APPENDIX A List of Findings and Recommendations
A complete list of the committee's findings and recommendations appears below in the order they appear in the body of the report.
CHAPTER 3 Causes of Incidents and Accidents
Finding 3-1. Safety management processes that focus on the primary causes of accidents are reactive and are unlikely to address some important cause factors adequately. Data from investigations of accidents and incidents are essential for planning proactive corrective action, which should address all important cause factors.
CHAPTER 4 Recommended Safety Management Process
The Major Finding. The recommended safety management process should improve the ability of the FAA/AIR, manufacturers, and operators to take corrective action based on assessments of incident data—before an accident takes place—and to set priorities based on current and future risk. However, the current process is already highly effective— as indicated by the small contribution of aircraft system malfunctions to the overall accident rate—and changes to the current system must be carefully structured to avoid unintended consequences that might reduce safety in some situations.
Major Recommendation 1. It is critically important that the FAA and AIR conduct business in a new fashion with regard to aircraft certification and continued airworthiness. As an essential first step, AIR should revise its budget and manpower allocations to better reflect its mission priorities, which are as follows:
continued airworthiness and other activities related to continued operational safety
rulemaking and policy development
Major Recommendation 2. It is essential that the FAA improve its safety management process. The FAA should work with the operators and manufacturers of large transport airplanes and engines to define and implement a proactive process that includes the following elements and tasks:
Manufacturers, with the advice and consent of operators and the FAA, should define data requirements and processes for sharing data. Comprehensive flight operations quality assurance systems similar to the British Airways Safety Information System (BASIS) should be used as a starting point.
Operators should provide required data, as agreed upon.
Manufacturers should solicit data from additional sources, such as the National Transportation, Safety Board, International Civil Aviation Organization, and National Aeronautics and Space Administration, to augment the operational database.
Manufacturers, with oversight from the FAA and the assistance of operators, as required, should collect, organize, and analyze data to identify potential safety problems.
Manufacturers should recommend corrective action for potential safety problems and seek consensus by operators. The FAA should make sure that actions proposed
by manufacturers and operators will be effective, making regulatory changes and mandating compliance as appropriate.
Manufacturers and operators, with oversight from the FAA, should monitor the effectiveness of corrective action and the safety management process.
Recommendation 4-1. In parallel with efforts to make appropriate regulatory changes, the FAA should expeditiously negotiate binding letters of agreement with manufacturers and operators to implement as much of the recommended safety management process as possible.
Recommendation 4-2. As the recommended safety management process is implemented, the FAA should eliminate internal efforts to collect and store data for aircraft manufactured by companies with whom agreements have been reached in accordance with Recommendation 4-1. Resources currently used for those purposes should be redirected to AIR's other safety-related functions.
Recommendation 4-3. Manufacturers should establish aviation safety database management systesms (DBMS) using the state-of-the-art data management technologies that are best suited to continued airworthiness applications. The most suitable type of DBMS currently available is the object-relational DBMS.
Recommendation 4-4. Consistent with regulatory procedures, the FAA should develop a more accurate methodology for assessing the costs and benefits of potential air-worthiness directives and other rulemaking actions. In particular, the FAA should work with industry to develop commonly accepted models for estimating time and cost.
Recommendation 4-5. To eliminate the regulatory backlog and the ambiguities about implementing airworthiness actions of foreign regulatory authorities, the FAA should expeditiously determine what regulatory action, if any, it will propose in response to foreign airworthiness actions. The FAA should initiate its regulatory response no later than two weeks after receiving notice of a foreign airworthiness action.
Major Recommendation 3. AIR should promote aircraft safety by certifying the competency of applicants' design organizations rather than relying on the FAA's ability to detect design deficiencies through spot checks. The FAA should work with industry and Congress to obtain legislative and regulatory authority in a timely fashion to do the following:
Certificate and rate approved design organization (ADOs) and invest them with the responsibility for ensuring that applications for type certificates, type certificate amendments, supplemental type certificates, technical standard order authorizations, and parts manufacturer approvals comply with applicable airworthiness standards. ADOs would be required to have the technical capabilities necessary for competently approving designs only within the limitations of their rating.
Require ADOs and holders of production certificates to collect and analyze relevant safety data received from operators and to define corrective action in the event unsafe conditions are detected.
Require applicants for design approvals to either hold an ADO certificate or employ the services of an ADO.
As an interim step, give higher priority to the ongoing rulemaking action that would increase organizational delegation to manufacturers of large aircraft and engines under the FAA's current legislative authority. The FAA already uses this authority to grant organizational delegation to manufacturers of small aircraft and engines.
CHAPTER 5 Human Factors
Finding 5-1. Maintaining situational awareness is the key to preventing the vast majority of serious incidents and accidents associated with human error.
