Aviation Safety
Better Data and Targeted FAA Efforts Needed to Identify and Address Safety Issues of Small Air Cargo Carriers Gao ID: GAO-09-614 June 24, 2009The air cargo industry contributed over $37 billion to the U.S. economy in 2008 and provides government, businesses, and individuals with quick delivery of goods. Although part of an aviation system with an extraordinary safety record, there have been over 400 air cargo accidents and over 900 incidents since 1997, raising concerns about cargo safety. GAO's congressionally requested study addresses (1) recent trends in air cargo safety, (2) factors that have contributed to air cargo accidents, (3) federal government and industry efforts to improve air cargo safety and experts' views on the effectiveness of these efforts, and (4) experts' views on further improving air cargo safety. To perform the study, GAO analyzed agency data, surveyed a panel of experts, reviewed industry and government documents, and interviewed industry and government officials. GAO also conducted site visits to Alaska, Ohio, and Texas.
From 1997 through 2008, 443 accidents involving cargo-only carriers occurred, including 93 fatal accidents. Total accidents declined 63 percent from a high of 62 in 1997 to 23 in 2008. Small cargo carriers were involved in the vast majority of the accidents--79 percent of all accidents and 96 percent of fatal accidents. Although accident rates for large cargo carriers fluctuated during this period, they were comparable to accident rates for large passenger carriers in 2007. GAO could not calculate accident rates based on operations or miles traveled for small carriers because the Federal Aviation Administration (FAA) does not collect the necessary data. Although several factors contributed to these air cargo accidents, our review of National Transportation Safety Board (NTSB) data found that pilot performance was identified as a probable cause for about 80 percent of fatal and about 53 percent of non-fatal cargo accidents. Furthermore, GAO's analysis of NTSB reports for the 93 fatal accidents, using an FAA flight-risk checklist, identified three or more risk factors in 63 of the accidents. Risk factors included low pilot experience, winter weather, and nighttime operations. Alaska's challenging operating conditions and remotely located populations who rely on air cargo are also a contributing factor. Many federal efforts to improve air cargo safety focus on large carriers. Air cargo experts that GAO surveyed ranked FAA's voluntary disclosure programs--in which participating carriers voluntarily disclose safety events to FAA--as the most effective effort to improve air cargo, but two of the three main voluntary disclosure programs are used typically by large carriers. Several industry initiatives, however, focus on carriers with smaller aircraft, such as the Medallion Foundation, which has improved small aircraft safety in Alaska through training and safety audits. The two actions experts cited most often to further improve air cargo safety were installing better technology on cargo aircraft to provide additional tools to pilots and collecting data to track small cargo carrier operations. Using flight risk checklists can also help pilots assess the accumulated risk factors associated with some cargo flights.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-09-614, Aviation Safety: Better Data and Targeted FAA Efforts Needed to Identify and Address Safety Issues of Small Air Cargo Carriers
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
June 2009:
Aviation Safety:
Better Data and Targeted FAA Efforts Needed to Identify and Address
Safety Issues of Small Air Cargo Carriers:
GAO-09-614:
GAO Highlights:
Highlights of GAO-09-614, a report to congressional requesters.
Why GAO Did This Study:
The air cargo industry contributed over $37 billion to the U.S. economy
in 2008 and provides government, businesses, and individuals with quick
delivery of goods. Although part of an aviation system with an
extraordinary safety record, there have been over 400 air cargo
accidents and over 900 incidents since 1997, raising concerns about
cargo safety.
GAO‘s congressionally requested study addresses (1) recent trends in
air cargo safety, (2) factors that have contributed to air cargo
accidents, (3) federal government and industry efforts to improve air
cargo safety and experts‘ views on the effectiveness of these efforts,
and (4) experts‘ views on further improving air cargo safety. To
perform the study, GAO analyzed agency data, surveyed a panel of
experts, reviewed industry and government documents, and interviewed
industry and government officials. GAO also conducted site visits to
Alaska, Ohio, and Texas.
What GAO Found:
From 1997 through 2008, 443 accidents involving cargo-only carriers
occurred, including 93 fatal accidents. Total accidents declined 63
percent from a high of 62 in 1997 to 23 in 2008. Small cargo carriers
were involved in the vast majority of the accidents”79 percent of all
accidents and 96 percent of fatal accidents. Although accident rates
for large cargo carriers fluctuated during this period, they were
comparable to accident rates for large passenger carriers in 2007. GAO
could not calculate accident rates based on operations or miles
traveled for small carriers because the Federal Aviation Administration
(FAA) does not collect the necessary data.
Although several factors contributed to these air cargo accidents, our
review of National Transportation Safety Board (NTSB) data found that
pilot performance was identified as a probable cause for about 80
percent of fatal and about 53 percent of non-fatal cargo accidents.
Furthermore, GAO‘s analysis of NTSB reports for the 93 fatal accidents,
using an FAA flight-risk checklist, identified three or more risk
factors in 63 of the accidents. Risk factors included low pilot
experience, winter weather, and nighttime operations. Alaska‘s
challenging operating conditions and remotely located populations who
rely on air cargo are also a contributing factor.
Many federal efforts to improve air cargo safety focus on large
carriers. Air cargo experts that GAO surveyed ranked FAA‘s voluntary
disclosure programs”in which participating carriers voluntarily
disclose safety events to FAA”as the most effective effort to improve
air cargo, but two of the three main voluntary disclosure programs are
used typically by large carriers. Several industry initiatives,
however, focus on carriers with smaller aircraft, such as the Medallion
Foundation, which has improved small aircraft safety in Alaska through
training and safety audits.
The two actions experts cited most often to further improve air cargo
safety were installing better technology on cargo aircraft to provide
additional tools to pilots and collecting data to track small cargo
carrier operations. Using flight risk checklists can also help pilots
assess the accumulated risk factors associated with some cargo flights.
Figure: Cargo being loaded at Anchorage International Airport, Alaska:
[Refer to PDF for image: photograph]
Source: GAO.
[End of figure]
What GAO Recommends:
GAO is recommending efforts to enhance small air cargo carrier safety,
including data collection of carrier operations, targeted safety
programs, and flight risk assessment. FAA and NTSB provided technical
comments, which were included as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-09-614] or key
components. For more information, contact Gerald Dillingham, Ph.D., at
(202) 512-2834 or dillinghamg@gao.gov.
[End of section]
Contents:
Letter:
Background:
Air Cargo Accidents and Fatal Accidents Have Decreased, but Small
Carriers Have Accounted for Higher Proportions of Both:
Pilot Performance, Accumulated Risk, and Other Factors Have Contributed
to Air Cargo Accidents:
FAA Safety Improvement Efforts Focus Primarily on Large Carriers and,
According to Experts, Vary in Effectiveness:
Experts Believe Additional Improvements to Air Cargo Safety Could Be
Achieved through Better Technology, Data, and Standards:
Conclusions:
Recommendations:
Agency Comments:
Appendix I: Objective, Scope, and Methodology:
Appendix II: Expert Responses to GAO Survey:
Appendix III: FAA's Sample Flight Risk Assessment Tool:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Top Five Flight Risk Factors in Fatal Cargo Accidents, 1997-
2008:
Table 2: Selected NTSB Recommendations Related Air Cargo Operations:
Table 3: Air Cargo Expert Panelists:
Figures:
Figure 1: An Illustration of the Interrelationship between Large,
Feeder, and Ad Hoc Carriers:
Figure 2: Trends in Fatal and Non-fatal Air Cargo Accidents, 1997-2008:
Figure 3: Trend in Fatal and Non-fatal Air Cargo Accidents, by Carrier
Type, 1997-2008:
Figure 4: Air Cargo Accidents, by Carrier Type, 1997-2008:
Figure 5: Number of Fatal and Non-fatal Air Cargo Accidents, by Carrier
Type, 1997-2008:
Figure 6: Factors Associated with Non-fatal and Fatal Air Cargo
Accidents, 1997-2008:
Figure 7: The Relative Effectiveness of Current Cargo Safety Efforts as
Ranked by Air Cargo Experts:
Figure 8: The Relative Improvement That Potential Measures Could Have
on Air Cargo Safety as Ranked by Air Cargo Experts:
Abbreviations:
AD: airworthiness directive:
ADS-B: Automatic Dependant Surveillance Broadcast:
ASAP: Aviation Safety Action Program:
ATOS: Air Transport Oversight System:
DOT: Department of Transportation:
FAA: Federal Aviation Administration:
FOQA: Flight Operations Quality Assurance:
hazmat: hazardous materials:
NATA: National Air Transportation Association:
NPG: National Flight Standards Work Program Guidelines:
NTSB: National Transportation Safety Board:
PHMSA: Pipeline and Hazardous Materials Safety Administration:
SMS: safety management system:
TCAS: Traffic Alert and Collision Avoidance System:
UPS: United Parcel Service:
VDRP: Voluntary Disclosure Reporting Program:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
June 24, 2009:
The Honorable James L. Oberstar:
Chairman:
Committee on Transportation and Infrastructure:
House of Representatives:
The Honorable Jerry F. Costello:
Chairman:
Subcommittee on Aviation:
Committee on Transportation and Infrastructure:
House of Representatives:
The air cargo industry, which contributed over $37 billion to the U.S.
economy in 2008, provides businesses and individuals with quick
delivery of everything from small packages to heavy equipment. As part
of the U.S. commercial aviation industry, air cargo--along with air
passenger service--enjoys an extraordinary safety record. This record
reflects the efforts of the Federal Aviation Administration (FAA),
airlines, manufacturers, the National Transportation Safety Board
(NTSB), and others to maintain one of the safest aviation systems in
the world. Nevertheless, over 900 air cargo incidents and over 400
accidents occurred from 1997 to 2008, including 93 fatal accidents with
128 fatalities, raising concerns about air cargo safety. Given the
economic importance of the cargo aviation sector and concerns about its
safety, you asked that we examine the nature and extent of safety
issues in the air cargo industry and determine what is being done to
address these issues. While cargo is also carried by passenger air
carriers, we focused on all-cargo (cargo-only) air carriers operating
fixed-wing aircraft[Footnote 1] and addressed the following questions:
1. What have been recent trends in air cargo safety?
2. What factors have contributed to air cargo accidents in recent
years?
3. What have FAA and the industry done to improve air cargo safety, and
how do experts view the effectiveness of these efforts?
4. What do experts say FAA and industry could do to further improve air
cargo safety?
To answer these questions, we obtained and analyzed accident data from
NTSB and incident, oversight, and enforcement data from FAA for all-
cargo carriers operating fixed-wing aircraft. We assessed the
reliability of these data and determined that they were sufficiently
reliable for our purposes. We also surveyed a panel of 27 air cargo
safety experts and asked them to rate and provide relative rankings on
the effectiveness of current efforts to improve air cargo safety, the
severity of challenges to air cargo safety, and the potential
improvements that additional efforts could have on air cargo safety.
With the assistance of the National Academy of Sciences, we selected
the panel of experts to represent the perspectives of a cross-section
of stakeholders, including pilots, carriers, manufacturers, airports,
federal government, and human factors and safety performance. We also
conducted site visits in Alaska, Ohio, and Texas because they were
geographically diverse and as the states with the largest number of air
cargo accidents or because of the relatively large number of air cargo
carriers of various sizes located there. Finally, we analyzed documents
and interviewed officials from FAA, NTSB, and air cargo industry
organizations and an employee group. We conducted our review from
December 2007 through June 2009 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.
More details of our scope and methodology can be found in appendix I
and the experts' responses to our survey can be found in appendix II.
Background:
The U.S. economy depends on the air cargo industry for the delivery of
small, time-sensitive packages under 100 pounds, freight of 100 pounds
or more, and mail. Air cargo carriers fall into two distinct
categories: (1) all-cargo carriers that transport only cargo and (2)
passenger carriers that transport cargo as belly freight in passenger
aircraft. For the most part, all-cargo carriers can be categorized
according to three business models: (1) large carriers, such as United
Parcel Service (UPS) and FedEx, which operate large narrow-body and
wide-body aircraft under part 121 of federal aviation regulations;
[Footnote 2] (2) feeder carriers, which operate midsize and small
aircraft (e.g., Cessna Caravans, Mitsubishi MU-2B-60s) under part 135
or part 121 on regularly scheduled flights in support of large cargo
carriers; and (3) ad hoc carriers, which operate small aircraft (e.g.,
Cessna 401s, Beech Bonanzas) under part 135 and are individually
contracted to haul cargo out of smaller airports while not necessarily
operating on a regular schedule.[Footnote 3] Throughout this report, we
use the term "small carriers" when referring to both feeder carriers
and ad hoc carriers. Some carriers operate under both part 121 and part
135, and one large carrier leases aircraft to small carriers to provide
feeder operations. (See figure 1 for an illustration of a large carrier
feeder-ad hoc relationship.) FAA estimated that as of May 6, 2009, the
large all-cargo fleet contained 471 narrow-body and 593 wide-body
aircraft and the small carrier all-cargo fleet contained 1,515
aircraft.
Figure 1: An Illustration of the Interrelationship between Large,
Feeder, and Ad Hoc Carriers:
[Refer to PDF for image: three photographs]
Photograph #1: Cargo arrives on large carriers into Anchorage
International Airport, Alaska.
Photograph #2: Cargo travels by large or feeder carriers from Anchorage
into Bethel, Alaska.
Photograph #3: At Bethel Airport, the cargo is reloaded onto smaller ad-
hoc carriers for distribution to surrounding villages.
Source: GAO.
[End of figure]
Several federal transportation agencies play significant roles in air
cargo safety. These agencies are FAA, the Department of
Transportation's (DOT) Pipeline and Hazardous Materials Safety
Administration (PHMSA), and NTSB.
Two FAA offices in particular have important responsibility for the
oversight of air cargo carriers. First, FAA's Flight Standards Service
oversees cargo carrier operations conducted under parts 121 and 135.
For each carrier, Flight Standards assembles a team of inspectors
(known as a "certificate management team") led by principal inspectors
who focus on avionics, maintenance, or operations. For large carriers,
dedicated teams of inspectors use the risk-based Air Transport
Oversight System (ATOS) to carry out their duties. Under ATOS,
inspectors develop surveillance plans for each carrier based on data
analysis and risk assessment, and adjust the plans periodically in
accordance with inspection results. For feeder and ad hoc carriers
operating under part 135, inspectors--who unlike ATOS's dedicated
inspection teams may be assigned to multiple air carrier and other
certificates--use the National Flight Standards Work Program Guidelines
(NPG) to ensure that carriers comply with safety regulations.[Footnote
4] For NPG, Flight Standards annually identifies a minimum set of
required inspections to be undertaken. In addition, individual
inspectors determine annual sets of planned inspections based on their
knowledge of and experience with the carriers they oversee. Second,
FAA's Office of Security and Hazardous Materials enforces hazardous
materials (hazmat) safety policies and conducts annual inspections of
cargo and passenger carriers. Inspectors in this office work
exclusively on issues related to compliance with hazmat requirements.
When violations of statutory and regulatory requirements are
identified, FAA has a variety of enforcement tools at its disposal with
which to respond, including administrative and legal sanctions.
In addition, PHMSA ensures the safe transport of hazmat by air and
other modes. PHMSA promulgates regulations concerning the types and
amounts of hazmat that can or cannot be transported by air--often
differentiating between what hazmat can be carried on all-cargo versus
passenger aircraft--and maintains its own database of hazmat incidents
as well as a portal that pulls together hazmat data from other
databases.
NTSB investigates and determines a probable cause for each U.S.
aviation accident, which is defined as "an occurrence associated with
the operation of an aircraft which takes place between the time any
person boards the aircraft with the intention of flight and all such
persons have disembarked, and in which any person suffers death or
serious injury, or in which the aircraft receives substantial damage."
