Airline Pilots’ Performance Was a Contributing Factor in Many Accidents and Incidents

About 30 percent of the 169 accidents and 18 percent of the 3,901 incidents that occurred from 1983 through 1995 were caused at least in part by pilots’ performance, according to our analysis of the National Transportation Safety Board’s (NTSB) and FAA’s data. Figure 2 shows the types of accidents and incidents in the air that were reported. For example, in the Charlotte, North Carolina, crash in July 1994, communication among crew members did not occur, according to NTSB’s accident investigation report. The first officer did not question the order, as he should have, according to NTSB, because the windshear was creating an unstable situation; the plane could not recover from the sudden downward shift in direction caused by following the captain’s order. FAA’s Guidance and Oversight Do Not Ensure Effectiveness of CRM Training

For AQP training, FAA has specified the process airlines need to follow to develop and implement a curriculum that integrates CRM concepts with technical flying skills, but FAA’s guidance for CRM training under part 121 does not have the same degree of specificity. As a result, airlines continue to need specific guidance for CRM under part 121—both those airlines that have opted not to enter AQP as well those that will continue to train at least some of their crews under part 121 until they have fully implemented AQP, which could take up to 8 years. FAA’s Guidance for CRM Training Is Detailed Under AQP but Not Under Part 121

Once an airline elects to participate in AQP, it must follow SFAR 58 (the AQP regulation) for developing a formal curriculum—including assessing the skills pilots need to safely operate the aircraft they fly, developing curriculum objectives for teaching those skills, having measurable criteria for evaluating whether the pilots have achieved those objectives, and developing materials to teach those objectives. As a result, the pilots trained under AQP are assessed on CRM principles as well as on technical flying skills. In contrast, FAA’s requirements for CRM training under part 121 do not require airlines to develop a curriculum for CRM training with measurable criteria or to integrate that curriculum with other aspects of part 121 training. While all the airlines provide classroom training in CRM principles under part 121 training, they may not integrate this training with technical flying skills. (See table 1.) We identified pilots’ performance as the cause of about one-third of all the accidents and nearly one-fifth of the incidents for the 10 major airlines from 1983 through 1995. However, while FAA’s guidance for the implementation of the Advanced Qualification Program specifies a process for curriculum development that integrates this training with training in technical flying skills, FAA’s guidance for curriculum development under part 121 is ambiguous and does not provide standards that inspectors can use to evaluate and approve airlines’ training in crew resource management. To determine the adequacy of FAA’ s guidance for and oversight of pilots’ training, we reviewed FAA’s role in the airlines’ implementation of CRM.
Why GAO Did This Study

Pursuant to a congressional request, GAO examined the role of airline pilots' performance in accidents and the Federal Aviation Administration's (FAA) efforts to address any inadequate performance, focusing on the: (1) types and frequency of accidents in which an airline pilot's performance was cited as a contributing factor, including those in which failure to use crew resource management (CRM) principles was identified; and (2) adequacy of FAA's guidance for and oversight of the airlines' implementation of pilots' training for CRM.

What GAO Found

GAO noted that: (1) of the 169 accidents that involved the major airlines and that were investigated and reported on in detail by the National Transportation Safety Board (NTSB) from 1983 through 1995, about 30 percent were caused in part by the pilots' performance; (2) in at least one-third of these accidents, GAO determined that the pilots did not correctly use CRM principles; (3) for example, according to NTSB, just before the 1994 crash in Charlotte, North Carolina, which killed 37 people, the aircraft had encountered a sudden change in wind direction and the captain gave an incorrect order to the first officer, who did not question the order, as CRM principles would require; (4) during the same period, of the nearly 4,000 incidents, GAO found that about one-fifth were caused in part by the pilots' performance; (5) FAA's guidance for and oversight of training in CRM does not ensure the adequacy of this training under part 121 of the federal aviation regulations, while they do under the new Advanced Qualification Program (AQP); (6) FAA's guidance for the implementation of AQP specifies a process for curriculum development that the airlines must follow in order to integrate CRM training with technical flying skills; (7) FAA inspectors overseeing this training assess the curriculum to see if FAA's process has been followed, enabling them to determine whether the pilots' training under this curriculum is adequate; (8) although FAA requires airlines to teach CRM in their traditional part 121 training, the guidance it provides on how to develop the curriculum for this training is ambiguous and does not provide standards that inspectors can use to evaluate airlines' CRM training; (9) because AQP training generally differs from traditional part 121 training in how it develops a curriculum for training CRM, the guidance for this training in AQP may not be applicable to CRM training under part 121; (10) FAA needs to develop guidance for teaching CRM under traditional part 121 training; (11) and although 8 of the 10 major airlines plan to train all their pilots under AQP, the need for guidance on CRM training under part 121 remains--both for those airlines that have opted not to enter AQP as well as for those that participate in the program but will nonetheless continue to have some of their pilots trained under part 121 for up to 8 years as they make the transition to AQP.