FAA Lacks Effective Oversight Controls To Determine Whether American Airlines Appropriately Identifies, Assesses, and Mitigates Aircraft Maintenance Risks

FAA Lacks Effective Oversight Controls To Determine

Whether American Airlines Appropriately Identifies,

Assesses, and Mitigates Aircraft Maintenance Risks

Report AV2022004

October 20, 2021

FAA

What We Looked At

American Airlines, one of the world’s largest commercial air carriers, has not experienced a fatal

accident in nearly two decades. Despite this safety record, reports of potentially unsafe maintenance

practices have raised concerns about the Federal Aviation Administration’s (FAA) oversight of the

carrier’s maintenance programs. At the request of then-ranking members of the House Committee on

Transportation and Infrastructure and its Aviation Subcommittee, we initiated this review. Specifically,

we examined whether FAA ensures that American Airlines implemented effective corrective actions to

address the root causes of maintenance problems and FAA’s oversight of American Airlines’ safety

management systems (SMS).

What We Found

FAA lacks effective oversight controls to ensure American Airlines’ corrective actions for maintenance

non-compliances addressed root causes. According to FAA guidance, FAA inspectors should

collaborate with the air carrier to correctly identify and fix the root cause(s) of deviations or non-

compliances. However, in 171 of 185 (92 percent) of cases we sampled, FAA inspectors accepted root

cause analyses by the air carrier that did not identify the true root cause of the problem. Furthermore,

FAA closed compliance actions before the air carrier implemented its corrective actions. FAA’s

oversight controls are also not effective for evaluating if American Airlines’ SMS sufficiently assesses

and mitigates risk. FAA requires American Airlines to use its SMS to determine the level of risk

associated with maintenance non-compliances. However, we found that FAA inspectors did not

routinely or consistently evaluate whether the carrier adequately and effectively assessed and rated

risks. This is in part because FAA did not provide its inspectors with comprehensive training and tools

for overseeing and evaluating the carrier’s SMS.

Our Recommendations

FAA concurred with five and partially concurred with two of our seven recommendations to improve

FAA’s oversight of American Airlines maintenance programs. We consider recommendations 1, 2, 4,

and 6 resolved but open, pending completion of planned actions. However, we are asking FAA for

additional information and to reconsider its actions for recommendations 3, 5, and 7.

FAA Lacks Effective Oversight Controls To Determine Whether

American Airlines Appropriately Identifies, Assesses, and

Mitigates Aircraft Maintenance Risks

Requested by

the Ranking Members of the House Committee on Transportation and Infrastructure and its

Aviation Subcommittee

Federal Aviation Administration

| AV2022004 | October 20, 2021

All OIG audit reports are available on our website at www.oig.dot.gov.

For inquiries about this report, please contact our Office of Legal, Legislative, and External Affairs at (202) 366-8751.

AV2022004

Contents

Memorandum 1

Results in Brief 3

Background 4

FAA Lacks Effective Oversight Controls To Ensure American Airlines’

Corrective Actions for Maintenance Non-Compliances Addressed Root

Causes 7

FAA’s Oversight Controls Are Not Effective for Evaluating if American

Airlines’ Safety Management System Sufficiently Assesses and

Mitigates Risk 13

Conclusion 18

Recommendations 18

Agency Comments and OIG Response 19

Actions Required 20

Exhibit A. Scope and Methodology 21

Exhibit B. Organizations Visited or Contacted 23

Exhibit C. List of Acronyms 24

Exhibit D. Major Contributors to This Report 25

Appendix. Agency Comments 26

AV2022004 1

Memorandum

Date: October 20, 2021

Subject: ACTION: FAA Lacks Effective Oversight Controls To Determine Whether American

Airlines Appropriately Identifies, Assesses, and Mitigates Aircraft Maintenance

Risks | Report No. AV2022004

From: Matthew E. Hampton

Assistant Inspector General for Aviation Audits

To: Federal Aviation Administrator

American Airlines, one of the world’s largest commercial air carriers, has not

experienced a fatal accident in nearly two decades. Despite this safety record,

reports of potentially unsafe maintenance practices—such as congressional

allegations that mechanics have been forced to shortcut repairs to keep aircraft in

service—have raised concerns about the Federal Aviation Administration’s (FAA)

oversight of maintenance programs at American Airlines. FAA shares the

responsibility to ensure the safety of air carrier maintenance programs along with

aircraft manufacturers and air carriers.

Safety is FAA’s top priority. In March 2015, the Agency developed a formal, top-

down approach to manage safety risks, known as Safety Management Systems

(SMS), and required air carriers to implement it in March 2018. SMS uses the

safety risk management process to identify hazards and address unacceptable

risk. FAA established the Compliance Program in October 2015, which helped to

address safety risk management. This program outlines a process for inspectors

to address non-compliances by correctly identifying root causes and

recommending appropriate corrective actions to adequately mitigate the risks

involved. Nearly 6 years after FAA implemented its Compliance Program, the

Agency is still refining its inspector guidance

for identifying and addressing root

causes of identified non-compliances.

Federal Aviation Administration Order 8900.1, Volume 14, Compliance and Enforcement, November 4, 2016, and

October 14, 2020. Federal Aviation Administration Order 2150.3C, FAA Compliance and Enforcement Program,

September 18, 2018. For the purpose of this report, we refer to FAA Order 8900.1 as “inspector guidance.”

AV2022004 2

At the request of then-ranking members of the House Committee on

Transportation and Infrastructure and its Aviation Subcommittee,

we initiated a

review of FAA’s oversight of air carrier maintenance programs at two air carriers

in May 2018. This report presents the results of our review of FAA’s oversight of

American Airlines’ maintenance programs. Specifically, we examined whether FAA

ensures that American Airlines implemented effective corrective actions to

address the root causes of maintenance problems and FAA’s oversight of

American Airlines’ safety management systems.

We conducted this audit in accordance with generally accepted Government

auditing standards. Exhibit A details our scope and methodology, exhibit B lists

the organizations we visited or contacted, and exhibit C lists the acronyms used

in this report.