[Footnote 5] NTSB makes transportation safety recommendations to
federal, state, and local agencies and private organizations to reduce
the likelihood of recurrences of transportation accidents but has no
authority to enforce its recommendations. NTSB also conducts annual
reviews of aircraft accident data and determines U.S. aviation accident
and fatal accident rates. NTSB also periodically holds public hearings
and forums, and issues special studies on various transportation safety
topics.
Air Cargo Accidents and Fatal Accidents Have Decreased, but Small
Carriers Have Accounted for Higher Proportions of Both:
From 1997 through 2008, air cargo accidents and fatal accidents each
declined by about two-thirds. Despite this decline, small cargo
carriers consistently experienced the largest shares of accidents and,
especially, fatal accidents.
Air Cargo Accidents and Fatal Accidents Declined from 1997 through
2008:
Annually, air cargo accidents decreased 63 percent, from 62 in 1997 to
23 in 2008. Average annual air cargo accidents declined from the first
to the second half of our review period, from an average of 45
accidents per year from 1997 through 2002 to an average of 28 accidents
per year from 2003 through 2008.[Footnote 6] Fatal air cargo accidents
also decreased over our 12-year review period, falling from 12 in 1997
to 4 in 2008. In addition, from the first to the second half of our
review period, fatal cargo accidents dropped from an average of 10 per
year to an average of 6 per year. The fluctuation in annual air cargo
accidents could be the result of a number of factors, including the
general decline in aviation activity after September 11, 2001; a
fluctuation in overall U.S. aviation accidents; and other factors. (See
figure 2.)
Figure 2: Trends in Fatal and Non-fatal Air Cargo Accidents, 1997-2008:
[Refer to PDF for image: stacked vertical bar graph]
Calendar year: 1997;
Fatal accidents: 12;
Non-fatal accidents: 50;
Total: 62.
Calendar year: 1998;
Fatal accidents: 10;
Non-fatal accidents: 32;
Total: 42.
Calendar year: 1999;
Fatal accidents: 8;
Non-fatal accidents: 31;
Total: 39.
Calendar year: 2000;
Fatal accidents: 11;
Non-fatal accidents: 40;
Total: 51.
Calendar year: 2001;
Fatal accidents: 10;
Non-fatal accidents: 34;
Total: 44.
Calendar year: 2002;
Fatal accidents: 8;
Non-fatal accidents: 25;
Total: 33.
Calendar year: 2003;
Fatal accidents: 6;
Non-fatal accidents: 34;
Total: 40.
Calendar year: 2004;
Fatal accidents: 11;
Non-fatal accidents: 19;
Total: 30.
Calendar year: 2005;
Fatal accidents: 5;
Non-fatal accidents: 28;
Total: 33.
Calendar year: 2006;
Fatal accidents: 5;
Non-fatal accidents: 17;
Total: 22.
Calendar year: 2007;
Fatal accidents: 3;
Non-fatal accidents: 21;
Total: 24.
Calendar year: 2008;
Fatal accidents: 4;
Non-fatal accidents: 19;
Total: 23.
Source: GAO analysis of NTSB data.
Note: During this period, there were 443 accidents, including 93 fatal
accidents.
[End of figure]
Ad hoc carriers experienced the largest decline in accidents, with 28
fewer accidents--dropping from 36 to 8--followed by large carriers,
with 9 fewer accidents--dropping from 14 to 5 from 1997 through 2008.
Feeder carrier accidents fluctuated during this period, reaching a high
of 17 accidents in 2003 compared to a low of 7 accidents both in 1999
and in 2007. We do not know why the spike occurred in 2003. Large
carriers had 3 fatal accidents during our review period, which occurred
in 1997, 2000, and 2004. (See figure 3.) Without actual data on the
number of flight hours, however, we cannot determine an accident rate,
and thus we do not know if the decline in ad hoc carrier accidents
represents a better safety record for that sector of the air cargo
industry.
Figure 3: Trend in Fatal and Non-fatal Air Cargo Accidents, by Carrier
Type, 1997-2008:
[Refer to PDF for image: three line graphs]
Year: 1997;
Large carrier, fatal: 1;
Large carrier, non-fatal: 13;
Feeder carriers (small), fatal: 1;
Feeder carriers (small), non-fatal: 9;
Ad hoc carriers (small), fatal: 8;
Ad hoc carriers (small), non-fatal: 28.
Year: 1998;
Large carrier, fatal: 0;
Large carrier, non-fatal: 15;
Feeder carriers (small), fatal: 4;
Feeder carriers (small), non-fatal: 4;
Ad hoc carriers (small), fatal: 6;
Ad hoc carriers (small), non-fatal: 12.
Year: 1999;
Large carrier, fatal: 0;
Large carrier, non-fatal: 9;
Feeder carriers (small), fatal: 1;
Feeder carriers (small), non-fatal: 6;
Ad hoc carriers (small), fatal: 7;
Ad hoc carriers (small), non-fatal: 16.
Year: 2000;
Large carrier, fatal: 1;
Large carrier, non-fatal: 9;;
Feeder carriers (small), fatal: 5;
Feeder carriers (small), non-fatal: 8;
Ad hoc carriers (small), fatal: 5;
Ad hoc carriers (small), non-fatal: 22.
Year: 2001;
Large carrier, fatal: 0;
Large carrier, non-fatal: 11;
Feeder carriers (small), fatal: 3;
Feeder carriers (small), non-fatal: 11;
Ad hoc carriers (small), fatal: 6;
Ad hoc carriers (small), non-fatal: 12.
Year: 2002;
Large carrier, fatal: 0;
Large carrier, non-fatal: 5;
Feeder carriers (small), fatal: 5;
Feeder carriers (small), non-fatal: 5;
Ad hoc carriers (small), fatal: 3;
Ad hoc carriers (small), non-fatal: 15.
Year: 2003;
Large carrier, fatal: 0;
Large carrier, non-fatal: 4;
Feeder carriers (small), fatal: 3;
Feeder carriers (small), non-fatal: 14;
Ad hoc carriers (small), fatal: 3;
Ad hoc carriers (small), non-fatal: 16.
Year: 2004;
Large carrier, fatal: 1;
Large carrier, non-fatal: 5;
Feeder carriers (small), fatal: 3;
Feeder carriers (small), non-fatal: 7;
Ad hoc carriers (small), fatal: 8;
Ad hoc carriers (small), non-fatal: 7.
Year: 2005;
Large carrier, fatal: 0;
Large carrier, non-fatal: 7;
Feeder carriers (small), fatal: 2;
Feeder carriers (small), non-fatal: 7;
Ad hoc carriers (small), fatal: 3;
Ad hoc carriers (small), non-fatal: 14.
Year: 2006;
Large carrier, fatal: 0;
Large carrier, non-fatal: 4;
Feeder carriers (small), fatal: 3;
Feeder carriers (small), non-fatal: 5;
Ad hoc carriers (small), fatal: 2;
Ad hoc carriers (small), non-fatal: 8.
Year: 2007;
Large carrier, fatal: 0;
Large carrier, non-fatal: 2;
Feeder carriers (small), fatal: 1;
Feeder carriers (small), non-fatal: 6;
Ad hoc carriers (small), fatal: 2;
Ad hoc carriers (small), non-fatal: 13.
Year: 2008;
Large carrier, fatal: 0;
Large carrier, non-fatal: 5;
Feeder carriers (small), fatal: 3;
Feeder carriers (small), non-fatal: 7;
Ad hoc carriers (small), fatal: 2;
Ad hoc carriers (small), non-fatal: 6.
Trends, 1997-2008:
Large carrier: decrease of 9;
Feeder carriers: fluctuated;
Ad hoc carriers: decrease of 28.
Source: GAO analysis of NTSB data.
Note: During this period, there were 443 cargo accidents, including 93
fatal accidents, that included 92 large carrier accidents, 123 feeder
carrier accidents, and 224 ad hoc carrier accidents.
[End of figure]
Small Cargo Carriers Had Higher Proportions of Accidents and Nearly All
Fatal Accidents:
The small carriers (feeders and ad hoc) in our review experienced 79
percent of the air cargo accidents. Ad hoc carriers accounted for about
half of accidents while the feeders were involved in over a quarter of
them. (See figure 4.) Feeder and ad hoc carriers averaged 29 accidents
per year while large carriers averaged 8 accidents each year.
Figure 4: Air Cargo Accidents, by Carrier Type, 1997-2008:
[Refer to PDF for image: pie-chart]
Ad hoc (small): 51%;
Feeders (small): 28%;
Large: 21%.
Source: GAO analysis of NTSB data.
[End of figure]
Small air cargo carriers accounted for 96 percent of the fatal air
cargo accidents that occurred from 1997 through 2008. Ad hoc carriers
accounted for the majority of fatal accidents and feeders for over one-
third of fatal accidents. (See figure 5.) Together, feeder and ad hoc
carriers averaged 8 fatal accidents per year while large cargo carriers
experienced a total of 3 fatal accidents from 1997 through 2008.
Figure 5: Number of Fatal and Non-fatal Air Cargo Accidents, by Carrier
Type, 1997-2008:
[Refer to PDF for image: vertical bar graph]
Large, fatal accidents: 3;
Large, non-fatal accidents: 89;
Feeders (small), fatal accidents: 34;
Feeders (small), non-fatal accidents: 89;
Ad hoc (small), fatal accidents: 55;
Ad hoc (small), non-fatal accidents: 168.
Source: GAO analysis of NTSB data.
Note: During this period, there were 443 accidents, including 93 fatal
accidents, but we were unable to categorize all accidents due to lack
of information.
[End of figure]
Accident Rates Have Fluctuated for Large Cargo Carriers but Are Not
Available for Small On-demand Cargo Carriers:
The accident rate per departure for large air cargo carriers has
fluctuated over the last 25 years, but the overall trend has been
downward, and in 2007 was roughly the same as for passenger carriers.
[Footnote 7] It is possible to calculate these rates because FAA
requires those carriers to report operational data (e.g., flight hours
or departures).
However, FAA does not require small on-demand carriers operating under
part 135 to report operational information, and the majority of feeder
and ad hoc cargo carriers fall into this group. In 2003, NTSB
recommended that FAA collect this type of data and, according to NTSB,
FAA is still reviewing the costs and benefits as well as options for
collecting and processing the data.[Footnote 8] However, the lack of
data about the flight hours for small on-demand carriers precludes
calculation of the industry's current accident or fatality rates or
changes in the rates over time, making it difficult to determine
whether the industry is becoming more or less prone to accidents.
Instead, FAA relies on an annual survey of aircraft owners to form the
basis for estimates of small carrier operations, but this survey does
not distinguish between passenger and cargo operations, making it
impossible to use the survey estimates to calculate cargo or passenger
accident rates for on-demand operations or for the cargo industry as a
whole.
Even though operational data are not available for small air cargo
carriers, their fatal accident rates would exceed those of large
carriers for the latter part of our review period. From 2005 through
2008, there were no fatal accidents among large cargo carriers, so
their fatal accident rate for those years was zero. However, there were
17 fatal feeder and ad hoc accidents over the same period, meaning that
their fatal accident rate, if it could be determined, would be higher
than zero--though it is unclear how much higher. This logic would not
hold for air cargo accidents in general because large carriers had
accidents in each year from 1997 through 2008, though they had fewer
accidents than the feeder and ad hoc carriers. The lack of data makes
it difficult for FAA and industry to target further improvements to the
areas with the highest risk.
Pilot Performance, Accumulated Risk, and Other Factors Have Contributed
to Air Cargo Accidents:
Our review of NTSB and FAA air cargo accident and incident data as well
as our interviews with industry officials and analyses of industry
documents revealed that pilot performance was a prominent factor in air
cargo accidents. Additionally, we concluded that accumulated risk,
challenging operating conditions in Alaska, and undeclared hazmat were
also prominent contributors to air cargo accidents.
Pilot Performance Was a Major Contributor to Air Cargo Accidents from
1997 through 2008:
Our review of NTSB reports for 417 completed air cargo accident
investigations found that pilot performance was cited as the probable
cause for about 59 percent of them.[Footnote 9] Specifically, we found
that NTSB cited pilot performance as the probable cause for about 53
percent of non-fatal and about 80 percent of fatal air cargo accidents.
(See figure 6.) Examples of pilot performance issues in these accidents
included the pilot's failure to maintain control of the aircraft or to
execute the appropriate procedure. Our review determined that the
second most prominent cause of air cargo accidents was some type of
equipment failure or malfunction.
Figure 6: Factors Associated with Non-fatal and Fatal Air Cargo
Accidents, 1997-2008:
[Refer to PDF for image: two pie-charts]
Non-fatal accidents (330):
Pilot performance: 54%;
Equipment: 26%;
Other: 21%.
Fatal accidents (87):
Pilot performance: 80%;
Equipment: 13%;
Other: 7%.
Source: GAO analysis of NTSB data.
Note: NTSB had not yet completed its investigations for 26 of the 443
air cargo accidents--including 6 fatal accidents. Other causes include
weather and wildlife.
[End of figure]
Pilots of small cargo aircraft have fewer human and other resources
available to them to help avoid mistakes or recover from unexpected
circumstances. Typically, there is no second pilot to share in the
pilot's many duties[Footnote 10] and help respond to emergencies.
Eighty-one percent of the fatal air cargo accidents from 1997 through
2008 were single-pilot flights. The lack of a second pilot coupled with
the many duties of a single pilot merits a mention of the issue of
pilot fatigue. Although NTSB indicated fatigue as a contributing
factor--not a probable cause--in just 4 of the 443 accidents in our
data, 12 of 27 experts we surveyed ranked pilot fatigue as one of the
three most serious challenges to safe air cargo operations. The view of
the experts is not out of line with the accident record to the extent
that the concern about pilot fatigue has led to vigilance in
identifying and addressing fatigue issues.
Further compounding the lack of pilot resources, cargo aircraft
operated under part 135 are not required to have on-board safety
technology such as a traffic collision and avoidance system, a terrain
awareness and warning system, or an autopilot,[Footnote 11] which could
aid a single pilot in monitoring the environment or responding to
changing weather conditions. Most of these systems are required for
small passenger aircraft that also operate under part 135.
Additionally, small cargo aircraft may fly into airports where FAA does
not provide air traffic control services at all hours and the airports
offer fewer services than might be required for passenger operations.
For example, at the Bethel, Alaska, airport--the transportation hub for
the remote villages in the area and the third-busiest airport in
Alaska--FAA provides air traffic control services from 7 a.m. to 8 p.m.
from November to March and 2 hours later in other months, and the
airport clears its runway of snow and staffs its aircraft rescue and
fire-fighting equipment only during operations of passenger aircraft
with more than 30 passenger seats.
Our Analysis Indicates That Most Fatal Accidents Involved Multiple Risk
Factors:
We analyzed NTSB reports of the 93 fatal air cargo accidents that
occurred from 1997 through 2008 using FAA's Flight Risk Assessment Tool
and identified three or more risk factors in 63 of the accidents and
four or more risk factors in 41 accidents. FAA's tool is located in
appendix III and includes 38 risk factors--in the areas of pilot
qualifications and experience, operating environment, and equipment--
each with an assigned value ranging from 2 to 5, with 5 indicating the
highest risk.[Footnote 12] While we do not know how the presence of
these risk factors differs from their occurrence during normal
operations, the experts told us that the unrecognized accumulation of
multiple risk factors can create a potentially dangerous situation. One
1997 fatal accident, which NTSB attributed to the pilot's disregard of
the preflight weather briefing for severe weather, involved six risk
factors. The pilot had not flown a minimum number of hours during the
previous 90 days, had not accumulated a minimum amount of experience
flying the aircraft type involved in the accident, and was flying solo.
