s recommendations, DOT and FAA will need a comprehensive
           strategy that includes (1) clear goals and objectives, (2) measurable
           performance criteria to assess how the goals and objectives are being met,
           and (3) a monitoring, evaluation, and reporting system to periodically
           evaluate the implementation. This strategy could serve as a mechanism to
           track progress and establish the basis for determining funding trade-offs
           and priorities. In addition, successful implementation will require strong,
           stable leadership at DOT and at FAA. Although several complex questions
           remain unanswered, we hope that the Commission’s work can serve as a
           catalyst for change and a strengthened commitment to resolving these
           challenges to improving safety.

           This concludes my prepared statement. We would be glad to respond to
           any questions that you and Members of the Committee might have.

(341527)   Page 9                              GAO/T-RCED-97-90 Aviation Safety and Security
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