We appreciate the courtesies and cooperation of Department of Transportation

representatives during this audit. If you have any questions concerning this

report, please call me at (202) 366-0500 or Tina Nysted, Program Director, at

(404) 562-3770.

cc: The Secretary

DOT Audit Liaison, M-1

FAA Audit Liaison, AAE-100

Letter from Congressmen Peter DeFazio and Rick Larsen to DOT Inspector General Calvin Scovel III, dated June 7,

2016.

AV2022004 3

Results in Brief

FAA lacks effective oversight controls to ensure American Airlines’

corrective actions for maintenance non-compliances addressed

root causes.

According to FAA guidance,

FAA inspectors should conduct an investigation and

collaborate with the air carrier to correctly identify and fix the root cause(s) of

deviations or non-compliances. However, we found that FAA inspectors accepted

root cause analyses by the air carrier that did not identify the true root cause of

the problem. In 171 of 185 (92 percent) maintenance compliance cases we

sampled from fiscal years (FY) 2016 to 2020, American Airlines did not identify

the root cause at all, or the root cause was determined to be related to human

factors issues—which, according to FAA guidance and industry best practices, are

not considered true root causes. FAA accepted insufficient root causes in part

because FAA inspectors were not adequately trained on root cause analysis.

Furthermore, we found that FAA closed compliance actions before the air carrier

implemented its corrective actions. Of the 394 corrective actions proposed by the

carrier that we reviewed, FAA inspectors accepted all of the corrective actions—

including 20 actions that were closed out before American Airlines could actually

implement them. This occurred because, at the time of our review, FAA’s

Compliance Program did not require inspectors to verify that the carrier had

taken its planned corrective actions. Without conducting comprehensive root

cause analysis and verifying corrective actions, FAA cannot reasonably ensure

that American Airlines is sufficiently identifying root causes and mitigating future

maintenance non-compliances.

FAA’s oversight controls are not effective for evaluating if

American Airlines’ SMS sufficiently assesses and mitigates risk.

FAA requires American Airlines to use its SMS to determine the level of risk (e.g.,

“risk rating”) associated with maintenance non-compliances and report to FAA

what controls failed and what consequences would occur had safety controls

failed. However, our review found that FAA inspectors did not routinely or

consistently evaluate whether the carrier adequately and effectively assessed and

rated risks. This is because inspectors do not conduct comprehensive team

inspections of the carrier’s risk rating process on a regular basis. For example,

from October 2020 to March 2021, a team inspection of SMS yielded 27 findings

where an individual inspector using the same inspection checklist identified only

one. Further, FAA does not provide its inspectors with comprehensive training on

how to assess an air carrier’s risk assessment process, and FAA inspectors stated

Federal Aviation Administration Order 8900.1, Volume 14, Compliance and Enforcement, October 14, 2020.

AV2022004 4

that their data collection tool is insufficient for comprehensively evaluating the

effectiveness of the carrier’s SMS. As a result, FAA is limited in its ability to

reasonably ensure that American Airlines is assigning risk levels that are

commensurate to the identified non-compliance and that the carrier’s

corresponding corrective actions and controls are appropriate to address the

problem.

We are making recommendations to improve FAA’s oversight of American

Airlines maintenance programs. We made similar recommendations in our

previous report on FAA’s oversight of Allegiant Air’s maintenance programs.

that report, we recommended that FAA review the quality of its root cause

analysis training and revise inspector guidance to ensure corrective actions are

implemented before closing compliance action cases. According to FAA officials,

the Agency has made progress in addressing recommendations from our

previous report; however, until FAA has completed these actions, these

recommendations will remain open. The recommendations in this report further

refine the actions FAA needs to take to address our findings related to American

Airlines.

Background

Since its first mail carrier flight in 1926, American Airlines has grown into one of

the world’s largest air carriers, operating nearly 900 Boeing and Airbus aircraft. As

shown in figure 1 below, much of American’s growth was likely due to mergers

with other major airlines such as Trans World Airlines and US Airways. As a result

of the worldwide coronavirus pandemic in 2020 and the sudden drop in demand

for air travel, American decommissioned more than 150 aircraft and retired five

aircraft types: Embraer 190, Boeing 757, Boeing 767, Airbus A330,

and Bombardier CRJ200. American replaced many of these aircraft with newer

aircraft, such as the Boeing 737 MAX and the Airbus 321 Neo. As a result,

American currently has one of the youngest fleets in the world. Together with

regional partner American Eagle, the American Airlines Group averages nearly

6,000 flights per day to 318 destinations in 42 countries.

FAA Needs To Improve Its Oversight To Address Maintenance Issues Impacting Safety at Allegiant Air (OIG Report No.

AV2020013), December 17, 2019. We made nine recommendations, of which two remain open. OIG reports are

available on our website: https://www.oig.dot.gov/

This data is based on American’s projected flight activity for July 2021 (July 2020 flight data is skewed by the drop in

demand for air travel as a result of the coronavirus pandemic of 2020). According to American, July is its peak travel

month.

AV2022004 5

Figure 1. History of American Airlines

American Airlines employs approximately 9,000 certificated mechanics and

aircraft inspectors at maintenance facilities in the United States and around the

world, and operates one of the world’s largest and most sophisticated aviation

maintenance facilities in Tulsa, OK. This facility employs over 2,700 mechanics, all

whom are licensed aircraft and jet engine mechanics.

To oversee a large air carrier such as American Airlines, FAA inspectors based in

Irving, TX, and Coraopolis, PA, are responsible for overseeing American’s

maintenance programs. Approximately 60 inspectors manage the air carrier’s

operating certificate by performing inspections to ensure the carrier is meeting

Federal safety standards. To conduct its oversight, FAA relies on its Safety

Assurance System (SAS), a risk-based oversight system, which is intended to

evaluate an air carrier’s ability to manage risk and ensure safe operations, as well

as focus on air carriers’ safety systems and controls. In addition, it provides a risk-

assessment tool for FAA inspectors to identify and document potential risks. SAS

is also part of FAA’s broader SMS, which is focused on enhancing safety through

data analysis to better respond to changes in industry business models (i.e.,

growth and fleet changes).

SMS has been adopted worldwide as a standardized approach to managing risk.

FAA requires air carriers to implement SMS to identify and analyze potential

hazards and mitigate risk to an acceptable level based on each carrier’s operating

environment. Under this approach, FAA and air carriers develop systems to

AV2022004 6

identify hazards and implement corrective actions. Specifically, air carriers must

identify root causes for hazards and proactively manage risk to prevent accidents.