Additionally, the pilot encountered severe turbulence and icing during
the night flight. Table 1 lists the five most common risk factors we
identified in the 93 fatal air cargo flights.
Table 1: Top Five Flight Risk Factors in Fatal Cargo Accidents, 1997-
2008:
Rank: 1;
Risk factor: Single-pilot flight;
Risk value[A]: 5;
Number of fatal air cargo accidents in which factor was present: 82.
Rank: 2;
Risk factor: Night flight;
Risk value[A]: 5;
Number of fatal air cargo accidents in which factor was present: 48.
Rank: 3;
Risk factor: Winter operation;
Risk value[A]: 3;
Number of fatal air cargo accidents in which factor was present: 37.
Rank: 4;
Risk factor: Low pilot experience in accident aircraft type (less than
200 hours)[B];
Risk value[A]: 5;
Number of fatal air cargo accidents in which factor was present: 23.
Rank: 5;
Risk factor: Low pilot flying experience last 90 days (less than 100
hours)[B];
Risk value[A]: 3;
Number of fatal air cargo accidents in which factor was present: 17.
Source: GAO analysis of NTSB.
[A] The tool specifies 38 risk factors--in the areas of pilot
qualifications and experience, operating environment, and equipment--
and each is assigned a risk value ranging from 2 to 5, with the higher
values indicating greater risk.
[B] These numbers may actually be higher because the NTSB reports did
not list the pilot's flight hours in the last 90 days for 22 of the
accident pilots and total flying time in the accident aircraft type for
17 of the accident pilots.
[End of table]
Alaska's Challenging Operating Conditions Factored Prominently in Air
Cargo Accidents:
With 18 fatal air cargo accidents from 1997 through 2008, Alaska led
all states in this statistic because aviation operations in that state
face several unique challenges. Alaska is more dependent on aviation
for the transport of goods and people than other states because it
lacks a comprehensive road system.[Footnote 13] Less than 10 percent of
the state is accessible by road. Therefore, goods must be transported
to remote villages via air or barge, and barge transport is not an
option during the winter months. These factors make Alaska highly
dependent on cargo aircraft, which often fly into poorly maintained
airports that often do not meet FAA standards. Consequently, most of
the accidents in Alaska involved small aircraft. Alaska is also subject
to unusual weather conditions. Taken together, we believe these
challenges render Alaska more susceptible to aviation accidents and
fatal accidents than other states.
Of the 27 experts we surveyed, 5 ranked operating conditions in Alaska
as one of the top three challenges to the safe operation of cargo
flights; in addition, 12 experts in our panel indicated that Alaskan
operating conditions do pose at least moderate challenges to safety,
whereas 2 experts (a pilot of large aircraft and a government official)
said these conditions were not a challenge. Seven experts said they did
not have enough specific knowledge to judge the degree of challenge
that Alaskan operating conditions pose to safety.
Some Experts Indicated that One of the Most Serious Challenges to Safe
Air Cargo Operations Is Undeclared Hazmat, but Few Accidents Have Been
Attributed to Hazardous Cargo:
Very few of the cargo accidents occurring from year to year were
conclusively caused by hazmat. However, 11 experts on our panel ranked
undeclared hazmat--materials not noted as hazardous in shipping
documents and/or labeled as such on their packaging---among the
greatest challenges to safe cargo operations, second only to pilot
fatigue. According to our review of the NTSB accident data, only three
cargo accidents involved hazmat. They occurred in 1997, 1998, and 2006
to large carriers, and none resulted in fatalities.[Footnote 14] The
2006 accident resulted in an NTSB hearing and recommendations that we
discuss later in this report.
The problem of undeclared hazmat was cited primarily by government and
large carrier experts in our survey. Specifically, three of the four
government experts and two of the three large carrier experts cited it
as the most serious challenge to air cargo safety. These opinions may
stem from the previously cited fires and the relative rarity of a
destroyed aircraft among large carriers, as well as government concerns
about the transport of lithium batteries on aircraft.
FAA hazmat officials told us that undeclared shipments of hazardous
materials represent the biggest challenge they face and that lithium
batteries are the most challenging type of hazmat in air
transportation. We reported in January 2003 that FAA, in the early
1990s, identified a number of incidents associated with batteries,
particularly lithium batteries, aboard aircraft in which the batteries
caused fires, smoke, or extreme heat.[Footnote 15] In response to these
and other concerns, DOT took a number of actions designed to strengthen
the regulations for the transportation of lithium batteries.[Footnote
16] In January 2008, NTSB noted that lithium batteries had been
involved in at least 9 aviation incidents, and both primary and
secondary lithium batteries are regulated as hazardous materials for
the purposes of transportation.[Footnote 17] In December 2007, NTSB
made six recommendations to PHMSA following a UPS aircraft fire at
Philadelphia International Airport in February 2006, in which a number
of secondary lithium batteries were found in the accident debris.
[Footnote 18] The recommendations included requirements for
transporting primary lithium batteries in fire-resistant containers and
stowing cargo containing secondary lithium batteries in crew-accessible
locations so that any fire hazards can be quickly addressed. These
recommendations remain open with acceptable responses from PHMSA
because they have not yet been implemented, but according to NTSB,
actions are planned that, if satisfactorily completed, may comply with
the safety recommendations. FAA and PHMSA have embarked on a lithium
battery action plan, which aims to reduce the risk associated with the
transport of batteries on aircraft by passengers and as cargo. The
primary focus of this plan is all types of lithium batteries. According
to DOT, PHMSA and FAA have also initiated a rule-making project to
consider additional measures to enhance the safety of lithium battery
shipments such as packaging, hazard communication, and stowage
requirements. PHMSA plans to publish a notice of proposed rulemaking by
December 2009. FAA, the Air Line Pilots Association, and PHMSA also
issued safety alerts or advisories in 2007 that addressed smoke and
fire hazards, recommended crew actions in the event of a battery fire,
noted the availability of guidance for the safe transport of batteries
and battery-powered devices on board aircraft, and provided information
on proper packing and handling procedures for these batteries.[Footnote
19]
Large Numbers of Air Cargo Incidents May Be Precursors to Accidents:
Although our analysis for this study included 443 air cargo accidents,
cargo carriers were involved in more than twice as many incidents
during the first 11 years of our review period, and FAA and others
recognize that incidents are potential precursors to more serious
accidents. In an analysis of air cargo data for 1997 through 2007 from
FAA's Accident/Incident Data System, we identified over 900 air cargo
incidents.[Footnote 20] These incidents covered a broad set of events,
such as an engine losing power at 7,000 feet; a cargo door opening in
flight; and an aircraft engine coming into contact with a fuel truck.
FAA does not use incident data to identify precursors to aviation
accidents, because the data were not developed for this purpose.
However, the agency is moving toward using data to better identify
precursors to accidents, but until it does so, it may be missing
opportunities to make air cargo operations and aviation, in general,
safer.[Footnote 21] For example, from 2000 to 2007, one ad hoc cargo
carrier was listed in FAA's database 10 times with incidents that
resulted in varying degrees of damage to its aircraft, from none to
substantial, and in NTSB's database with one non-fatal accident. This
carrier subsequently experienced a fatal accident in 2008. Had this
carrier's incident data been used to identify accident precursors,
inspectors might have been alerted to underlying problems that might
have been addressed, potentially preventing the subsequent fatal
accident. In addition, NTSB's accident database also does not track
incidents in a way that would allow empirical analysis.
The notion that incidents can be precursors to more serious accidents
is accepted both inside and outside aviation. NASA's Aviation Safety
Reporting System collects, analyzes, and responds to aviation safety
incident reports voluntarily submitted by pilots and others to lessen
the likelihood of aviation accidents. In its 2005 Safety Management
Manual, the International Civil Aviation Organization noted that for
accidents, there are precursors evident before the accident, and
focusing solely on instances of serious injury or significant damage is
a wasted opportunity, since the factors contributing to such accidents
may be present in hundreds of incidents. The International Civil
Aviation Organization further noted that "effective safety management
requires that staff and management identify and analyze hazards before
they result in accidents," particularly since there is the opportunity
"to identify why the incidents occurred and, equally, how the defenses
in place prevented them from becoming accidents." The National Academy
of Engineering undertook an accident precursor project in February
2003, which culminated in a report that included aviation accident
precursor analysis and management. The report concluded that existing
initiatives are not as effective as they could be and encourages
government agencies that regulate high-hazard industries to increase
their support of research into methods for effectively analyzing and
managing precursors.[Footnote 22]
FAA Safety Improvement Efforts Focus Primarily on Large Carriers and,
According to Experts, Vary in Effectiveness:
Many government and industry efforts to improve safety focus primarily
on large carriers. Such efforts include programs in which carriers and
employees voluntarily disclose potential safety issues, attempts by
carriers to institutionalize their safety procedures through safety
management systems (SMS)--a proactive, risk-based approach to
addressing potential hazards--and FAA's ATOS oversight program even
though there is nothing intrinsic to preclude these concepts from being
implemented among small cargo carriers. Cargo experts view voluntary
disclosure programs, efforts by associations to improve their members'
safety procedures, and carrier-implemented SMSs as the most effective
current safety programs affecting air cargo (see figure 7).
Figure 7: The Relative Effectiveness of Current Cargo Safety Efforts as
Ranked by Air Cargo Experts:
[Refer to PDF for image: stacked horizontal bar graph]
Safety effort: Voluntary disclosure programs;
Greatest improvement: 7;
Second greatest improvement: 5;
Third greatest improvement: 4;
Total: 16.
Safety effort: Association efforts with members;
Greatest improvement: 3;
Second greatest improvement: 6;
Third greatest improvement: 5;
Total: 14.
Safety effort: Carrier safety management systems;
Greatest improvement: 6;
Second greatest improvement: 3;
Third greatest improvement: 4;
Total: 13.
Safety effort: FAA airworthiness directives and operations
specifications;
Greatest improvement: 7;
Second greatest improvement: 1;
Third greatest improvement: 2;
Total: 10.
Safety effort: NTSB recommendations;
Greatest improvement: 1;
Second greatest improvement: 2;
Third greatest improvement: 6;
Total: 9.
Safety effort: FAA oversight;
Greatest improvement: 2;
Second greatest improvement: 3;
Third greatest improvement: 0;
Total: 5.
Safety effort: Association lobbying efforts;
Greatest improvement: 1;
Second greatest improvement: 1;
Third greatest improvement: 3;
Total: 5.
Safety effort: NTSB public meetings;
Greatest improvement: 0;
Second greatest improvement: 4;
Third greatest improvement: 1;
Total: 5.
Safety effort: Airport safety management systems;
Greatest improvement: 0;
Second greatest improvement: 1;
Third greatest improvement: 2;
Total: 3.
Safety effort: FAA Infos, seminars, and other communication efforts;
Greatest improvement: 0;
Second greatest improvement: 1;
Third greatest improvement: 0;
Total: 1.
Source: GAO.
[End of figure]
Experts Rate Voluntary Disclosure Programs as One of the Most Effective
Cargo Safety Programs, but Primarily Large Carriers Participate:
The intent of voluntary disclosure programs is to identify and correct
safety problems in a nonpunitive way and to provide additional safety
information to FAA. Our panel of experts ranked FAA's voluntary
disclosure programs as the most effective current program for improving
air cargo safety. Specifically, 16 of 27 experts ranked FAA's voluntary
disclosure programs as one of the most effective current efforts to
improve air cargo safety, and all experts able to judge indicated that
the programs were effective on some level. FAA operates multiple
voluntary disclosure programs, which use different data sources to help
identify safety deficiencies. The three major ones are Flight
Operations Quality Assurance (FOQA), the Aviation Safety Action Program
(ASAP), and the Voluntary Disclosure Reporting Program (VDRP). At the
current time, FOQA is used only by large carriers because of the level
of technology required and ASAP is not typically used by small
carriers.
* FOQA collects and makes available for analysis digital flight data
generated during the normal operations of the 23 participating
carriers. As of January 2008, the only cargo carriers participating in
FOQA were large carriers. Participating carriers pay for the special
flight data recorders that can record FOQA data; these recorders cost
approximately $20,000 each. Although such an investment can be
expensive for some air carriers, some aircraft models come with the
data recorder already built in. However, smaller carriers tend to
operate older aircraft, which lack the data recorder equipment.
* ASAP encourages industry employees to report safety information that
may be critical in identifying potential precursors to accidents. Under
this program, employees of air cargo carriers and other participating
entities report safety events, which a committee that includes the
carrier, the employee labor group, and FAA then reviews and determines
appropriate corrective actions, such as remedial training. FAA agrees
not to pursue enforcement actions for safety violations reported
exclusively under this program.[Footnote 23] As of December 2008, 73
carriers participated in ASAP, including 8 cargo carriers. Seven of
these 8 cargo carriers were large carriers, possibly because large
carriers are more likely than small carriers to have the time and
resources required for participation. Officials from an ad hoc carrier
we interviewed said it was not practical for their carrier to enter
into an agreement with FAA and then organize meetings to discuss
disclosures when the carrier could operate an informal safety issue
disclosure program internally.
* VDRP encourages regulated entities, such as air carriers or repair
stations, to voluntarily report instances of regulatory noncompliance.
FAA does not take legal action on VDRP disclosures, but a violation
with the same root cause can be reported only once by a carrier. Cargo
carriers of all types we interviewed indicated that they have
participated or would participate in VDRP. However, a 2008 DOT Blue
Ribbon Panel found FAA does not routinely analyze VDRP data to identify
trends and patterns that could indicate safety risks.[Footnote 24] FAA
noted in commenting on a draft of this report that it began conducting
regular analysis of VDRP data in January 2009 and that it modified the
VDRP data software system and associated guidance to enable the
identification of national trends of disclosures that represent the
highest risk to safety.
Numerous Other Initiatives Including Industry Association Efforts Are
Aimed at Improving Safety for Carriers of All Sizes; Some Experts
Believe These Are among the Most Effective at Improving Air Cargo
Safety:
Numerous industry efforts to improve safety are aimed at different
sectors of the air cargo industry. These include efforts by membership
associations to improve safety among their members, which 14 of the 27
experts on our panel ranked among the top three most effective current
efforts to improve air cargo safety--second only to voluntary
disclosure. In addition, all experts in a position to comment indicated
that these association efforts were at least slightly effective, and 11
of those experts indicated that they were greatly effective. We were
unable to identify a central clearinghouse for these association
efforts, but the ones we did identify fell into the following six
general categories: establishing SMSs, providing fatigue awareness
training, providing pilot skills training, adding on-board safety
systems, improving flight risk assessments, and providing cargo-
specific aircraft rescue and fire-fighting training. One expert said
that membership-based efforts are often the most effective because they
directly reflect the voluntary priorities of the membership
organization and are often directly tailored to the group's specific
needs. Examples of industry efforts, including some by industry
associations and one joint industry-federal effort, follow.
* The Regional Air Cargo Carriers Association--an association of
primarily feeder cargo carriers--has developed an SMS template tailored
to the needs of smaller, feeder cargo carriers. A Regional Air Cargo
Carriers Association official said that the organization's members
found FAA's SMS guidance appropriate for large carriers with safety
departments, but less useful for feeder or ad hoc carriers that might
have only a few employees. SMSs are considered in the international
community to be an important way to improve safety in aviation
operations and are required by the International Civil Aviation
Authority. In commenting on a draft of this report, FAA indicated that
it has not endorsed the Regional Air Cargo Carriers Association's SMS
program, nor does FAA believe it is consistent with FAA training and
program guidelines for SMS. SMS is discussed in more detail later in
this report.
