FAA's Process for Reporting and Investigating Operational Errors
On March 24, 2009, we issued our review of FAA’s process for reporting and investigating operational errors. This review was requested by Chairman Oberstar of the House Committee on Transportation and Infrastructure and Chairman Costello of the House Subcommittee on Aviation. Their request was prompted by our 2007 investigation at the Dallas Fort–Worth (DFW) Terminal Radar Approach Control (TRACON) facility, which we conducted after whistleblowers alleged that facility management was intentionally misclassifying operational errors. Chairmen Oberstar and Costello were concerned that the operational error reporting problems found at the DFW TRACON may be occurring at other Air Traffic facilities. Accordingly, our audit objectives were to: (1) determine whether FAA has adequate policies and procedures to ensure accuracy and consistency in operational error reporting and (2) review the roles and responsibilities of the Air Traffic Organization (ATO) and FAA’s Aviation Safety line of business in reporting and investigating operational errors. While the events that transpired at DFW TRACON were not occurring system–wide, we did identify control and oversight weaknesses in FAA’s process for reporting and investigating losses of separation caused by pilots and controllers. These weaknesses were due in part to inadequate FAA guidance for investigating these events and insufficient staffing in the ATO Safety Office. Further, FAA’s current processes do not ensure that all losses of separation are accurately reported across terminal and en route facilities or consistently evaluated for severity. FAA has initiated actions to correct some of these weaknesses, but additional actions and follow–up are still needed. Specifically, FAA needs to improve its process for reporting and investigating losses of separation by: (1) improving inspectors’ procedures for investigating pilot deviations, (2) evaluating losses of separation caused by pilots and controllers consistently, and (3) implementing a full–time separation conformance tool. FAA also needs to enhance the ATO’s oversight role in ensuring that losses of separation are reported accurately by: (1) implementing planned organizational changes in a timely manner, (2) involving Flight Standards early in the event determination process, and (3) improving its facility oversight during Air Traffic facility audits.