To identify safety issues and effectively correct them in a timely manner, FAA

shifted from an enforcement-based oversight model in October 2015 to one that

stresses a more collaborative approach with carriers. Previously, under FAA’s

enforcement-based program, the level of action taken by the Agency was

commensurate with the type of violation. For example, FAA inspectors

investigating a mechanic’s failure to follow aircraft manual repair instructions

would likely initiate enforcement action in the form of an administrative letter of

correction. In contrast, the Compliance Program encourages a collaborative

approach between FAA and air carriers to achieve rapid compliance, identify

safety errors, and emphasize improvements to procedures or training programs

over penalizing air carriers—as long as the carrier demonstrates that it is willing

and able to take corrective action.

Now when an FAA inspector identifies a non-

compliance that meets the criteria, FAA may issue a non-punitive compliance

action to an air carrier, and the Agency expects the carrier to determine the root

cause and proposed corrective action(s) to prevent reoccurrence. The errors are

identified, reported, and analyzed to establish accountability without assigning

blame so that the specifics of each case can determine the appropriate corrective

action. However, for instances where an air carrier is unwilling or unable to

collaboratively correct compliance or safety issues, inspectors must use

enforcement-based oversight tools, such as assessing civil penalties or

suspending operations. As shown below in figure 2, the number of enforcement

actions against American Airlines dropped dramatically since FAA transitioned to

its Compliance Program approach in 2015.

A compliance action is FAA’s non-punitive method for addressing unintentional deviations stemming from flawed

systems and procedures, simple mistakes, lack of understanding, or diminished skills. In contrast, a legal enforcement

action is punitive in nature and could result in civil penalties or suspension of operations. In this report, we refer to

legal enforcement action as an enforcement action imposed by FAA.

AV2022004 7

Figure 2. FAA’s Shift From Enforcement Actions to

Compliance Actions—American Airlines

Source: OIG analysis of FAA data

FAA Lacks Effective Oversight Controls To

Ensure American Airlines’ Corrective Actions for

Maintenance Non-Compliances Addressed

Root Causes

FAA lacks effective controls to ensure that American Airlines provided

comprehensive root cause analyses to show why maintenance non-compliances

occurred. In addition, FAA accepted the results of the carrier’s root cause analysis

and closed out compliance actions before the air carrier implemented its

corrective actions.

FAA Did Not Ensure American Airlines

Provided Comprehensive Root Cause Analyses

for Maintenance Non-Compliances

FAA did not ensure American Airlines provided comprehensive root cause

analysis for maintenance non-compliances. The concept of root cause analysis is

to get to the underlying cause of the problem, identify the factors that are

572

516

2010-2015 2015-2020

Number of Actions

Years

Enforcement Actions vs. Compliance Actions

Enforcement Actions Compliance Actions

AV2022004 8

causing the problem, and recommend solutions that address all of the factors. A

key principle of root cause analysis is to identify underlying problems that

increase the likelihood of errors while avoiding the trap of focusing on mistakes

by individuals. Root cause analysis became an integral part of FAA oversight with

the implementation of the Compliance Program in 2015. According to FAA

guidance, inspectors should work with air carriers to identify and address the root

cause of a problem and then develop appropriate corrective actions to prevent

future reoccurrence.

However, we found that FAA inspectors accepted root cause analyses by the air

carrier that did not identify the true root cause of the problem. Specifically, we

reviewed 60 randomly selected compliance actions from fiscal years 2016 to

2020, consisting of 185 maintenance non-compliance cases. In 171 of 185 cases

(92 percent), American Airlines did not identify the true root cause of non-

compliances either because the root cause was not identified at all or the root

cause was determined to be related to human factors issues. The remaining

14 non-compliances were instances in which the carrier conducted thorough

investigations but did not explicitly state the underlying cause of the non-

compliance (see figure 3).

Figure 3. Breakdown of FAA’s Acceptance of American Airlines’

Root Cause Analysis of Maintenance Non-Compliances

Source: OIG analysis of FAA data

Of the 171 instances of insufficient root cause analysis, we identified 50 instances

(29 percent) in which the carrier did not address the root cause of the problem at

all. In these 50 instances, the carrier either did not provide a root cause or merely

restated the results of its investigation as a root cause without determining why

the non-compliance occurred. For example, in 2016, FAA notified American

AV2022004 9

Airlines that unidentified aircraft parts were found in an administrative building

on a paper recycle bin and tops of lockers. These parts were not properly tagged

to indicate whether they were usable or not. FAA expected the carrier to

investigate and provide a root cause analysis into why the non-compliance

occurred and identify appropriate corrective actions to prevent reoccurrence.

However, in its response, American Airlines repeated that the aircraft parts were

found on the paper recycle bin and the carrier was unable to determine why they

were there. Conversely, American Airlines did identify the root cause of a non-

compliance involving mechanics documenting excessive tire pressure in hot

aircraft tires. In this example, the carrier conducted a thorough investigation into

FAA’s finding and determined that errors occurred because the mechanic’s

maintenance manual did not clearly state that hot tire pressure is permitted to be

higher than the maximum operational pressure.

FAA also accepted root cause analysis in which human factors

were identified as

the root cause. According to recently issued FAA guidance,

human factors

should not be considered the root cause of a non-compliance; instead,

investigations into root cause should determine why the individual erred. FAA’s

guidance is consistent with aviation industry practices in calling for more

comprehensive analyses rather than attributing the cause of non-compliance on

human factors, such as “the technician did not follow procedures.” Further,

according to TapRooT,

a widely recognized root cause analysis tool, “human

error is probably a causal factor.

When you see human error as a root cause, the

result is often to find blame and ineffective corrective action.” Similarly, the

healthcare industry stresses addressing root causes that are inherent to the

system, and not the people, to improve overall system safety. When individuals

are blamed for an incident, remedial action focuses on the person or people

involved, but this represents a missed opportunity to make wider reaching

changes to the system to prevent future occurrences of a similar error.

Contrary to industry best practices and subsequently FAA’s own guidance,

inspectors accepted root cause analyses identifying human error as the root

cause in 121 (71 percent) of the 171 non-compliances reviewed. For example, in

September 2019, FAA found mechanics overlooked a work step on a

maintenance task card pertaining to passenger cabin doors. According to the air

carrier response to FAA, “the Root Cause was complacency of the Supervisor.”