* The National Air Transportation Association (NATA)--an association
primarily of general aviation service companies whose members include
some feeder and ad hoc carriers--has tailored flight risk assessments
to the needs of its members by automating much of the assessment
process. NATA officials said that feeder or ad hoc cargo carriers, like
many general aviation operators, do not have the support personnel that
larger carriers have to help with preflight checklists and other tasks,
and that risk assessments would just add to those tasks unless they
were largely automated. NTSB has recommended that a segment of the part
135 community--emergency medical services--utilize flight risk
assessments before accepting flights.
* In some cases, large carriers act as membership associations by
helping their feeder network acquire safety enhancements. For example,
the Federal Express feeder program, which helps finance on-board safety
enhancements on feeder aircraft, has reduced the number of accidents
among its feeder network according to Federal Express officials.
* Since 2002, Alaska's Medallion Foundation--a federally-funded, safety
promotion organization that is overseen by FAA--offers training for
part 135 pilots and has developed safety audits that can lead to
carrier certifications in various areas, such as operational risk
management, maintenance and ground service, and internal evaluation, to
improve air transportation safety in Alaska. According to FAA, it has
also approved a modified protocol for ASAP administered centrally by
the Medallion Foundation in order to increase the feasibility of ASAP
for small operators in Alaska. Meetings with FAA personnel to review
reports submitted under the program are conducted by telephone, and all
reports are tracked in a central database according to the agency. DOT
said that the modified ASAP protocol with the Medallion Foundation has
worked well for enabling small, remotely situated operators in Alaska
to participate in the program.
* The Commercial Aviation Safety Team, a joint FAA-industry effort, has
developed an integrated, data-driven strategy to reduce the commercial
aviation fatality risk in the United States and promote new government
and industry safety initiatives throughout the world. The Team has
completed work on 40 of its 65 safety enhancements aimed at eliminating
accident causes. Six of the safety enhancements specifically target
cargo operations, and each of them is still under way as of the Team's
most recent update in May 2007.
* The Dallas-Fort Worth International Airport is developing a
curriculum and a cargo-specific aircraft rescue and fire-fighting
training course. Airport officials said that the course will focus on
the unique challenges and approaches to fighting a cargo fire. For
example, airport officials said that many aircraft rescue and fire-
fighting teams treat passenger/cargo fires and cargo fires similarly
when they should be treated differently, because passenger/cargo fires
can involve hundreds of people whereas cargo fires typically only
endanger the flight crew. The course will also provide hands-on
training in the use of cargo-specific fire-fighting tools, such as hull-
penetrating tools or devices for locating hot spots--tools that most
fire fighters rarely use.
Carrier-Based SMSs Are Viewed as Effective by Experts but Are Currently
Geared toward Large Carriers:
Thirteen cargo experts ranked carrier SMSs as one of the most effective
current efforts to improve air cargo safety, making this the third most
frequently cited current safety effort. SMSs can differ in their
specifics, but FAA defines SMS as a proactive, risk-based approach to
addressing potential hazards by categorizing the risk level and taking
appropriate mitigating actions to reduce the risk to an acceptable
level. Some countries, such as Canada, require carriers to implement an
SMS, but the United States does not yet require domestic carriers to do
so. FAA and industry officials agreed that FAA will require part 121
carriers to implement SMSs in the next few years. In addition, FAA has
issued guidance on developing an SMS, but none of the air cargo
carriers we interviewed have implemented one. However, several of the
air cargo carriers we interviewed said they had safety programs that
are similar to SMSs. An expert in aviation safety said that effective
SMSs are good for institutionalizing safety improvements and taking
proactive steps to reduce the number of accidents. He further noted
that larger companies with more airplanes and more resources are better
positioned to do this. By contrast, companies with one airplane and one
pilot will not have enough staff time to submit the paper work. As a
result, the Regional Air Cargo Carriers Association--a membership
organization for feeder carriers--has developed simplified SMS guidance
specifically for part 135 cargo carriers. Some airports are also
implementing SMSs. Most experts in our panel did not rank airport SMSs
among the most effective current efforts, possibly because cargo
airports have not implemented them nationwide.
FAA Uses Airworthiness Directives and Operations Specifications to
Improve Aviation Safety:
FAA uses airworthiness directives (AD) and operations specifications to
improve aviation safety. An AD is a notification to owners and
operators of aircraft that a particular model of aircraft, engine,
avionics, or other system has a known safety deficiency that must be
corrected. Carriers are prohibited from operating any aircraft that is
out of compliance with any applicable AD. Operations specifications are
specific limits and requirements developed for individual operators,
such as the specific aircraft the carrier is allowed to operate. Ten
experts on our panel ranked ADs and operations specifications among the
three most effective current efforts to improve air cargo safety. Our
interviews with carriers showed that some carriers depend on ADs and
operations specifications to learn about safety issues that other
carriers have discovered. An official from one feeder carrier said that
ADs are like product recalls, and without them, she would never know
that there was a problem until there was an accident. FAA also uses
other methods for communicating with carriers, such as informational
messages, alerts, advisory circulars, and seminars. However, none of
the 27 experts on our panel indicated that FAA informational materials
and seminars were any more than moderately effective at improving the
safety of air cargo operations.
FAA Uses Risk-Based Inspection System for Large Carriers Only, and
Experts Did Not Rate FAA's Oversight as One of the Most Effective
Efforts to Improve Air Cargo Safety:
FAA oversees the compliance with safety regulations of all 58 part 121
cargo large carriers[Footnote 25] by using ATOS, which applies a risk-
based inspection system tailored to each carrier regulated under part
121. For example, under ATOS, principal inspectors develop surveillance
plans for each airline based on data analysis and risk assessment, and
adjust the plans periodically to reflect inspection results. Under
ATOS, principal inspectors are assigned to just one part 121 carrier.
Our interviews with part 121 carriers and FAA inspectors revealed mixed
opinions about ATOS. Some of the carriers, particularly the smaller
part 121 carriers, indicated that transitioning to ATOS was too
complicated and costly and that its focus on administrative reviews has
reduced the number of on-site FAA inspections they receive. In
addition, some FAA inspectors said that the ATOS paperwork is time
consuming and can have the effect of tethering them to their computers.
For example, officials from a small part 121 air carrier said that they
had to hire a full-time person to work on implementing ATOS as well as
spend over $500,000 to hire a company to help revise the carrier's
manuals to satisfy FAA requirements under ATOS.[Footnote 26] However,
officials from a large carrier indicated that ATOS is a more effective
oversight system than NPG once it is fully implemented. In addition,
some officials from large carriers said that the bureaucratic nature of
ATOS limited the amount of direct oversight they receive. FAA officials
said that ATOS does not impose new requirements on carriers, and FAA
does not require carriers to set up an ATOS program. FAA officials also
said that because ATOS is more robust than the oversight system it
replaced--NPG--inspectors may find omissions in manuals that were
overlooked before. Carriers may then be required to correct these
deficiencies to meet regulatory requirements. In addition, FAA
officials said they are exploring options for reducing the time
inspectors spend at their computers and increasing the time they spend
doing hands-on inspections. For example, FAA officials said that FAA is
reducing the number of ATOS program elements in order to make
inspection planning and management easier.
The 303 part 135 carriers[Footnote 27] remain under the NPG system,
which requires all active carriers to be inspected at least once a year
and sets the numbers of required inspections nationally and planned
inspections at the local level. Some FAA inspectors we interviewed who
use the NPG system said they do not base their planned inspections on
risk factors but, rather, on what was done the previous year or what
they have time to do (NPG inspectors typically oversee several
carriers). FAA officials said that FAA is moving toward a risk-based
oversight "Safety Assurance System" for part 135 carriers. FAA has
completed a gap analysis that compared the existing part 135 oversight
system to the system requirements of the new system, and it plans to
have the risk-based system developed for part 135 carriers by 2013.
The number of inspections that part 135 carriers receive each year
varies greatly under NPG. For fiscal years 2004 through 2007, we found
18 part 135 carriers received one inspection in a year, while 6 part
135 carriers received hundreds of inspections in a year. An FAA
official said that variation should be expected. For example, carriers
with more airplanes, airplanes of more types, and routes to more
regions will receive more required inspections under NPG.
The number of part 135 carriers that each cargo inspector oversees also
varies greatly. On the low end (bottom 10 percent), part 135 cargo
inspectors oversee 5 passenger and cargo carriers on average, and on
the high end (top 10 percent), inspectors oversee 34 passenger and
cargo carriers. While some variation is unavoidable, FAA officials said
that FAA has not established guidelines to ensure that the workload is
balanced among inspectors. The National Academy of Sciences also found
FAA had inadequate staffing standards for its safety inspectors.
[Footnote 28]
The majority of the experts on our panel did not rank FAA oversight and
inspections among the most effective current efforts to improve air
cargo safety. Although 5 of the 27 experts rated FAA oversight and
inspections among the three most effective current efforts to improve
air cargo safety, none of the experts representing carriers'
perspectives listed FAA oversight among the most effective current
efforts. Officials from an ad hoc cargo carrier said that FAA
inspectors do not have enough specific knowledge of cargo operations to
effectively oversee cargo operations. Two FAA cargo inspectors that
also oversee passenger carriers said that their formal cargo oversight
training consisted of a 2-hour online course. FAA officials said part
135 does not differentiate between passenger and cargo operations.
However, FAA officials recognized that inspectors that oversee part 135
ad hoc operations may benefit from additional training and are revising
an existing multiday course for maintenance inspectors to address cargo
operations. Our analysis of oversight data for part 135 carriers showed
that cargo inspectors also oversee passenger carriers, often in larger
numbers. This could limit inspectors' ability to focus on cargo-
specific issues. Officials from several cargo carriers of different
types said that FAA inspectors do not do enough on-site inspections to
effectively find and correct safety problems. For example, FAA
inspectors and carrier officials said that part 135 inspectors often
focus on administrative reviews. FAA officials said there needs to be
an appropriate balance of on-site inspections and administrative
reviews, both of which are important for determining carrier compliance
and ensuring safe operations. Ultimately, however, FAA officials said
that regulatory compliance is an air carrier responsibility; FAA is
responsible for ensuring that air carriers are capable of complying
and, in some cases, administrative reviews may be the best way for FAA
to do that.
FAA Rarely Responds to Cargo Carrier Regulatory Violations with Legal
Action or Fines:
FAA's oversight includes enforcement efforts, which are designed to
promote compliance with statutory and regulatory requirements for
aviation safety. When violations are identified, an FAA order calls for
inspectors to take the actions most appropriate to achieve future
compliance. These actions range from educational and remedial efforts,
to administrative actions (such as warning notices), to punitive legal
sanctions (such as fines or loss of operation certificate). Violations
can be identified by FAA inspectors or by others, such as air traffic
controllers or state or local government officials. The relevant FAA
inspector prepares a report and recommends an enforcement action. That
report and proposed enforcement action are then reviewed and possibly
changed at various levels depending on the nature of the recommended
enforcement action.
FAA closes most air cargo regulatory violations with administrative
action, such as a warning notice, or without taking any action. For
1997 through 2008, over half (56 percent) of the 6,564 enforcement
actions against cargo carriers were administrative, and another 17
percent involved no action. These were very similar to the percentages
for passenger carriers. Within cargo, the ad hoc sector had the lowest
percentage of legal actions. Fourteen percent of ad hoc carrier
enforcement actions were legal, compared with 24 percent of larger
carrier enforcement actions and 16 percent of feeder carrier
enforcement actions. Ad hoc cargo carriers also had the largest
reductions, on average, among cargo carrier types, with the reduced
fines 64 percent below the initially recommended fines. Our previous
work found that FAA reduced legal actions for several reasons,
including proof that the violator took corrective action to prevent a
reoccurrence of the violation or economic hardship that might accrue to
the entity that caused the violation.
The percentages of cargo carrier violation cases closed with
administrative or no action represent a continuation of trends that we
observed in our last work on FAA enforcement in 2004.[Footnote 29] At
that time, we found that FAA generally closes cases against passenger
and cargo carriers with administrative actions, and reducing the
amounts of fines may reduce the deterrent effects of those actions.
Since then, our analysis of FAA's Enforcement Information System data
shows that the share of violations resolved using administrative or no
action has increased slightly. Moreover, FAA still lacks information on
how these actions have influenced the effectiveness of the enforcement
actions, and the recommendation we made in that report--that FAA
develop a process for measuring the performance and effectiveness of
its enforcement actions--remains open.
Some NTSB Recommendations for Improving Cargo Safety Have Not Been
Implemented, and the Experts Did Not Consider These Recommendations
among the Most Effective Measures:
NTSB investigates transportation accidents, including air cargo
accidents, and makes recommendations to improve safety. NTSB made
numerous recommendations based on air cargo accidents but not all of
those were related specifically to cargo issues. For example, after an
air cargo accident in 1997, NTSB recommended that FAA require all part
121 air carriers to include additional information and training to
flight crews in order to avoid that type of accident in the future.
Other NTSB recommendations, however, are cargo-specific
recommendations, and all of them remain open. Table 2 summarizes the
status of NTSB's cargo-specific recommendations.
Table 2: Selected NTSB Recommendations Related Air Cargo Operations:
Topic (year): Hazardous materials (1997);
Summary of recommendation (NTSB recommendation number): The Air
Transport Association should develop, in cooperation with FAA and the
U.S. Postal Service, programs to educate passengers, shippers, and
postal customers about the dangers of transporting undeclared hazardous
materials aboard aircraft. (A-97-082);
Current status: Open. NTSB has not yet responded to the Air Transport
Association's 2009 correspondence, in which it asserts that the
problems with undeclared hazardous materials may no longer exist as
they did in 1997 due to the post-9/11 security increases and several
hazardous materials awareness efforts by government and industry.
Topic (year): Cargo loading (1998);
Summary of recommendation (NTSB recommendation number): FAA should
require improved training and advisory materials related to weight and
balance, cargo handling, cargo restraint, and hazards of misleading.
(A-98-047);
Current status: Open. FAA has questioned its authority to mandate
training for cargo handlers.
Topic (year): Effects of dry ice (2001);
Summary of recommendation (NTSB recommendation number): FAA should
conduct testing to determine acceptable loads of dry ice and its
potential effects and revise FAA advisory circulars on the issue.
(A-01-014 and A-01-015);
Current status: Open. FAA indicated in 2006 that it was preparing a
report on its study of dry ice packed in containers commonly used in
air cargo services.
Topic (year): Cargo handlers (2003);
Summary of recommendation (NTSB recommendation number): FAA should
modify its list of safety-sensitive functions for part 121 carriers to
include all personnel with access to an aircraft, including cargo
handlers and others. (A-03-036);
Current status: Open. FAA has not issued a final rule on the issue.
Topic (year): Fire detection (2007);
Summary of recommendation (NTSB recommendation number): FAA should
ensure that fire detection systems account for the effects of cargo and
cargo containers. (A-07-098);
Current status: Open. FAA has not completed its research on the issue
or revised its technical standards order.
Topic (year): Fire suppression (2007);
Summary of recommendation (NTSB recommendation number): FAA should
require fire suppression systems be installed in the cargo compartments
of all part 121 cargo aircraft. (A-07-099);
Current status: Open. FAA has not established the requirement.
Topic (year): Aircraft fire-fighting training (2007);
Summary of recommendation (NTSB recommendation number): FAA should
require airport inspectors to ensure that commercial airports with
cargo operations include cargo aircraft in their aircraft rescue and
fire-fighting familiarization training programs. (A-07-101);
Current status: Open. FAA has not revised the training guidance.