Major Recommendation 4. The FAA should support and accelerate efforts (1) to define the minimum data required by the flight crew to maintain adequate situational awareness during all phases of flight and reasonable emergency scenarios and (2) to determine how this data can be presented most effectively.
Recommendation 5-1. The FAA should ensure that its human factors projects, especially the FAA Human Factors Study Group, include strong representation in the fields of cognitive science and basic neuroscience.
Recommendation 5-2. Advances in understanding human factors should be quickly applied to the key task of reducing the role of human errors in incidents and accidents, particularly with regard to improving the situational awareness of operational personnel and improving the effectiveness of maintenance personnel. The FAA should strongly support its Human Factors Study Group and other projects that contribute to this task.
CHAPTER 6 Barriers
Major Recommendation 5. In order for AIR to contribute as much as possible to improvements in aviation safety, the FAA—in partnership with industry, Congress, the Department of Transportation, and other involved parties—must take aggressive action to overcome barriers associated with the following:
external pressures and influences faced by the FAA
coordination and communications within the FAA
the rulemaking process
the economic impact of proposed changes to the safety management process
Finding 6-1. Following some highly publicized accidents, there is a technically unjustified loss of public confidence, which leads to political pressure and a counterproductive atmosphere of crisis management in the FAA that interferes with ongoing efforts by government and industry to improve aviation safety.
Recommendation 6-1. As a first step towards reducing the negative impact of external pressure on the safety management process, the FAA should work with other responsible agencies to educate the public more fully about ongoing efforts to improve aviation safety. Fully addressing this issue is likely to require major organizational changes, such as the establishment of a senior interagency communications or safety management board, that were beyond the scope of this study.
Recommendation 6-2. The FAA should develop a process to facilitate communications and improve coordination among offices within AIR and between AIR and the Flight Standards Service. For example, the Associate Administration for Regulation and Certification could establish a central coordinating office to facilitate the exchange of continued airworthiness information within the FAA and the dissemination of complete and consistent information to industry.
Recommendation 6-3. The FAA should initiate regulatory action, legislative action (through the Congress), and/or letters of understanding with manufacturers, operators, pilot organizations, and others to serve the public interest and improve safety by encouraging the voluntary sharing of safety data. This may involve limiting enforcement action based on voluntarily shared data and protecting such data from release to other parties.
Recommendation 6-4. Efforts to reform the Aviation Rulemaking Advisory Committee (ARAC) should (1) establish more timely and effective processes and (2) encourage the assignment of industry and FAA personnel who have the expertise to develop well written notices of proposed rulemaking (NPRMs) and final rules and the influence necessary for building broad support for documents approved by the ARAC.
Finding 6-2. It quite often takes 5 to 10 years to issue new regulations or modify existing regulations. This is an important safety issue because it constrains the ability of the rulemaking process to improve aviation safety. The FAA is in the process of reforming its internal procedures, including ARAC procedures. This is a positive first step, but much more needs to be done in this area.
Recommendation 6-5. The FAA should make the rule-making process substantially more responsive by convincing the Department of Transportation, other executive branch agencies, and Congress to modify legislation, directives, and regulations to allow major changes in the current process.
Recommendation 6-6. The FAA should work with industry to develop confidence in the cost-benefit analyses used to justify changes in the safety management process. The FAA should also subsidize pilot projects by operators and manufacturers to validate the cost effectiveness of new systems for data collection, database management, and analysis.
CHAPTER 7 Small Airplanes and Rotorcraft
Major Recommendation 6. Plans to implement the recommended safety management process within the small airplane and rotorcraft communities should be developed in cooperation with small airplane and rotorcraft operators, manufacturers, and associations of operators and manufacturers. The FAA should establish cooperative agreements that define the roles of individual operators, individual manufacturers, their associations, and AIR. These agreements should define the following:
responsibilities of operators for submitting data
responsibilities of operators, manufacturers, associations of operators and manufacturers, and AIR for data collection, database management, risk analysis, risk management/action, and monitoring effectiveness
processes for the routine exchange of data and risk analysis results between operators, manufacturers, associations, and AIR to facilitate effective risk management/action
a publicity program to inform the small airplane and rotorcraft communities of the new safety management process
Recommendation 7-1. The FAA should conduct separate safety assessments for each segment of the general aviation community to identify the continued airworthiness problems of greatest significance as a function of the type of operation, class of aircraft, and experience level of the pilots.
Recommendation 7-2. AIR, in conjunction with the original equipment manufacturers of military surplus helicopters, should take timely action to define specific guidance for aircraft certification offices and industry to use in evaluating the airworthiness of military surplus helicopters in accordance with current regulatory standards.