Additionally, in January 2018, FAA identified an erroneous maintenance task card

Human factors is the scientific discipline concerned with understanding how humans interact with other elements of

a system in order to optimize human well-being and overall system performance.

Federal Aviation Administration Order 8900.1, Volume 14, Compliance and Enforcement, October 16, 2020.

According to its website, TapRooT is a systematic process, software, and training for finding the real root causes of

audits, precursor incidents, or major accidents.

A causal factor is a mistake, error, or failure that leads directly to or causes an incident, or fails to mitigate the

consequences of the original error.

AV2022004 10

pertaining to fuselage repairs in which all steps were signed as completed when

they should not have been because some steps did not apply to that situation.

According to the carrier’s assessment of the discrepancy, “The Structures

Mechanic was unable to explain why he failed to properly document the

inspection.” In both of these cases, FAA did not press American Airlines for root

causes of the problems and just accepted human error as the reason for the non-

compliances.

FAA accepted insufficient root causes in part because the Agency did not

adequately train its inspectors on root cause analysis. FAA’s Compliance Program

and its inspector guidance emphasize the importance of inspectors using critical

thinking in problem solving and correctly identifying root causes so they can

recommend appropriate corrective actions. While 13 of 18 maintenance

inspectors we interviewed received some form of root cause analysis training

(e.g., 2-hour computer-based training), 5 of these inspectors received no training.

Furthermore, 6 of the 13 inspectors who did receive training—including

managers—stated that these courses did not provide the level of detail needed

to determine whether corrective action plans would effectively address the root

cause of non-compliances.

Further, FAA did not initially ensure the carrier documented its root cause analysis

process. According to FAA inspectors and American Airlines officials, they

typically work together to uncover the root cause of maintenance non-

compliances. The carrier stated that it conducted root cause analyses and verbally

discussed the results with FAA to gain concurrence, but at the outset of the

Compliance Program, FAA did not require the carrier to formally document root

cause determinations. When we asked for documentation of root cause analysis

discussions, neither FAA nor American Airlines could provide any. According to

inspectors, FAA did not require air carriers to submit written root cause analyses

even though inspectors asked American to identify root causes in their

notification letters. However, starting in mid-2018, the local oversight office

stated that it began requiring the carrier to provide written root cause

determinations in its response letters to FAA. As noted above, we also found that

many of these root cause analyses still did not identify the true root cause of

maintenance discrepancies, and FAA continued to accept the analyses to close

out compliance actions. Without a determination of the true root cause of the

problem, FAA cannot be sure that corrective actions proposed to address

maintenance non-compliances will effectively mitigate the problems and prevent

future recurrences.

Ineffective root cause analysis and the associated corrective actions may have

contributed to a number of repetitive non-compliances at American Airlines.

Based on our review, the most frequent non-compliances were maintenance

recordkeeping errors and omissions, insufficient maintenance training, and

improperly completed maintenance. For example, recordkeeping errors

AV2022004 11

(i.e., failure to document required maintenance steps) occurred in 29 of the 60

compliance actions we sampled over a 5-year period. Repetitive maintenance

record errors likely occurred because the carrier identified human factors as the

root cause of the problem and did not continue its investigations to determine

why maintenance personnel erred. As a result, FAA and the carrier missed an

opportunity to make more expansive enhancements to the system to prevent

future occurrences of the same or a similar error.

FAA Inspectors Closed Out Compliance

Actions Prematurely

FAA inspectors prematurely closed compliance actions before ensuring that the

carrier completed its corrective actions. This is because at the time of our review,

FAA’s Compliance Program guidance

did not require inspectors to validate

(i.e., conduct an inspection) that corrective actions are in place and effective at

addressing the discrepancies prior to closing out a compliance action, as long as

the corrective action follow-up inspection is tracked in a separate FAA database.

Yet, inspectors could not identify these actions in the database when asked to do

so. As a result, the trail of corrective actions tied to a specific compliance action is

lost, and inspectors cannot be sure that air carrier non-compliances are actually

resolved and corrective actions are effective.

In our review of 185 non-compliances between March 2016 and March 2020, we

determined that American Airlines proposed 394 corrective actions (many of

these 185 non-compliances contained multiple corrective actions). FAA inspectors

accepted all of the corrective actions—including 20 actions that were closed out

before American Airlines could actually implement them. For example, in 2018, an

inspector identified weaknesses in the carrier’s maintenance procedures and its

tool calibration program and initiated a compliance action to address the issue.

After the carrier submitted its corrective action plan to FAA, the inspector

reviewed and approved the plan, closing out the compliance action and stating

that FAA had validated the corrective actions—even though the carrier’s

documented response showed that 8 of the 19 corrective actions would not be

completed for up to 5½ months later.

According to senior FAA inspectors, FAA guidance at that time permitted

inspectors to close out compliance actions before corrective actions were

completed, but guidance stated inspectors should hold open the follow-up

inspection record in FAA’s inspection database until inspectors can validate the

FAA revised Order 8900.1, Volume 14, Compliance and Enforcement on October 16, 2020, which is after the time

period of our review of compliance actions.

AV2022004 12

corrective action. However, we found that inspectors could not determine

whether the follow-up inspection had occurred when consulting their inspection

database. This is because when inspectors closed out the compliance action, they

did not clearly link the follow-up inspection to its corresponding compliance

action. As a result, inspectors were unable to determine whether a follow-up

inspection actually occurred, which would have validated that corrective actions

were implemented and effective at addressing non-compliances.

In comparison, a similar program—FAA’s Voluntary Disclosure Reporting

Program used by air carriers to self-disclose errors to FAA—also requires root

causes analysis and submission of comprehensive fixes to prevent future

reoccurrence of problems. However, this program goes one step further by

requiring FAA inspectors to validate that comprehensive fixes address the

problem before closing out the disclosure.

Further, as part of its compliance action close-out process, FAA formally notifies

American Airlines that it accepts its root cause analyses and proposed corrective

actions and considers the compliance actions closed. Yet, we found that this

formal notification occurred whether or not FAA had completed its work related

to the compliance action. According to FAA guidance at the time of our review, a

compliance action is typically considered closed when inspectors document their

validation of corrective actions in its inspection database. Further, some

corrective actions can be complex and take time for the carrier to implement.