Topic (year): Aircraft fire-fighting information (2007);
Summary of recommendation (NTSB recommendation number): The Cargo
Airline Association in coordination with others should develop and
disseminate accurate, complete aircraft emergency response diagrams to
aircraft rescue and fire-fighting teams at airports with cargo
operations. (A-07-110);
Current status: Open. The Cargo Airline Association convened a working
group of cargo carriers, aircraft manufacturers, the aircraft rescue
and fire-fighting representatives, and others, and, with their input,
has decided to provide aircraft rescue and fire-fighter personnel with
information through video and other advanced media formats. Cargo
Airline Association officials said that the association plans to
complete its work and close the recommendation to the satisfaction of
NTSB within the year.
Topic (year): Emergency exits (2007);
Summary of recommendation (NTSB recommendation number): FAA should
require improvements to emergency exits on cargo aircraft. (A-07-102
and A-07-103);
Current status: Open. FAA has not taken the recommended actions.
Source: GAO analysis of NTSB data.
[End of table]
Most experts did not rank NTSB recommendations among the top efforts to
improve air cargo safety. One expert on our panel described NTSB
recommendations as the most effective effort to improve air cargo
safety, and another 8 of the experts in our panel ranked NTSB
recommendations as one of the top three efforts, but 18 experts did not
include them among the top three efforts. According to our interviews,
NTSB recommendations related to cargo operations are not always
practical to implement. For example, one carrier noted that NTSB's
recommendation related to aircraft fire-fighting information (cited
above) is challenging to implement because there are many cargo
aircraft configurations, and even knowledge of the configuration
involved in the incident that prompted the recommendation would not
have helped firefighters respond to the incident. Despite these
reservations, the carrier indicated that it is helping to implement the
recommendation because NTSB believes it would improve safety.
NTSB also holds public hearings and meetings on topics of particular
interest to transportation safety personnel. For example, it held a
forum on air cargo safety in 2004, but no explicit recommendations
emerged from the forum. Five experts on our panel ranked NTSB's
meetings as one of the three most effective current air cargo safety
efforts and none of the experts ranked the meetings as the most
effective effort.
Experts Believe Additional Improvements to Air Cargo Safety Could Be
Achieved through Better Technology, Data, and Standards:
The 27 experts in our panel commented on numerous additional steps that
could further improve air cargo safety. Experts in our panel ranked
installing state-of-the-art on-board safety systems on all cargo
aircraft and tracking part 135 operations as the potential measures
that would most improve air cargo safety (see figure 8).
Figure 8: The Relative Improvement That Potential Measures Could Have
on Air Cargo Safety as Ranked by Air Cargo Experts:
[Refer to PDF for image: stacked horizontal bar graph]
Measure: Install onboard safety technology;
Greatest improvement: 5;
Second greatest improvement: 3;
Third greatest improvement: 4;
Total: 12.
Measure: Track part 135 operations;
Greatest improvement: 2;
Second greatest improvement: 4;
Third greatest improvement: 5;
Total: 11.
Measure: Align cargo and passenger standards;
Greatest improvement: 4;
Second greatest improvement: 2;
Third greatest improvement: 2;
Total: 8.
Measure: Improve shipper knowledge of hazmat;
Greatest improvement: 3;
Second greatest improvement: 4;
Third greatest improvement: 1;
Total: 8.
Measure: Assess the risk of individual flights;
Greatest improvement: 2;
Second greatest improvement: 3;
Third greatest improvement: 3;
Total: 8.
Measure: Set nongovernment standards ramp employees;
Greatest improvement: 2;
Second greatest improvement: 2;
Third greatest improvement: 3;
Total: 7.
Measure: Improve FAA inspector training;
Greatest improvement: 3;
Second greatest improvement: 1;
Third greatest improvement: 2;
Total: 6.
Measure: Improve hazmat enforcement;
Greatest improvement: 0;
Second greatest improvement: 4;
Third greatest improvement: 2;
Total: 6.
Measure: Increase FAA inspections;
Greatest improvement: 3;
Second greatest improvement: 1;
Third greatest improvement: 1;
Total: 5.
Measure: Improve pilot training;
Greatest improvement: 2;
Second greatest improvement: 1;
Third greatest improvement: 2;
Total: 5.
Measure: Set Government standards for ramp employees;
Greatest improvement: 1;
Second greatest improvement: 2;
Third greatest improvement: 1;
Total: 4.
Source: GAO.
[End of figure]
Experts Believe Improved On-Board Safety Technology Would Most Improve
the Safety of Air Cargo Operations:
Adding state-of-the-art on-board safety technology was the potential
measure to improve air cargo safety endorsed by the most experts in our
panel. Better on-board technology, particularly for smaller aircraft,
could provide additional tools to better inform pilots' judgment and
decision making. One expert said that the type of technology needed
depends on the type of carrier. He noted that large carriers often
already have state-of-the-art technology, and that keeping pace with
new technologies as they emerge is the challenge for them. However, he
said that feeder and ad hoc air cargo carriers are not required to have
certain on-board technologies, and that they would benefit from
installing better situational awareness technologies, like Traffic
Alert and Collision Avoidance Systems (TCAS) or Automatic Dependant
Surveillance Broadcast (ADS-B), on their aircraft. TCAS monitors warn
the pilot of potential collision dangers, and ADS-B uses satellite-
based technology to broadcast aircraft identification, position, and
speed with once-per-second updates. Other experts on the panel also
indicated that TCAS and ADS-B would most improve safety on the smaller
aircraft that lack it.
FAA's Capstone Program in Alaska has shown that better technology can
reduce aircraft accidents. As described earlier, Alaska's challenging
operating conditions factored prominently in air cargo accidents over
the last decade. The Capstone Program funded technology upgrades that
provide pilots with information on terrain, weather, and air traffic.
FAA's goal was to reduce Alaska's higher-than-average aviation accident
rate. FAA has stated that an independent study found that, from 2000
through 2004, accidents for Capstone-equipped aircraft were reduced by
47 percent.
However, the experts on our panel were not unanimous about the
potential for improving safety through better on-board technologies.
The experts who represent the part 135 perspective did not rate
improving on-board safety systems as highly as the other experts did.
Only one of the six part 135 pilots or carriers we surveyed ranked this
as one of the top three potential improvements. The other five
indicated that improving on-board safety systems is not feasible or
would only slightly improve air cargo safety. For example, some part
135 ad hoc and feeder carriers we interviewed indicated that state-of-
the-art on-board safety systems are not affordable relative to the
value of the aircraft. Specifically, officials from one ad hoc cargo
carrier said that traffic collision avoidance systems (such as TCAS or
ADS-B) installed on a Cessna, valued at $100,000 to $200,000, would
make the biggest improvement in safety, but such a system would cost
about $25,000 to install on each aircraft, which the officials said was
not practical.
Tracking Part 135 Cargo Operations Ranked Second among Top Steps toward
Improving Air Cargo Safety among Experts:
As stated earlier, we were unable to determine accident rates for small
feeder or ad hoc cargo carriers because FAA does not track part 135
operations. However, operational data--such as flight hours or
landings--for on-demand part 135 cargo operations would allow analysts
to determine accident rates for all cargo carriers as they currently
can do for all part 121 (large) carriers. This is important because a
higher proportion of air cargo accidents and nearly all fatalities
occur to part 135 (small) carriers. Many experts who responded to our
survey indicated that better data on part 135 cargo flight and
operations could improve air cargo safety.[Footnote 30] Specifically,
tracking these data was ranked among the top measures with the greatest
potential by the second largest share of experts in our panel.
Industry experts and officials we spoke with said there is a need for
FAA to have this type of data. For example, NTSB has recommended in
2003 that FAA collect additional operational data from small air
carriers in order to generate accident and incident rate information
for all sectors of commercial aviation, including air cargo, but the
recommendation remains open because an FAA official said that FAA chose
not to collect the information. In addition, numerous industry
stakeholders told us that not having these data precludes FAA from
effectively targeting its safety initiatives. One of the experts on our
panel said that people might assume that the part 135 carriers with the
most accidents are the ones with the poorest safety records, but that
may not be the case when the number of operations is considered.
One official from a part 135 carrier said that the industry is
generally against greater reporting because it would increase workload.
However, he stated that if FAA begins requiring such data, companies
will find a way to comply because they already collect the data. We
interviewed part 135 carriers of various sizes, and they all indicated
that they already track operational data internally and could report
these data to FAA without a substantial additional effort, but this was
not designed to be a representative sample.
Pilot and Carrier Experts Are Divided on How Aligning Cargo Regulations
with Passenger Regulations Would Affect Air Cargo Safety:
As discussed earlier in this report, the regulations under which most
large cargo carriers typically operate (supplemental) differ from the
regulations under which most passenger carriers operate (domestic or
flag). Although part 121 pilot experts on our panel indicated that
aligning cargo regulations with passenger carrier regulations would
improve safety, carrier experts generally disagreed. All three pilots,
who fly under part 121, ranked alignment of regulations as the top
potential measure to improve air cargo safety. As an example, the Air
Line Pilots Association, the employee organization for most commercial
U.S. pilots, supports the alignment of duty time regulations for all
part 121 carriers. The Association believes that longer flight times
can increase pilot fatigue and thus increase mistakes and accidents,
and, as stated earlier in this report, the experts rated pilot fatigue
as a serious challenge to safe cargo operations. On the other hand,
none of the seven carrier experts ranked aligning cargo regulations
with passenger regulations among their top three potential measures for
improving air cargo safety. Five of them indicated that aligning
regulations would have a slight or no improvement, and the other two
indicated that aligning regulations would not be feasible.
Although not specifically related to cargo operations, NTSB has also
recommended that FAA revisit its time and duty regulations as they may
be related to fatigue. For example, in 2008, it recommended that FAA
develop guidance for operators to use in establishing fatigue
management systems and then continually assess the effectiveness of the
systems. It also recommended in 1995 that FAA review its flight and
duty time regulations to include the findings of fatigue and sleep
research. These recommendations remain open because FAA has not
completed its actions related to these issues. In commenting on a draft
of this report, FAA said that it convened a committee to address pilot
fatigue issues and that the data it collects may be used in future rule-
making efforts regarding pilot flight time, duty, and rest regulations.
Conducting Flight Risk Assessments before a Flight Can Help Reduce
Accumulated Risk and, According to Experts, Improve Safety:
As described earlier, many air cargo accidents over the last 10 years
occurred in conditions of accumulated risk--when several risk elements
were present, but none was individually significant enough to result in
the flight's cancellation. FAA, the Flight Safety Foundation, and NATA
have each developed tools that pilots or carriers could voluntarily use
to assess accumulated risk factors and determine if the flight should
go forward. These tools assign values to various risk elements, such as
single pilot operations, night flights, and flights into areas without
accurate weather reports. See appendix III for FAA's sample flight risk
assessment tool.
Eight of the 27 experts on our cargo safety panel ranked flight risk
assessment as one of the three potential efforts that could most
improve safety. Additionally, 18 experts indicated that incorporating
flight risk assessment checklists into air cargo daily operations would
have a moderate or great effect on improving the safety of their
operations. One expert on our panel said that flight risk assessment
cannot prevent all accidents and that not all flights with multiple
accumulated risk factors have accidents, but assessing the risk factors
may help pilots reduce the number of cargo accidents by recognizing
when the accumulated risks become unacceptably high and at which point
pilots would either find ways to mitigate those risk factors or delay
the flight.
Despite the high level of support among our expert panelists for using
flight risk assessment checklists, only 1 of the 10 carriers we
interviewed used them in their daily operations. Officials from one
part 135 carrier said that carriers are busy enough doing all the
things that FAA requires to worry too much about ideas that might be
very productive but are nonetheless optional. Other experts pointed out
that all of the flight risk assessment checklists currently available
were designed for passenger operations and that cargo carriers would
have to tailor the tools to their needs--potentially a critical
obstacle to implementation.
Conclusions:
Aviation in the United States remains safe and air cargo accidents have
declined over the last 10 years, although fatal accidents do occur
every year. Most of those accidents and nearly all of the fatal
accidents in the last decade have happened to feeder and ad hoc
carriers. However, the lack of operational data for part 135 carriers,
which make up the bulk of the feeder and ad hoc carriers, makes it
impossible to determine accident and fatality rates for small carriers
or to track cargo-wide accident or fatality rates over time. FAA's
information on small carrier operations is based on its annual survey
of aircraft owners, which does not differentiate between passenger and
cargo operations, making it impossible to use the survey results for
cargo operators. While the numbers of accidents suggest that the
fatality rates for feeder and ad hoc carriers are higher than the rates
for large carriers, it is impossible to know how much higher the
fatality rates are for feeder and ad hoc carriers without data on the
numbers of operations for all types of cargo aircraft. It is also
difficult for FAA and industry to target further safety improvements to
the areas with the highest risk.
Despite the higher numbers of accidents and fatal accidents among small
cargo carriers, FAA's safety programs have focused primarily on large
cargo carriers, the industry segment in which accidents and accident
rates have steadily declined. While it makes sense to focus first on
large carriers, which operate larger aircraft with larger crews and
cargo holds, the safety of the smaller aircraft is also important.
There is nothing intrinsic to small carriers that precludes risk-based
oversight, voluntary disclosure programs, or the use of SMSs, but these
efforts are usually targeted toward, or at least primarily used by, the
large cargo carriers. However, cost is a concern for carriers, and poor
economic conditions throughout the air cargo sector may mean that few
funds will be available in the near term for new safety initiatives.
In addition, FAA has increasingly focused on potential accident
precursors that would reduce the risk of accidents before a related
accident even occurs. However, neither FAA nor NTSB systematically
tracks incidents in a way that would allow empirical analysis, even
though incidents are widely viewed as accident precursors. Over half of
the fatal air cargo accidents since 1997 had multiple risk factors.
However, preflight risk assessment checklists are not required to be
used within the cargo industry. The concept of assessing and
recognizing accumulated risk through flight risk assessment presents an
additional low-cost opportunity for identifying and reducing the risk
associated with some cargo flights that might otherwise go unnoticed.
Recommendations:
To help FAA improve the data on and the safety of air cargo operations,
we recommend that the Secretary of Transportation direct the FAA
Administrator to take the following four actions:
* Gather comprehensive and accurate data on all part 135 cargo
operations to gain a better understanding of air cargo accident rates
and better target safety initiatives. This can be done by separating
out cargo activity in FAA's annual survey of aircraft owners or by
requiring all part 135 cargo carriers to report operational data as
part 121 carriers currently do.
* Promote the increased use of safety programs by small (feeder and ad
hoc) cargo carriers that use the principles underpinning SMS and
voluntary self-disclosure programs.
* Evaluate the likelihood that cargo incidents could be precursors to
accidents and, if FAA determines they are, create a process for
capturing incidents that would allow in-depth analysis of incidents to
identify accident precursors related to specific carriers, locations,
operations, and equipment.
* Create incentives for cargo carriers to use flight risk assessment
checklists in their daily operations, including tailoring a sample
flight risk assessment checklist for part 135 cargo carriers.
Agency Comments:
We provided copies of a draft of this report to DOT and NTSB for their
review and comment. Both agencies provided technical comments, which we
incorporated as appropriate.
We are sending copies of this report to interested congressional
committees, the Secretary of Transportation, and the Chairman of the
National Transportation Safety Board. We are also making copies
available to others on request. In addition, this report is available
at no charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-2834 or dillinghamg@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix IV.
Signed by:
Gerald L. Dillingham, Ph.D.
Director, Physical Infrastructure Issues:
[End of section]
Appendix I: Objective, Scope, and Methodology:
Our objective in conducting this study was to review the nature and
extent of safety issues in the air cargo industry and what the Federal
Aviation Administration (FAA) and others are doing and could do to
address them. To accomplish this objective, we established the
following research questions: (1) What have been recent trends in air
cargo safety? (2) What factors have contributed to air cargo accidents
in recent years? (3) What have FAA and the industry done to improve air
cargo safety, and how do experts view the effectiveness of these
efforts? (4) What do experts say FAA and industry could do to further
improve air cargo safety?