However, FAA sent the carrier close out letters, leaving the air carrier to believe

that it has met FAA’s requirements for compliance action closure. For example,

FAA closed out a compliance action for incorrectly signed maintenance work

cards one day after the carrier provided its response to FAA. Some of these work

cards showed mechanics how to perform aircraft maintenance checks. This quick

turnaround raises questions as to whether inspectors would have had enough

time to review the response and validate the effectiveness of the corrective

action. American Airlines stated in its response to FAA that one of the corrective

actions was not due to be completed until one month later. Yet, FAA informed

the carrier in its close-out letter that it “verified that the implementation of the

agreed upon comprehensive fixes.” As a result of this process, FAA closeout

letters may lead the carrier to believe it does not have to take corrective actions

and the case is closed, even though inspectors have not yet validated corrective

actions.

AV2022004 13

FAA’s Oversight Controls Are Not Effective for

Evaluating if American Airlines’ Safety

Management System Sufficiently Assesses and

Mitigates Risk

FAA’s oversight of American Airlines’ SMS hinders the Agency from fully

assessing the carrier’s risk management process and assuring the effectiveness of

safety risk controls. In particular, FAA is not routinely evaluating the carrier’s risk

assessments.

Performing risk assessments is the most challenging part of the risk management

process because of the subjectivity of accurately identifying the severity of the

consequences. As part of the risk assessment, each hazard’s associated safety risk

is assessed against the risk acceptance criteria and plotted on a risk matrix based

on the severity and likelihood of the outcome. The objective of this step is to

determine the safety risk level acceptability. A risk matrix provides a visual

depiction of the safety risk and enables prioritization in the control of the

hazards.

FAA is responsible for overseeing American Airlines’ implementation of its SMS,

including the carrier’s assessment of safety risk ratings and controls. FAA requires

American Airlines to use its SMS to determine the level of risk (e.g., “risk rating”)

associated with maintenance non-compliances and report to FAA what controls

failed and what consequences would occur as a result of the failed safety

controls.

However, our review found weaknesses in American Airlines’ risk assessments and

FAA’s oversight. Our analysis of 193 findings (from our sample of 60 compliance

actions) indicated that the carrier rated 141 of them (73 percent) as “low” or “very

low” risk. Table 1 shows examples of non-compliances that were rated “low” or

“very low.”

AV2022004 14

Table 1. Examples of American Airlines’ Non-Compliances

Rated Low or Very Low Related to Potential Outcomes

Non-Compliance

Potential Outcome Had the

Non-Compliance Continued

Severity Risk

Category

Reactive Risk

Rating

Mechanic failed to

perform a bird strike

damage inspection

The aircraft departed

without the maintenance

task being accomplished

Operational

Event

Low

Mechanic failed to

perform an engine

leak check

The work task card would

continue to have a signature

stamp missing

Operational

Event

Very Low

Mechanic

documented that

tire pressure checks

were performed, but

never used a tire

pressure gauge

Calibrated tire gauges would

not have been tracked in

accordance with American’s

procedures manual

Operational

Event

Very Low

Source: OIG analysis of FAA data

While categorizing risk assessments is inherently subjective, accurately identifying

these ratings is integral to decision making in SMS, as all actions performed to

address the safety issue depend on the initial and subsequent risk assessments.

According to American Airlines’ Risk Assessment Matrix, only five risk severity

categories are used for risk assessment, although there are 14 severity categories

identified. An air carrier official explained that these are the only five categories

on its risk matrix that could lead to an accident, incident, injuries, or threats of

injuries to their employees. The five categories the carrier uses are:

• Accident or incident (e.g., accident with fatalities or significant aircraft

damage),

• Employee or customer injury (e.g., injury or fatality),

• Operational event (e.g., operating with no meaningful safety margins or

operating beyond aircraft limitations),

• Security (e.g., terrorist activity or civil unrest), and

• Systems or processes (e.g., disruptions to aircraft operations or system

breakdown).

Two of the remaining categories—“regulatory” and “airworthiness”—are rarely

used. (According to American Airlines’ SMS guidance, the regulatory category

may only be used with management approval.) This is significant because,

AV2022004 15

according to FAA, the use of “regulatory” or “airworthiness” categories could

result in higher risk ratings. Additionally, the risk rating ultimately determines the

corrective actions the carrier must take and what level of air carrier management

will be responsible for accepting and mitigating the risk. For example, American

flew an aircraft with an inoperable emergency evacuation slide for 877 days

before reporting the non-compliance to FAA. The inoperable slide was

categorized as an “accident or incident” (even though neither event occurred)

resulting in a “moderate” risk rating. For this rating, a director-level management

authority would be required to approve the risk mitigation plan. However, had

American categorized the event as an “airworthiness” issue, the level of risk could

have risen to a “serious” risk rating. As a result, this new rating would have

required a different set of corrective actions and controls and a higher level of

management at American Airlines—a Vice President or higher level—to review

and accept the risk mitigation plan.

However, FAA did not evaluate whether American Airlines’ risk ratings adequately

captured the level of risk for these findings. This is in part because inspectors lack

training on how to review the risk assessments. As part of its oversight of an air

carrier’s SMS, FAA inspectors are required to evaluate risk ratings, determine root

causes, and develop corrective actions in a similar way the air carrier uses its SMS.

To effectively oversee an air carrier’s SMS, inspectors need to be properly trained

on safety risk management and have comprehensive guidance to help to

facilitate inspections. However, inspectors told us that the training they received

was more of a high-level overview of SMS, and it lacked details of how to

accurately review air carrier risk ratings. As a result, FAA could not verify whether

the 73 percent of findings that American Airlines rated as “low” or “very low” were

indeed low risk. This also limits FAA’s ability to effectively assess the carrier’s

controls for those safety risks.

A lack of an effective inspection checklist (i.e., data collection tool) also limits

FAA’s SMS oversight. Inspectors routinely evaluate SMS using inspection

checklists that are designed to identify whether a carrier’s SMS is working

effectively. However, according to FAA inspectors, the way FAA’s checklist is

written does not provide an opportunity to dig down to the level of detail

needed to effectively review American Airlines’ SMS. This is because the

questions they answer during a typical inspection are aimed at determining

whether the air carrier’s management has sufficient authority and effective

processes in place to operate an SMS. For example, one question used in the

inspection was “Were the certificate holder’s process measurement(s) used to

evaluate the performance of the Accountable Executive process and if necessary,

implement corrective action?” Although the inspectors’ response to this question

contained two examples of aircraft flown in non-airworthy conditions, the details

did not relate to whether process measurements were effective and corrective

actions were implemented. This indicates that the inspectors devised a

AV2022004 16

workaround to the inspection checklist in a way that allowed them to more

thoroughly examine the carrier’s SMS. Even though this workaround was not a

standard inspection process, it allowed FAA to conduct a more comprehensive

review of the carrier’s SMS which ultimately disclosed system weaknesses.

As a result of FAA’s limited inspector guidance and training, inspectors may not

be effectively and consistently reviewing American Airlines’ SMS. In the last year,

FAA has conducted three inspections pertaining to American Airlines’ SMS. Each

inspection yielded very different results, as shown in table 2 below.

Table 2. American Airlines’ SMS Inspection Results

Type of

Inspection

January

2020

October –

December 2020

October 2020 –

March 2021

Individual Finding in 1 of 21

inspection questions

National

(one inspector)

No findings

Team

(six inspectors)

Findings in 19 of 21

inspection questions

Source: OIG analysis of FAA data

While the January 2020 inspection was a routine inspection of SMS, the

inspection in October–December 2020 was directed from FAA Headquarters. FAA

inspectors for all major air carrier

oversight offices were directed to review and

report on the overall effectiveness of air carrier’s SMS using a specially-designed

checklist. This review did not require any new data collection, and inspectors were

asked to simply answer six high-level questions to assess whether air carriers

made progress since the inception of SMS. Although this national review was

conducted while the team inspection was ongoing, the FAA principal inspector

had no findings as a result of this review.

In contrast, during this same timeframe, a team of inspectors conducted a routine

inspection of American Airlines’ SMS using the same data collection tool used in

January 2020. However, the team used a workaround to be able to assess the

SMS more comprehensively, as we mentioned previously. This inspection

reported 27 findings to American Airlines. According to FAA, the reason for the

This refers to large, commercial operators regulated under 14 CFR Part 121, Operating Requirements: Domestic,

Flag, and Supplemental Operations. These carriers operate larger aircraft with primarily scheduled flights.

AV2022004 17

significant number of findings in this inspection was twofold: the team consisted

of six inspectors that were assigned to review specific portions of SMS; and the

workaround resulted in a more thorough review of SMS. The team found multiple

issues with maintenance manuals and training, but the team also identified a

pattern of improper risk categorization, risk control ineffectiveness, and missing

hazard identification documentation, as shown in table 3 below. According to

FAA, improper risk categorization and/or control effectiveness negatively impacts

the risk assessment.

Table 3. Findings From FAA’s Team Inspection of American Airlines’ SMS

Finding Type Example 1 Example 2 Example 3

Corrective Actions Unable to provide data to

support that corrective actions

were validated and the risk was

mitigated for voluntarily

reported events

Discrepancy identified in

early 2020 remained

unresolved, indicating gaps

in monitoring corrective

actions

Risk Assessments Aircraft used in two revenue

flights with open mechanical

discrepancies. No risk

identification documentation

found although aircraft was

operated contrary to

regulatory standards

No hazard identification for

discrepancies identified in

Voluntary Disclosures,

Airworthiness Directive

Overflies, and Compliance

Actions

No risk assessment for

missing engine bushings and

improper engine mount strut

installation. Aircraft operated

for 1,002 cycles in an

unairworthy condition.

Root Cause "Primary Cause" listed does

not correlate with the Root

Cause found on the FAA

Voluntary Disclosure

Risk Categorization

Aircraft operated in service

for 877 days with an

inoperable door slide. Risk

category was “Accident or

Incident.” The Hazard

identification did not

document operating an

unairworthy aircraft in

revenue service for 877 days

or the associated risk

assessment.

Operated an aircraft for two

flights with an open

maintenance discrepancy.

Risk category was “Systems or

Processes.” No associated risk

assessment was completed.

Source: OIG analysis of FAA data

The team’s report not only identified weaknesses in American Airlines’ SMS, but

also in FAA’s own review and acceptance of the carrier’s risk ratings. Specifically,

AV2022004 18

the team sampled compliance actions and voluntary disclosures from American

Airlines that the local inspection office had previously reviewed and approved.

The team found that the carrier’s responses lacked sufficient details to justify

appropriate root causes, corrective actions, and risk controls, calling into question

why the local inspection office originally closed out these cases. For example, in

2020, the carrier disclosed an engine maintenance non-compliance and described

that, had the problem not been caught by maintenance mechanics, the aircraft

would have continued to operate in an unairworthy condition. Yet, at the time of

disclosure, FAA accepted the disclosure and corrective actions and closed the

case even though American Airlines stated the aircraft was unairworthy. In

another example in 2020, an aircraft operated for over 2 years with an inoperable

emergency escape slide. According to the team’s assessment, the carrier

incorrectly identified the hazard category and risk controls to prevent the event

from reoccurring. However, the local inspection office reviewed and accepted the

carrier’s response anyway and closed the case.

While the local oversight office’s team inspection of the SMS successfully

uncovered significant findings, they have not previously conducted any such

team inspections. As a result, FAA may be missing opportunities to identify

weaknesses in American Airlines’ SMS related to assessing and mitigating safety

risks.

Conclusion

Ensuring that air carriers are complying with maintenance requirements and

promptly addressing non-compliances is critical to maintaining safety of

commercial air carrier operations. FAA continues to improve its oversight system,

including working more closely with air carriers such as American Airlines to

improve compliance and implement effective SMS. To further enhance aviation

safety, FAA must continue to lead and implement strong oversight controls to

help ensure that American Airlines more closely analyzes risks to its operations,

adequately identifies root causes of issues, and develops appropriate and

effective corrective actions that will prevent reoccurrence of maintenance non-

compliances. These steps will be critical to maintain confidence that U.S. air

carriers are operating at the highest degree of safety.