To determine trends in air cargo safety, we obtained and analyzed
accident and incident data for calendar years 1997 through 2008.
* From the National Transportation Safety Board (NTSB), we obtained
accident data for part 121 and part 135 all-cargo and mail operations
that occurred from January 1, 1997, through December 31, 2008. To
capture the full extent of cargo operations in Alaska, however, we also
included passenger/cargo accidents because Alaska's by-pass mail
system, which requires carriers to have a certain share of the
passenger market to obtain a by-pass mail contract, resulted in fewer
all-cargo carriers in that state. From these data we identified 443
fixed-wing aircraft accidents, including 93 fatal accidents. Six of the
accidents involved 2 aircraft, so our data included a total of 449
accident aircraft.
* From FAA, we obtained data on part 121 and part 135 fixed-wing all-
cargo accidents and incidents that occurred from January 1, 1997,
through December 31, 2007. From these data, we eliminated accidents
that were also included in the NTSB data, for a total of 937 accidents
and incidents. To avoid confusion when discussing the two data sets, we
refer to the FAA data as "incidents" and the NTSB data as "accidents."
Because we are familiar with and have previously determined that these
data were sufficiently reliable for the nationwide descriptive and
comparative analyses used in this report, we interviewed agency
officials knowledgeable about the databases from which the data were
derived to determine that the accident and incident data used in this
report continue to be sufficiently reliable for the types of analyses
we performed. We also obtained information on industry trends by
conducting a literature search and reviewing the resulting documents,
conducting a survey of air cargo experts, and interviewing officials
and reviewing relevant documents from FAA, the Pipeline and Hazardous
Materials Safety Administration (PHMSA), air cargo industry
associations, air cargo carriers, airports, an employee group, and
others.
We also conducted site visits to Alaska, Ohio, and Texas. Those
locations were selected to be geographically diverse and as the states
with the largest number of air cargo accidents or because of the
relatively large number of air cargo carriers of various sizes located
there.
To assess what factors have contributed to air cargo accidents in
recent years, we conducted several analyses. First, to determine
prominent accident causes, we analyzed data on probable causes and
contributing factors from completed NTSB investigations of 417 air
cargo accidents. Second, to assess accumulated risk, we applied FAA's
proposed flight risk assessment tool to NTSB's reports on the 93 fatal
cargo accidents that occurred during our review period. To do this, we
searched each accident report for the 38 risk factors in the tool, such
as "pilot flight time less than 100 hours in the last 90 days." For
each factor found, we noted its corresponding risk value on an Excel
spreadsheet and tabulated the total score as well as the total number
of risk factors for each fatal accident. Third, for indications of
other factors contributing to air cargo accidents, we surveyed a panel
of air cargo experts, which is discussed in more detail later below;
analyzed documents and interviewed officials from FAA, PHMSA, NTSB, air
cargo industry associations, air cargo carriers, airports, an employee
group, and others; and conducted site visits to Alaska, Ohio, and Texas
(see the previous paragraph).
To determine what FAA and the air cargo industry have done to improve
safety, we interviewed FAA and industry officials, reviewed key
documents, and analyzed FAA's oversight and enforcement data for all-
cargo carriers. We interviewed officials and tested the data and found
it sufficiently reliable for our purposes. To obtain experts' opinions
about how FAA and the air cargo industry could further air cargo
safety, we surveyed a panel of 27 air cargo safety experts. The experts
rated and provided relative rankings on the effectiveness of current
efforts to improve air cargo safety, the severity of safety challenges
faced by the air cargo sector of aviation, and the potential
improvements that additional efforts could have on air cargo safety. We
selected the panel of experts with the assistance of the National
Academy of Sciences to represent the perspectives of a cross-section of
air cargo stakeholders. The specific experts, their affiliation, and
their expert perspectives are listed below.
Table 3: Air Cargo Expert Panelists:
Large cargo carriers:
1;
Name: Robert Gray;
Title: Vice President, Regulatory Compliance and Government Affairs;
Affiliation: ABX Air.
2;
Name: David A. Prewitt;
Title: Managing Director, Air Safety and Regulatory Compliance;
Affiliation: Federal Express.
3;
Name: Christopher Williams;
Title: Director of Airline Safety;
Affiliation: UPS Airlines.
Feeder and ad hoc cargo carriers:
4;
Name: Teak Biondo;
Title: Operations Director;
Affiliation: Ameristar.
5;
Name: Richard Mills;
Title: Director of Safety and Compliance;
Affiliation: Empire Airlines.
6;
Name: Jacqueline Rosser;
Title: Executive Director;
Affiliation: Air Charter Safety Foundation.
7;
Name: Thomas D. Schaner;
Title: Director of Operations;
Affiliation: AirNet Systems.
Larger aircraft cargo pilots:
8;
Name: Captain Bill McReynolds;
Title: Pilot;
Affiliation: Federal Express.
9;
Name: Captain Dennis Nugent;
Title: Pilot;
Affiliation: Kalitta Airlines.
10;
Name: Captain Ken Young;
Title: Pilot;
Affiliation: ASTAR Air Cargo.
Smaller aircraft cargo pilots:
11;
Name: Michael Looby;
Title: Chief Pilot;
Affiliation: Castle Aviation.
12;
Name: Quinn Hammon;
Title: Chief Pilot;
Affiliation: AirNet.
Federal government:
13;
Name: Anthony J. Broderick;
Title: Associate Administrator for Regulation and Certification
(retired);
Affiliation: FAA.
14;
Name: Peter Neff;
Title: Aviation Safety Inspector & Operations Specialist;
Affiliation: FAA.
15;
Name: Joseph M. Sedor;
Title: Senior Air Safety Investigator;
Affiliation: NTSB.
Cargo aircraft manufacture and conversion:
16;
Name: Nils Lache;
Title: Head of Cargo, Freighter, and GHS Definition Cabin & Cargo
Customization;
Affiliation: Airbus.
17;
Name: Paul D. Russell;
Title: Chief Engineer, Aviation System Safety;
Affiliation: Boeing Commercial Airplanes.
18;
Name: David Steinmetz;
Title: Vice President and General Manager;
Affiliation: Precision Conversions, LLC.
Cargo loaders:
19;
Name: Robert Kiss;
Title: Vice President, Ground Operations;
Affiliation: Atlas Air Worldwide Holdings Cargo.
Cargo airports:
20;
Name: Charles T. Miller;
Title: Executive Director;
Affiliation: Louisville Regional Airport Authority.
21;
Name: Robert W. O'Brien, Jr.;
Title: Executive Director;
Affiliation: Greater Rockford Airport Authority.
22;
Name: Jim Iagulli;
Title: Operations Manager;
Affiliation: Ted Stevens Anchorage International Airport.
Human factors and safety performance:
23;
Name: R. Wade Allen;
Title: President and Technical Director;
Affiliation: Systems Technology, Inc.
24;
Name: James Burin;
Title: Director, Technical Programs;
Affiliation: Flight Safety Foundation.
25;
Name: John K. Lauber;
Title: Large cargo carriers: Senior Vice President and Chief Product
Safety Officer (retired);
Affiliation: Airbus.
26;
Name: Dr. Terry L. von Thaden;
Title: Assistant Professor;
Affiliation: University of Illinois Institute of Aviation, Human
Factors Division.
International:
27;
Name: Jean Abouchaar;
Title: Director of Cargo, Regulatory and Industrial Affairs (retired);
Affiliation: International Air Transport Association.
Source: GAO.
[End of table]
To develop our survey of air cargo experts, we reviewed existing
studies about air cargo safety, including previous and ongoing GAO
work, and interviewed air cargo safety stakeholders. GAO subject matter
experts designed draft questionnaires in close collaboration with a
social science survey specialist. We conducted pretests with four
people knowledgeable in the field of air cargo (representatives from
air carriers, airports, and air transportation associations) to help
further refine our questions, develop new questions, clarify any
ambiguous portions of the survey, and identify any potentially biased
questions. These pretests were conducted in-person and by telephone. We
worked with the National Academy of Sciences and internally to develop
the panel of experts and obtain contact information.
We launched our Web-based survey on August 18, 2008, and received all
responses by November 5, 2008. Log-in information to the Web-based
survey was e-mailed to participants. We sent one follow-up e-mail
message to all nonrespondents a week later, and contacted by telephone
all those who had not completed the questionnaire within 3 weeks. We
received responses from all 27 of our selected experts.
Because our survey was not a sample survey, there are no sampling
errors; however, the practical difficulties of conducting any survey
may introduce nonsampling errors. For example, differences in how a
particular question is interpreted, the sources of information
available to respondents, or the types of people who do not respond can
introduce unwanted variability into the survey results. We included
steps in both the data collection and data analysis stages for the
purpose of minimizing such nonsampling errors. As indicated above, GAO
subject matter experts collaborated with a social science survey
specialist to design draft questionnaires, and versions of the
questionnaire were pretested with four knowledgeable people in the air
cargo field. From these pretests, we made revisions as necessary. We
examined the survey results and performed computer analyses to identify
inconsistencies and other indications of error. A second, independent
analyst checked the accuracy of all computer analyses.
[End of section]
Appendix II Expert Responses to GAO Survey:
We worked with the National Academy of Sciences to identify air cargo
experts that included carrier, pilot, airport, aircraft manufacturer,
government, and human factors and safety performance perspectives. We
sent our Web-based survey to 27 air cargo experts and received
responses from all 27 experts. Our survey was composed of closed-and
open-ended questions. In this appendix, we include all the survey
questions and aggregate results of responses to the closed-ended
questions; we do not provide information on responses provided to the
open-ended questions. For a more detailed discussion of our survey
methodology, see appendix I.
Q1. In your opinion, how effective, if at all, is each of the following
current efforts to improve the safety of cargo-only flights?
a. Federal Aviation Administration (FAA) airworthiness directives or
FAA operational specifications that affect air cargo;
Not effective: 1;
Slightly effective: 6;
Moderately effective: 9;
Greatly effective: 8;
Unable to judge: 3;
Number of respondents: 27.
b. FAA informational materials and seminars related to cargo-only
safety;
Not effective: 2;
Slightly effective: 8;
Moderately effective: 13;
Greatly effective: 0;
Unable to judge: 4;
Number of respondents: 27.
c. FAA oversight and inspections;
Not effective: 2;
Slightly effective: 7;
Moderately effective: 11;
Greatly effective: 5;
Unable to judge: 2;
Number of respondents: 27.
d. National Transportation Safety Board's (NTSB) public meetings,
hearings, and forums;
Not effective: 6;
Slightly effective: 6;
Moderately effective: 9;
Greatly effective: 4;
Unable to judge: 2;
Number of respondents: 27.
e. The implementation of NTSB safety recommendations that affect cargo-
only operations;
Not effective: 4;
Slightly effective: 9;
Moderately effective: 6;
Greatly effective: 5;
Unable to judge: 3;
Number of respondents: 27.
f. Cargo-only carriers' participation in FAA's voluntary safety
disclosure programs;
Not effective: 0;
Slightly effective: 4;
Moderately effective: 5;
Greatly effective: 14;
Unable to judge: 4;
Number of respondents: 27.
g. Trade association endeavors to work within their membership to
improve cargo safety;
Not effective: 0;
Slightly effective: 5;
Moderately effective: 9;
Greatly effective: 11;
Unable to judge: 2;
Number of respondents: 27.
h. Trade association endeavors to advocate that others beyond their
members, including FAA and Congress, make cargo safety improvements;
Not effective: 1;
Slightly effective: 6;
Moderately effective: 10;
Greatly effective: 6;
Unable to judge: 4;
Number of respondents: 27.
i. Carrier implementation of safety management systems;
Not effective: 0;
Slightly effective: 7;
Moderately effective: 6;
Greatly effective: 11;
Unable to judge: 3;
Number of respondents: 27.
j. Airport implementation of safety management systems;
Not effective: 1;
Slightly effective: 5;
Moderately effective: 6;
Greatly effective: 6;
Unable to judge: 9;
Number of respondents: 27.
Q2. Considering the above list of efforts (question 1 a-j), which three
do you believe are the most effective in improving air cargo safety?
a. Federal Aviation Administration (FAA) airworthiness directives or
FAA operational specifications that affect air cargo;
Most effective: 7;
Second most effective: 1;
Third most effective: 2.
b. FAA informational materials and seminars related to cargo-only
safety;
Most effective: 0;
Second most effective: 1;
Third most effective: 0.
c. FAA oversight and inspections;
Most effective: 2;
Second most effective: 3;
Third most effective: 0.
d. National Transportation Safety Board's (NTSB) public meetings,
hearings, and forums;
Most effective: 0;
Second most effective: 4;
Third most effective: 1.
e. The implementation of NTSB safety recommendations that affect cargo-
only operations;
Most effective: 1;
Second most effective: 2;
Third most effective: 6.
f. Cargo-only carriers' participation in FAA's voluntary safety
disclosure programs;
Most effective: 7;
Second most effective: 5;
Third most effective: 4.
g. Trade association endeavors to work within their membership to
improve cargo safety;
Most effective: 3;
Second most effective: 6;
Third most effective: 5.
h. Trade association endeavors to advocate that others beyond their
members, including FAA and Congress, make cargo safety improvements;
Most effective: 1;
Second most effective: 1;
Third most effective: 3.
i. Carrier implementation of safety management systems;
Most effective: 6;
Second most effective: 3;
Third most effective: 4.
j. Airport implementation of safety management systems;
Most effective: 0;
Second most effective: 1;
Third most effective: 2.
Q3. Besides the efforts listed above, do you know of any other current
significant efforts to improve cargo-only aviation safety? If so,
please explain.
Q4. In your opinion, how much of a challenge, if any, does each of the
following issues pose to safely operating cargo-only flights?
a. Pilot fatigue related to nighttime flying, ineffective rest periods,
or commuting;
Not a challenge: 2;
Slight challenge: 4;
Moderate challenge: 12;
Great challenge: 8;
Unable to judge: 1;
Number of respondents: 27.
b. Carrier policies that, by their nature, give pilots economic
incentive to fly in less-than-ideal conditions;
Not a challenge: 6;
Slight challenge: 8;
Moderate challenge: 2;
Great challenge: 5;
Unable to judge: 6;
Number of respondents: 27.
c. Flights scheduled with less than 4 hours of notice given to the
crew;
Not a challenge: 6;
Slight challenge: 9;
Moderate challenge: 3;
Great challenge: 4;
Unable to judge: 4;
Number of respondents: 26.
d. Low piloting experience overall, as well as low piloting experience
in the specific types of cargo aircraft operated;
Not a challenge: 3;
Slight challenge: 4;
Moderate challenge: 12;
Great challenge: 6;
Unable to judge: 2;
Number of respondents: 27.
e. Single-pilot operations;
Not a challenge: 2;
Slight challenge: 9;
Moderate challenge: 5;
Great challenge: 6;
Unable to judge: 4;
Number of respondents: 26.
f. Variation within the cargo-only sector regarding the priority given
to safety;
Not a challenge: 5;
Slight challenge: 2;
Moderate challenge: 8;
Great challenge: 10;
Unable to judge: 2;
Number of respondents: 27.
g. Availability of aircraft rescue and fire-fighting services provided
by persons with cargo-specific knowledge and training;
Not a challenge: 8;
Slight challenge: 6;
Moderate challenge: 7;
Great challenge: 5;
Unable to judge: 1;
Number of respondents: 27.
h. Difficult cargo-only flight and operating conditions (e.g., airports
with limited technology, mountainous terrain, nighttime operations);
Not a challenge: 1;
Slight challenge: 9;
Moderate challenge: 9;
Great challenge: 6;
Unable to judge: 2;
Number of respondents: 27.
i. Alaska's aviation and operating environment;
Not a challenge: 2;
Slight challenge: 5;
Moderate challenge: 8;
Great challenge: 5;
Unable to judge: 7;
Number of respondents: 27.
j. The handling and transport of undeclared but potentially hazardous
materials;
Not a challenge: 3;
Slight challenge: 5;
Moderate challenge: 7;
Great challenge: 12;
Unable to judge: 0;
Number of respondents: 27.
k. The handling and transport of declared hazardous materials;
Not a challenge: 9;
Slight challenge: 10;
Moderate challenge: 5;
Great challenge: 3;
Unable to judge: 0;
Number of respondents: 27.
l. Cargo loading issues (e.g., weight and balance, shifting);
Not a challenge: 6;
Slight challenge: 9;
Moderate challenge: 7;
Great challenge: 3;
Unable to judge: 2;
Number of respondents: 27.
m. Differences in federal safety standards between some cargo-only and
passenger flights;
Not a challenge: 9;
Slight challenge: 8;
Moderate challenge: 5;
Great challenge: 4;
Unable to judge: 1;
Number of respondents: 27.
n. The ability to obtain quality parts for, and/or maintain the
airworthiness of, older cargo-only aircraft;
Not a challenge: 7;
Slight challenge: 7;
Moderate challenge: 5;
Great challenge: 6;
Unable to judge: 1;
Number of respondents: 26.