Recommendations

To improve the effectiveness of FAA’s oversight of American Airlines’

maintenance program, we recommend that the Federal Aviation Administrator:

AV2022004 19

1) Develop and implement root cause analysis training for inspectors more in

line with training in the aviation industry.

2) Develop and implement a management control to ensure that inspectors

maintain the link between the compliance action and the corrective action

validation inspection within its inspection databases.

3) Develop and implement a management control to ensure inspectors require

air carriers to provide written root cause analyses and that these analyses do

not specifically identify human factors issues as root causes.

4) Develop and implement a management control to ensure that inspectors do

not send compliance action close out letters until the corrective actions have

been completed and validated.

5) Develop and implement a team inspection approach in order to periodically

assess the air carrier’s Safety Management System.

6) Develop and implement Safety Management System training for inspectors

that is specifically designed to aid inspectors in evaluating air carrier risk

assessments.

7) Revise the Safety Management Systems data collection tool to allow

inspectors to perform more detailed reviews and accurately document the

results of these reviews.

Agency Comments and OIG Response

We provided FAA with our draft report on August 10, 2021, and received its

response on September 22, 2021, which is included as an appendix to this report.

FAA concurred with five of our seven recommendations and partially concurred

with two. FAA provided appropriate planned actions and completion dates for

recommendations 1, 2, 4, and 6. We are requesting that FAA reconsider its

response or provide additional information for recommendations 3, 5, and 7, as

detailed below.

FAA partially concurred with recommendation 3. The Agency agreed that

additional guidance is needed to address root cause analysis, but states it cannot

statutorily require an air carrier to provide written root cause analyses.

Alternatively, FAA stated it will publish a policy that provides clear expectations

when requesting outputs and performing analyses of an air carrier’s SMS

processes. However, the Agency did not address how it will ensure inspectors do

not accept human factors as root causes. While FAA’s response reflects a more

narrow interpretation of its power to obtain records of certificated air carriers

AV2022004 20

than the Agency’s long-standing interpretation of its authority as stated in 14

C.F.R. § 119.59 (Conducting tests and inspections), we agree with FAA’s proposed

alternative action if the additional guidance clarifies that human factors should

not be identified as the root cause of an non-compliance. Accordingly, we are

requesting additional information regarding how FAA’s planned actions will

address this concern. Until then, we consider recommendation 3 open and

unresolved.

FAA concurred with recommendation 5. However, FAA’s planned action does not

meet the intent of our recommendation. In its response, FAA proposed

enhancing its National Certificate Holder Evaluation Program (CHEP) to provide

an independent team inspection approach to oversight. However, CHEP

inspections are conducted by outside inspectors once every 5 years to evaluate

the air carrier’s ability to adhere to Federal aviation regulations. Conversely,

inspectors in the local inspection offices conduct SMS-specific evaluations

annually. As we noted in our report, FAA’s team inspection resulted in a more

comprehensive assessment than could be accomplished by a single inspector. We

ask FAA to reconsider its response regarding team inspections at local inspection

offices as part of SMS oversight. Until then, we consider recommendation 5 open

and unresolved.

FAA partially concurred with recommendation 7, stating that an update is not

needed to its current SMS Data Collection Tool (DCT). However, FAA did not

explain how it made this determination. During our audit, FAA inspectors

expressed concerns that the current tool hinders their ability to conduct detailed

SMS reviews. We agree with FAA’s proposed alternative action as long as the

additional guidance will demonstrate how inspectors can use the current tool to

conduct and document thorough SMS assessments. Accordingly, we are

requesting additional information regarding (1) how FAA determined the DCT did

not need to be updated and (2) how its updated guidance will demonstrate how

inspectors can use the current DCT to conduct a thorough assessment. Until then,

we consider recommendation 7 open and unresolved.

Actions Required

We consider recommendations 1, 2, 4, and 6 resolved but open pending

completion of the planned actions. In accordance with DOT Order 8000.1C, we

request that FAA provide, within 30 days of this report, the additional information

on recommendations 3, 5, and 7, as described above.

Exhibit A. Scope and Methodology 21

Exhibit A. Scope and Methodology

We conducted this performance audit between November 2019 and August 2021

in accordance with generally accepted Government auditing standards as

prescribed by the Comptroller General of the United States. 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.

We initially planned to conduct an industry-wide audit of FAA’s oversight of air

carrier maintenance programs. However, we decided to refocus the audit after

determining that FAA had adjusted its oversight strategy from emphasizing

enforcement actions to working with carriers collaboratively to address the root

causes for violations of safety regulations. Furthermore, the congressional request

asking us to examine FAA’s oversight of air carrier maintenance highlighted both

Allegiant Air and American Airlines. Allegiant Air was experiencing continued

maintenance problems while American Airlines was being sued by its own

mechanics due to alleged pressure to shortcut maintenance to keep aircraft in

service. We decided to report on these two carriers separately. We issued our

findings on FAA’s oversight of Allegiant Air in December 2019, and this report

presents our findings related to FAA’s oversight of American Airlines.

Our audit objective was to assess FAA’s processes for investigating improper

maintenance practices at American Airlines. Specifically, we examined the

effectiveness of FAA’s oversight of American Airlines and determined whether

FAA ensures that the carrier implemented effective corrective actions to address

the root causes of maintenance problems. We conducted our audit work both

physically and virtually at FAA Headquarters and the FAA Certificate Management

Offices in Irving, TX, and Coraopolis, PA—which are responsible for overseeing

American Airlines. We also interviewed key management officials at American

Airlines to understand their maintenance programs and obtain their perspective

of FAA’s air carrier oversight. Due to the COVID-19 pandemic, we conducted all

of our work at American and follow-up interviews with FAA management

virtually.

To assess FAA’s ability to investigate improper maintenance practices at

American Airlines, we reviewed and evaluated FAA policies and procedures that

govern the oversight of air carrier maintenance. We interviewed 17 inspectors—

who were available at the time of our site visits—regarding American Airlines’

maintenance programs. We also reviewed correspondence exchanged between

FAA and American. Additionally, we analyzed FAA inspection data from 2010 to

2021, obtained from its Enforcement Information System, SharePoint site,

submissions to FAA’s Hotline database, and its SAS.