Q5. Considering the above list of challenges (question 4 a-n), which
three do you believe are the greatest challenges to air cargo safety?
a. Pilot fatigue related to nighttime flying, ineffective rest periods,
or commuting;
Greatest challenge: 7;
Second greatest challenge: 2;
Third greatest challenge: 3.
b. Carrier policies that, by their nature, give pilots economic
incentive to fly in less-than-ideal conditions;
Greatest challenge: 0;
Second greatest challenge: 3;
Third greatest challenge: 1.
c. Flights scheduled with less than 4 hours of notice given to the
crew;
Greatest challenge: 1;
Second greatest challenge: 0;
Third greatest challenge: 1.
d. Low piloting experience overall, as well as low piloting experience
in the specific types of cargo aircraft operated;
Greatest challenge: 3;
Second greatest challenge: 6;
Third greatest challenge: 1.
e. Single-pilot operations;
Greatest challenge: 1;
Second greatest challenge: 2;
Third greatest challenge: 1.
f. Variation within the cargo-only sector regarding the priority given
to safety;
Greatest challenge: 4;
Second greatest challenge: 1;
Third greatest challenge: 6.
g. Availability of aircraft rescue and fire-fighting services provided
by persons with cargo-specific knowledge and training;
Greatest challenge: 0;
Second greatest challenge: 1;
Third greatest challenge: 1.
h. Difficult cargo-only flight and operating conditions (e.g., airports
with limited technology, mountainous terrain, nighttime operations);
Greatest challenge: 1;
Second greatest challenge: 2;
Third greatest challenge: 6.
i. Alaska's aviation and operating environment;
Greatest challenge: 1;
Second greatest challenge: 4;
Third greatest challenge: 0.
j. The handling and transport of undeclared but potentially hazardous
materials;
Greatest challenge: 7;
Second greatest challenge: 1;
Third greatest challenge: 3.
k. The handling and transport of declared hazardous materials;
Greatest challenge: 0;
Second greatest challenge: 0;
Third greatest challenge: 2.
l. Cargo loading issues (e.g., weight and balance, shifting);
Greatest challenge: 0;
Second greatest challenge: 2;
Third greatest challenge: 0.
m. Differences in federal safety standards between some cargo-only and
passenger flights;
Greatest challenge: 1;
Second greatest challenge: 1;
Third greatest challenge: 0.
n. The ability to obtain quality parts for, and/or maintain the
airworthiness of, older cargo-only aircraft;
Greatest challenge: 1;
Second greatest challenge: 2;
Third greatest challenge: 1.
Q6. Besides the challenges listed above, do you know of any other
significant challenges to safe cargo-only air operations? If so, please
explain.
Q7. In your opinion, how much improvement, if any, in the safety of
cargo-only air operations would be provided if each of the following
measures were implemented?
a. FAA increasing the amount of on-site inspections that it conducts;
No improvement: 4;
Slight improvement: 14;
Moderate improvement: 4;
Great improvement: 4;
Not feasible: 1;
Unable to judge: 0;
Number of respondents: 27.
b. FAA improving inspector training and knowledge of cargo-only air
operations;
No improvement: 2;
Slight improvement: 4;
Moderate improvement: 10;
Great improvement: 9;
Not feasible: 0;
Unable to judge: 1;
Number of respondents: 26.
c. Carriers and flight schools providing better training for cargo-only
pilots;
No improvement: 3;
Slight improvement: 8;
Moderate improvement: 11;
Great improvement: 3;
Not feasible: 0;
Unable to judge: 2;
Number of respondents: 27.
d. The Department of Transportation (DOT) or Transportation Security
Administration (TSA) increasing shipper knowledge and declaration of
hazardous materials;
No improvement: 5;
Slight improvement: 6;
Moderate improvement: 7;
Great improvement: 9;
Not feasible: 0;
Unable to judge: 0;
Number of respondents: 27.
e. DOT or TSA promoting better shipper compliance with rules for the
handling and transport of declared hazardous materials;
No improvement: 4;
Slight improvement: 7;
Moderate improvement: 7;
Great improvement: 8;
Not feasible: 0;
Unable to judge: 1;
Number of respondents: 27.
f. FAA setting uniform standards for ramp employees involved in loading
and unloading cargo;
No improvement: 4;
Slight improvement: 11;
Moderate improvement: 5;
Great improvement: 4;
Not feasible: 3;
Unable to judge: 0;
Number of respondents: 27.
g. Industry setting uniform standards for ramp employees involved in
loading and unloading cargo;
No improvement: 0;
Slight improvement: 10;
Moderate improvement: 7;
Great improvement: 6;
Not feasible: 3;
Unable to judge: 1;
Number of respondents: 27.
h. Cargo operators incorporating flight risk assessment checklists into
their daily operations;
No improvement: 2;
Slight improvement: 7;
Moderate improvement: 12;
Great improvement: 6;
Not feasible: 0;
Unable to judge: 0;
Number of respondents: 27.
i. FAA collecting and using part 135 and part 91 cargo flight and
operations data to better target safety efforts;
No improvement: 2;
Slight improvement: 6;
Moderate improvement: 6;
Great improvement: 9;
Not feasible: 0;
Unable to judge: 4;
Number of respondents: 27.
j. FAA bringing cargo-only standards into alignment with those for
passenger operations;
No improvement: 9;
Slight improvement: 5;
Moderate improvement: 4;
Great improvement: 7;
Not feasible: 2;
Unable to judge: 0;
Number of respondents: 27.
k. Owners installing state-of-the-art onboard safety technology on all
cargo-only aircraft;
No improvement: 0;
Slight improvement: 5;
Moderate improvement: 7;
Great improvement: 9;
Not feasible: 5;
Unable to judge: 1;
Number of respondents: 27.
Q8. Considering the above list of possible measures (question 7 a-k),
which three do you believe would provide the greatest improvement to
air cargo safety?
a. FAA increasing the amount of on-site inspections that it conducts;
Greatest improvement: 3;
Second greatest improvement: 1;
Third greatest improvement: 1.
b. FAA improving inspector training and knowledge of cargo-only air
operations;
Greatest improvement: 3;
Second greatest improvement: 1;
Third greatest improvement: 2.
c. Carriers and flight schools providing better training for cargo-only
pilots;
Greatest improvement: 2;
Second greatest improvement: 1;
Third greatest improvement: 2.
d. The Department of Transportation (DOT) or Transportation Security
Administration (TSA) increasing shipper knowledge and declaration of
hazardous materials;
Greatest improvement: 3;
Second greatest improvement: 4;
Third greatest improvement: 1.
e. DOT or TSA promoting better shipper compliance with rules for the
handling and transport of declared hazardous materials;
Greatest improvement: 0;
Second greatest improvement: 4;
Third greatest improvement: 2.
f. FAA setting uniform standards for ramp employees involved in loading
and unloading cargo;
Greatest improvement: 1;
Second greatest improvement: 2;
Third greatest improvement: 1.
g. Industry setting uniform standards for ramp employees involved in
loading and unloading cargo;
Greatest improvement: 2;
Second greatest improvement: 2;
Third greatest improvement: 3.
h. Cargo operators incorporating flight risk assessment checklists into
their daily operations;
Greatest improvement: 2;
Second greatest improvement: 3;
Third greatest improvement: 3.
i. FAA collecting and using part 135 and part 91 cargo flight and
operations data to better target safety efforts;
Greatest improvement: 2;
Second greatest improvement: 4;
Third greatest improvement: 5.
j. FAA bringing cargo-only standards into alignment with those for
passenger operations;
Greatest improvement: 4;
Second greatest improvement: 2;
Third greatest improvement: 2.
k. Owners installing state-of-the-art onboard safety technology on all
cargo-only aircraft;
Greatest improvement: 5;
Second greatest improvement: 3;
Third greatest improvement: 4.
Q9. Besides the possible measures listed above, do you have any other
suggestions for significantly improving cargo-only aviation safety? If
so, please explain.
Q10. Please provide any other comments that you have regarding cargo-
only safety.
[End of section]
Appendix III: FAA's Sample Flight Risk Assessment Tool:
InFO:
Information for Operators:
U.S. Department of Transportation:
Federal Aviation Administration:
InFO 07015
Approved by: AFS-200:
Date: 7/3/2007:
Flight Standards Service:
Washington, DC:
[hyperlink,
http://www.faa.gov/other_visit/aviation_industry/airline_operators/airli
ne_safety/info]
An InFO contains valuable information for operators that should help
them meet certain administrative, regulatory, or operational
requirements with relatively low urgency or impact on safety.
Subject: Flight Risk Assessment Tool:
Purpose: This InFO describes the proactive identification of possible
hazards and the use of risk management tools to mitigate risks as
aspects of a Safety Management System (SMS). These tools will provide
ways for air operators to determine which flights have more risk and
allow operators to intervene and reduce risk when possible. Risk
assessment tools are only part of an SMS and should not be considered
the whole system.
Background: Over the years the Federal Aviation Administration (FAA)
and the aviation industry have dramatically increased the safety of air
travel by managing and mitigating risks associated with flight. The
aviation industry currently provides the safest form of transportation
in the United States. However, the industry continues to have some
accidents that can be prevented. Therefore, both the FAA and industry
are working to continually improve the safety record of turbine-powered
aircraft. Over the next few years, the FAA will encourage operators and
certificate holders to develop Safety Management Systems (SMS). This
safety protocol is described in Advisory Circular (AC) 120-92,
Introduction to Safety Management Systems for Air Operators.
The Turbine Aircraft Operations Subgroup as part of the General
Aviation Joint Steering Committee has developed a risk assessment tool
for use in flight operations. In creating this tool, the Turbine
Aircraft Operations Subgroup reviewed accident data, identified
hazards, and used normal risk assessment development methodology. This
tool provides a simple way to implement proactive risk management. An
operator can use the risk assessment tool as a standalone tool but
incorporating it into an SMS is preferable.
Discussion: As discussed in AC 120-92, a hazard is defined as any
existing or potential condition that can lead to injury, illness, or
death to people; damage to or loss of a system, equipment, or property;
or damage to the environment. A hazard is a condition that is a
prerequisite of an accident or incident.
Every flight has hazards and some level of risk associated with it. It
is critical that operators and pilots arc able to differentiate, in
advance, between a low risk flight and a high risk flight, and then
establish a review process and develop risk mitigation strategies to
address flights throughout that range. A risk assessment tool should
allow operators and pilots to see the risk profile of a flight in its
planning stages. Each operator should determine an acceptable level of
risk for its flights based on the type of operation, environment,
aircraft used, crew training, and overall operating experience. When
the risk for a flight exceeds the acceptable level, the hazards
associated with that risk should be further evaluated and the risk
reduced. A higher risk flight should not be operated if the hazards
cannot be mitigated to an acceptable level.
The attached risk assessment tool has been developed for use in
understanding different levels of flight risk and to allow operators
and pilots to become familiar with this element of an SMS. It is
important for operators to understand that risk has several elements
that must be considered, including probability, severity, and weighted
value. What is the probability of a particular event occurring? If the
event does occur, what is the severity likely to be? And what is the
weighted value of this type of event compared to other aspects of the
operation? In the attached risk assessment tool, this work has been
done so the operator has a simplified form of the tool. Each operator
may want to add items that are unique to its operation using the
additional resources provided. An operator can also change any item
currently used in the tool provided it conducts a realistic assessment
of the hazard being changed.
To use the tool, the operator will need to create numerical thresholds
that trigger additional levels of scrutiny prior to a go/no-go decision
for the flight. These thresholds should be created to help ensure that
the safety standards of each individual operation are maintained.
However, it is important that the operator create realistic thresholds.
If every flight is within the acceptable range under any condition, it
is likely that the thresholds have not been set correctly. Small
operations (for example, where the pilot is also the chief pilot and
owner) should consider strategies for appropriate consideration of
elevated risk that best fit their operation.
Recommended Action: The FAA recommends that operators and pilots
familiarize themselves with the attached risk assessment tool and AC
120-92. They should then decide whether to use the tool as published or
to modify it as needed for their own operations. Once an operator has
established the parameters of the tool, it should create operational
thresholds and begin using the tool to establish a "risk number" for
each flight. This risk number should be used to control risk before a
flight takes place. Over time this tool will become unique to each
operator and can become a part of its complete SMS. The risk assessment
tool cannot guarantee a safe flightsafety is ultimately the
responsibility of the pilot and operator. However, it does provide an
additional tool to help the pilot and operator make sound safety
decisions.
Flight Risk Assessment Tool:
Date:
Departure:
Release/Trip #:
Tail #:
Destination:
Pilot Qualifications and Experience:
1. Captain with less than 200 hours in type:
Risk Value: 5;
Flight Value:
2. First Officer with less than 200 hours in type:
Risk Value: 5;
Flight Value:
3. Single Pilot Flight:
Risk Value: 5;
Flight Value:
4. Captain with less than 100 hours last 90 days:
Risk Value: 3;
Flight Value:
5. First Officer with less than 100 hours last 90 days:
Risk Value: 3;
Flight Value:
6. Duty day greater than 12 hours:
Risk Value: 4;
Flight Value:
7. Flight time (Greater than 8 hours in the duty day):
Risk Value: 4;
Flight Value:
8. Crew Rest (Less than 10 hours prior to the duty day):
Risk Value: 5;
Flight Value:
Total Factor Score - Section 1:
Operating Environment:
9. VOR/GPS/LOC/ADF (Best approach available w/o vertical guidance):
Risk Value: 3;
Flight Value:
10. Circling approach (best available approach):
Risk Value: 4;
Flight Value:
11. No published approaches:
Risk Value: 4;
Flight Value:
12. Mountainous airport:
Risk Value: 5;
Flight Value:
13. Control tower not operational at ETA or ETD:
Risk Value: 3;
Flight Value:
14. Uncontrolled airport:
Risk Value: 5;
Flight Value:
15. Alternate airport not selected:
Risk Value: 4;
Flight Value:
16. Elevation of primary airport greater than 5000 ft. MSL):
Risk Value: 3;
Flight Value:
17. Wet runway:
Risk Value: 3;
Flight Value:
18. Contaminated runway:
Risk Value: 3;
Flight Value:
19. Winter operation:
Risk Value: 3;
Flight Value:
20. Twilight operation:
Risk Value: 2;
Flight Value:
21. Night operation:
Risk Value: 5;
Flight Value:
22. Stopping distance greater than 80% of available runway:
Risk Value: 5;
Flight Value:
23. Repositioning flight (no passengers or cargo):
Risk Value: 5;
Flight Value:
24. Pop up trip (Less than 4 hours crew notice):
Risk Value: 3;
Flight Value:
25. International operation:
Risk Value: 2;
Flight Value:
26. No weather reporting at destination:
Risk Value: 5;
Flight Value:
27. Thunderstorms at departure and/or destination:
Risk Value: 4;
Flight Value:
28. Severe turbulence:
Risk Value: 5;
Flight Value:
29. Ceiling & visibility at destination less than 500 ft./2 sm:
Risk Value: 3;
Flight Value:
30. Heavy rain at departure and/or destination:
Risk Value: 5;
Flight Value:
31. Frozen precipitation at departure and/or destination:
Risk Value: 3;
Flight Value:
32. Icing (moderate-severe):
Risk Value: 5;
Flight Value:
33. Surface winds greater than 30 knots:
Risk Value: 4;
Flight Value:
34. Crosswinds greater than 15 knots:
Risk Value: 4;
Flight Value:
35. Runway braking action less than good:
Risk Value: 5;
Flight Value:
Total Factor Score - Section 2:
Equipment:
36. Special Flight Permit Operation (ferry permit):
Risk Value: 3;
Flight Value:
37. MEL/COL Items (items related to safety of flight):
Risk Value: 2;
Flight Value:
38. Special flight limitations based on AFM equipment limitations:
Risk Value: 2.
Flight Value:
Total Factor Score - Section 3:
Totals:
Example: Use of Flight Risk Assessment Tool:
The following discussion provides a practical example of the five step
process used to assess risk as outlined in AC 120-92. The example
involves the operation of a night flight where the destination airport
is experiencing windy, rainy conditions. The captain has fewer than 200
hours in type, and the first officer has flown less than 100 hours in
the last 90 days. The company SOPs require the Chief Pilot to evaluate
flight risk factor values over 20 from the perspective of accepting the
risk, rejecting the risk, or mitigating the risk. Further, the company
SOPS prevent the operation of a flight if the risk value exceeds 25. In
our example the non-parenthetical numerical value represents the
original risk value assigned to the hazard. Risk values in parenthesis
represent the reduced risk values assigned after the Chief Pilot acted
to mitigate the risks.
Step 1. Complete a system and task analysis.
* The captain is not highly experienced with less than 200 hours in
type.
* The first officer has less than 100 hours in the last 90 days.
Step 2. Identify the hazards:
* The runway is wet.
* The flight will operate at night.
* The destination crosswinds are greater than 15 knots.
Step 3. Analyze the safety risk:
* The combination of the risk factors associated with this flight
generates a risk value of 20 using the example risk assessment tool.
Step 4. Assess the safety risk:
* Company policy requires that the Chief Pilot assess and approve any
flight risk value greater than 15. Since the risk value of 20 exceeds
the company operational threshold risk of 15, the Chief Pilot decides
to operate the flight by reducing the flight risk value to a more
acceptable level.
Step 5. Control the safety risk:
* The Chief Pilot focuses on mitigating three hazards:
1. He decides to allow the scheduled captain to operate the flight;
2. However, he assigns the flight to a first officer who is more
current and who has flown more than 100 hours in the last 90 days;
3. Further, the Chief pilot changes the destination airport to an
airport with no crosswind expected.
* By controlling the risk value of these three hazards, the Chief Pilot
has reduced the flight overall risk value to 13 and elevates the
operational level of safety.
Flight Risk Assessment Tool:
Date: Any day;
Departure: DAL;
Release/Trip #: 153;
Tail #: N123;
Destination: PDK.
Pilot Qualifications and Experience:
1. Captain with less than 200 hours in type:
Risk Value: 5;
Flight Value: 5.
2. First Officer with less than 200 hours in type:
Risk Value: 5;
Flight Value:
3. Single Pilot Flight:
Risk Value: 5;
Flight Value:
4. Captain with less than 100 hours last 90 days:
Risk Value: 3;
Flight Value:
5. First Officer with less than 100 hours last 90 days:
Risk Value: 3;
Flight Value: 3 (0).
6. Duty day greater than 12 hours:
Risk Value: 4;
Flight Value:
7. Flight time (Greater than 8 hours in the duty day):
Risk Value: 4;
Flight Value:
8. Crew Rest (Less than 10 hours prior to the duty day):
Risk Value: 5;
Flight Value:
Total Factor Score - Section 1: 8 (5).
Operating Environment:
9. VOR/GPS/LOC/ADF (Best approach available w/o vertical guidance):
Risk Value: 3;
Flight Value:
10. Circling approach (best available approach):
Risk Value: 4;
Flight Value:
11. No published approaches:
Risk Value: 4;
Flight Value:
12. Mountainous airport:
Risk Value: 5;
Flight Value:
13. Control tower not operational at ETA or ETD:
Risk Value: 3;
Flight Value:
14. Uncontrolled airport:
Risk Value: 5;
Flight Value:
15. Alternate airport not selected:
Risk Value: 4;
Flight Value:
16. Elevation of primary airport greater than 5000 ft. MSL):
Risk Value: 3;
Flight Value:
17. Wet runway:
Risk Value: 3;
Flight Value: 3.
18. Contaminated runway:
Risk Value: 3;
Flight Value:
19. Winter operation:
Risk Value: 3;
Flight Value:
20. Twilight operation:
Risk Value: 2;
Flight Value:
21. Night operation:
Risk Value: 5;
Flight Value: 5.
22. Stopping distance greater than 80% of available runway:
Risk Value: 5;
Flight Value:
23. Repositioning flight (no passengers or cargo):
Risk Value: 5;
Flight Value:
24. Pop up trip (Less than 4 hours crew notice):
Risk Value: 3;
Flight Value:
25. International operation:
Risk Value: 2;
Flight Value:
26. No weather reporting at destination:
Risk Value: 5;
Flight Value:
27. Thunderstorms at departure and/or destination:
Risk Value: 4;
Flight Value:
28. Severe turbulence:
Risk Value: 5;
Flight Value:
29. Ceiling & visibility at destination less than 500 ft./2 sm:
Risk Value: 3;
Flight Value:
30. Heavy rain at departure and/or destination:
Risk Value: 5;
Flight Value:
31. Frozen precipitation at departure and/or destination:
Risk Value: 3;
Flight Value:
32. Icing (moderate-severe):
Risk Value: 5;
Flight Value:
33. Surface winds greater than 30 knots:
Risk Value: 4;
Flight Value:
34. Crosswinds greater than 15 knots:
Risk Value: 4;
Flight Value: 4 (0).
35. Runway braking action less than good:
Risk Value: 5;
Flight Value:
Total Factor Score - Section 2: 12 (8).
Equipment:
36. Special Flight Permit Operation (ferry permit):
Risk Value: 3;
Flight Value:
37. MEL/COL Items (items related to safety of flight):
Risk Value: 2;
Flight Value:
38. Special flight limitations based on AFM equipment limitations:
Risk Value: 2.
Flight Value:
Total Factor Score - Section 3: 0.
Totals: 20 (13).
Questions or comments on this InFO should be addressed to Peter Neff,
AFS-820, (202) 493-5400.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Gerald L. Dillingham, Ph.D., (202) 512-2834 or dillinghamg@gao.gov:
Staff Acknowledgments:
In addition to those named above, Teresa Spisak (Assistant Director),
Richard D. Brown, Keith Cunningham, Elizabeth Eisenstadt, Michele
Fejfar, David Hooper, Mitchell Karpman, Valerie Kasindi, Sara Ann
Moessbauer, Susie Sachs, Christine San, Pamela Vines, and Crystal Wesco
made key contributions to this report.
[End of section]
Footnotes:
[1] A fixed-wing aircraft is a heavier-than-air aircraft capable of
flight whose lift is generated not by wing motion relative to the
aircraft, but by forward motion through the air. The term is used to
distinguish fixed-wing aircraft from rotary-wing aircraft and
ornithopters in which lift is generated by blades or wings that move
relative to the aircraft.
[2] 14 CFR part 121.
[3] 14 CFR parts 135 and 121 differ in a number of ways. For example,
part 135 cargo aircraft are not required to have on-board safety
technology that are required on passenger aircraft such as a traffic
collision and avoidance system, a terrain awareness and warning system,
or an autopilot. Part 121 operations may be conducted under (1)
domestic rules--scheduled operations within the 48 contiguous states
conducted by aircraft with 10 or more passenger seats or a payload
capacity of over 7,500 pounds; (2) flag rules--scheduled domestic and
international operations conducted by aircraft with 10 or more
passenger seats or a payload capacity of over 7,500 pounds; or (3)
supplemental rules--nonscheduled operations conducted by aircraft with
more than 30 passenger seats and a payload capacity of over 7,500
pounds. Large all-cargo carriers typically operate under supplemental
rules. Under part 135, FAA regulates a variety of aviation operations,
including both "commuter" (scheduled flights with fewer than 10 seats)
and "on-demand" (unscheduled air carriers) operations. Most part 135
all-cargo carriers are certificated as on-demand regardless of whether
they operate on a regular timetable. Some cargo operations also may be
conducted under 14 CFR part 125, which applies to private operations
(not available to the public) with 20 or more seats and a payload
capacity of 6,000 pounds or more.
[4] For additional information on our assessment of NPG, see GAO,
Aviation Safety: System Safety Approach Needs Further Integration into
FAA's Oversight of Airlines, [hyperlink,
http://www.gao.gov/products/GAO-05-726] (Washington, D.C.: Sept. 28,
2005).
[5] Aviation accidents are defined at 49 CFR part 830.2.
[6] Our analysis of the NTSB data revealed a total of 443 air cargo
accidents for calendar years 1997 through 2008 involving 449 aircraft.
These numbers include 14 CFR part 121 and 135 cargo and mail flights,
except for Alaska, where we included passenger-cargo flights due to
circumstances resulting from the by-pass mail program. Of the 443
accidents, 93 were fatal for 128 people. See appendix I for more
information on our scope and methodology.
[7] These rates do not count "isolated risk" events where risk was
isolated to a single person (ramp accidents and turbulence). There were
no part 121 cargo nonisolated risk accidents in 2007.
[8] NTSB recommendation A-03-037 is classified by NTSB as open with an
acceptable response.
[9] Since accidents typically result from a combination of
circumstances, conditions, and events, NTSB often cites multiple causes
and contributing factors in its investigative findings. To determine
the incidence of pilot performance among NTSB's determinations of
probable cause, we counted pilot performance if it was cited as the
initial probable cause of an accident.
[10] For pilots of many small cargo aircraft, duties often include
loading and unloading the cargo, in addition to readying the aircraft
before the flight, flying the cargo to its destination, and servicing
the aircraft after completing the flight.
[11] Carriers operating under part 135 are required to have a deicing
program. FAA is developing a proposed rule change for current and
future air carrier aircraft with a maximum take-off weight up to 60,000
pounds to either require the installation of ice-detection equipment or
change the procedures for activating ice-protection systems to ensure
timely activation of the systems.
[12] Other organizations have also developed flight risk assessment
checklists. For example, the Flight Safety Foundation is developing a
decision-making tool called the flight operations risk assessment
system, which will assist managers in determining the relative risk of
an accident or incident during a flight operation.
[13] For Alaska, we included passenger/cargo accidents as well as cargo
and mail accidents in our analysis. We included this additional
category of accidents because of the by-pass mail system in Alaska,
which requires carriers to have a certain share of the passenger market
to obtain a by-pass mail contract. This requirement is intended to
decrease cargo-only carriers in Alaska. Therefore, to capture the full
scope of cargo operations in Alaska, we decided to include those
accidents flown as passenger/cargo operations.
[14] The 1997 and 1998 accidents were the result of fumes from the
cargo compartments while the 2006 accident was caused by an in-flight
cargo fire initiated by an unknown source.
[15] GAO, Aviation Safety: Undeclared Air Shipments of Dangerous Goods
and DOT's Enforcement Approach, [hyperlink,
http://www.gao.gov/products/GAO-03-22] (Washington, D.C.: Jan. 10,
2003).
[16] In August 2007, PHMSA banned nonrechargeable lithium battery
shipments on passenger aircraft, but the rule does not affect the
ability of passengers to carry or use personal devices containing
lithium batteries while aboard the aircraft. This ruling does not
include cargo-only aircraft.
[17] According to NTSB, primary lithium batteries are not rechargeable
while secondary lithium batteries are. Primary lithium batteries, which
are found in such devices as watches and pocket calculators, contain
metallic lithium sealed in a metal casing. These batteries will burn if
the lithium is exposed to the air, and halon fire suppressions systems,
which are the only systems certified for aviation, are not effective in
extinguishing fires involving primary lithium batteries. Secondary
lithium batteries are commonly used in such devices as cameras,
cellular phones, and laptop computers. These batteries contain lithium
ions in a flammable liquid electrolyte. Halon suppression systems are
effective in extinguishing secondary lithium battery fires.
[18] The NTSB recommendations are numbered A-07-104 through A-10-109.
[19] PHMSA guidance entitled "Shipping Batteries Safely by Air: What
You Need to Know" provides information on the methods of safely
transporting batteries and battery-powered equipment in compliance with
the hazardous materials regulations.
[20] Although the FAA database does not distinguish between accidents
and incidents, our analysis of these data included only air cargo
events that were not captured as accidents in NTSB's Aviation Accident
Database. Thus, to avoid confusion, we refer to data from the FAA
database as "incidents" and data from the NTSB database as "accidents."
[21] We will be reporting later this year on our assessment of FAA's
use of data for safety oversight.
[22] National Academy of Engineering, Accident Precursor Analysis and
Management: Reducing Technological Risk Through Diligence (Washington,
D.C., August 2004).
[23] The ASAP exceptions from Advisory Circular 120-66B include: (1)
the noncompliance must be inadvertent and not involve an intentional
disregard for safety; (2) the ASAP report must generally be within 24
hours of the end of the flight sequence or within 24 hours of the
person becoming aware of possible noncompliance; and (3) the event must
not appear to involve criminal activity, substance abuse, controlled
substances, alcohol, or intentional falsification.
[24] Report of the Independent Review Team: Managing Risks in Civil
Aviation: A Review of the FAA's Approach to Safety, A Blue Ribbon Panel
Appointed May 1, 2008 by Secretary of Transportation, Mary E. Peters to
Examine FAA's Safety Culture and Approach to Safety Management
(Washington, D.C.: Sept. 2, 2008).
[25] This number includes 16 cargo carriers with part 121 and part 135
certificates.
[26] In commenting on a draft of this report, FAA indicated that it
believed that operators should not be required to make major revisions
or rewrites of their manuals as part of this process. Cargo carriers
that we interviewed disagreed.
[27] This number includes 16 cargo carriers with part 121 and part 135
certificates.
[28] National Research Council of the National Academies, Staffing
Standards for Aviation Safety Inspectors, eds. William C. Howell and
Susan B. Van Hemel (Washington, D.C., 2007).
[29] GAO, Aviation Safety: Better Management Controls are Needed to
Improve FAA's Safety Enforcement and Compliance Efforts, [hyperlink,
http://www.gao.gov/products/GAO-04-646] (Washington, D.C.: July 6,
2004).
[30] In commenting on a draft of this report, FAA said that part 135
operators are encouraged to submit data through FAA's annual survey of
aircraft owners, but this survey does not distinguish between passenger
and cargo operations.
[End of section]
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