Exhibit A. Scope and Methodology 22

To determine whether FAA ensured American Airlines implemented effective

corrective actions to address the root causes of maintenance problems, we

analyzed FAA’s Compliance Actions. We obtained a list of all airworthiness

compliance action records—516 in all—from fiscal years 2016 to 2020. We then

drew a sample of 60 closed cases and requested that FAA provide corresponding

records. We performed a file review of all 60 closed records to determine if FAA

inspectors required the carrier to address the underlying causes of non-

compliances and if they conducted follow-up inspections of the Compliance

Actions.

To quantify how often FAA accepted root causes attributed to human error

instead of addressing the underlying root cause, we determined that the 60 cases

we reviewed contained a total of 185 instances of non-compliance. We then

analyzed the root causes of these 185 instances and determined that 121 of these

instances contained air carrier investigative results attributing human error as the

root cause. For example, if it was stated that American officials “coached and

counseled” an employee after the employee committed an error, we counted this

as a human factors root cause because no other reason was given as to why the

error was committed. Similarly, to determine whether FAA conducted follow-up

inspections for the 60 Compliance Actions in our analysis, we reviewed each of

the 185 non-compliances and identified 394 associated corrective actions. We

then compared the dates of closure for these corrective actions to the dates

associated with FAA’s close-out letters to determine that 20 corrective actions

were closed out before inspectors validated the effectiveness of the corrective

actions.

Exhibit B. Organizations Visited or Contacted 23

Exhibit B. Organizations Visited or Contacted

Department of Transportation

FAA Headquarters, Flight Standards Service

FAA Office of Audit and Evaluation

FAA System Approach for Safety Oversight Program Office

FAA Quality Control & Investigations Branch A

FAA American Airlines Certificate Management Office

FAA Contracts and Program Administration Branch

Other Organizations

American Airlines

Exhibit C. List of Acronyms 24

Exhibit C. List of Acronyms

CHEP Certificate Holder Evaluation Program

DCT Data Collection Tool

DOT Department of Transportation

FAA Federal Aviation Administration

OIG Office of Inspector General

SAS Safety Assurance System

SMS Safety Management System

Exhibit D. Major Contributors to This Report 25

Exhibit D. Major Contributors to This Report

TINA NYSTED PROGRAM DIRECTOR

KEVIN GEORGE PROJECT MANAGER

NATHANIEL CALDWELL SENIOR AUDITOR

RUTH FOYERE SENIOR ANALYST

MARK PERRILL SENIOR ANALYST

WAYNE VAN DE WALKER SENIOR AUDITOR

AUDRE AZUOLAS SENIOR TECHNICAL WRITER

SETH KAUFMAN DEPUTY CHIEF COUNSEL

MAKESI ORMOND STATISTICIAN

Appendix. Agency Comments 26

Appendix. Agency Comments

Federal Aviation

Administration

Memorandum

Date: September 22, 2021

To: Matthew E. Hampton, Assistant Inspector General for Aviation Audits

From: H. Clayton Foushee, Director, Office of Audit and Evaluation, AAE-1

Subject: Federal Aviation Administration’s (FAA) Response to Office of Inspector General

(OIG) Draft Report: FAA Lacks Effective Oversight Controls to Determine Whether

American Airlines Appropriately Identifies, Assesses, and Mitigates Aircraft

Maintenance Risks

The FAA’s approach to aviation industry safety oversight incorporates the principles of Safety

Management Systems (SMS) and the FAA Compliance Program. It is a risk management-based

approach that has sustained an exemplary safety record. The Agency is strongly committed to

continuous improvement of that record and will continuously implement enhancements to our

oversight programs as they are identified.

We have reviewed the draft report and offer the following observations:

• The draft report asserts that the FAA can require an air carrier to provide a written root

cause determination. The FAA can request a root cause determination from an air carrier

as part of an investigation, but there is no specific statutory or regulatory provision

requiring an air carrier to provide such a determination. However, the FAA can pursue

traditional enforcement mechanisms if a certificate holder is not effectively identifying

and addressing the root causes of non-compliance. The Agency believes that identifying

and effectively addressing root causes of noncompliance is the most effective way to

prevent a recurrence, and safety risk assessment is an essential element of a well

implemented SMS, which is required.

• The draft report suggests that there is no existing inspection team in place to periodically

assess an air carrier’s SMS program. However, the National Certificate Holder

Evaluation Program (CHEP) has been in existence since 2005. The CHEP is independent

of Certificate Management Offices (CMO) that have general oversight responsibility for

air carriers. The CHEP performs an in-depth evaluation of the design and performance of

14 CFR part 121 certificate holders’ systems. This evaluation includes oversight of the

application of safety attributes within the certificate holder’s technical processes. The

safety attributes directly correlate to the requirements in 14 CFR part 5 for an approved

SMS. A CHEP team is required to perform an evaluation when a certificate holder’s risk

Appendix. Agency Comments 27

factors increase. With enhancements, the Agency believes that the CHEP model can

satisfy the OIG’s recommendation for a “team inspection approach.”

• The OIG recommends “root cause analysis training for inspectors” and “Safety

Management System training for inspectors that is specifically designed to aid inspectors

in evaluating air carrier risk assessments.” The Agency agrees that training in these areas

is vital to the effectiveness of safety oversight, and the FAA intends to address the OIG

recommendations for both types of training in parallel. In a December 2019, audit report,

the OIG recommended additional root cause analysis training for inspectors, and in May

2021, the Agency provided an update to OIG stating that FAA would complete a

competency assessment for aviation safety inspectors and engineers by September 2022.

That competency assessment will form the basis for determining any necessary additional

root cause analysis and SMS training revisions.

Upon review of the recommendations, the FAA concurs with Recommendations 1, 2, 4, and 6.

For recommendations 1 and 6, the FAA plans to begin implementing this training by December 31,

2022. The FAA plans to implement controls for recommendations 2 and 4 by September 30, 2022.

The FAA concurs with Recommendation 5. The Agency intends to make enhancements to the

existing National CHEP to provide more comprehensive oversight of certificate holders’ SMS.

The FAA will incorporate SMS custom DCTs into the National CHEP. This will provide a

standardized team inspection approach to the assessment of a certificate holder’s SMS. The FAA

plans to complete this action by March 31, 2022.

The FAA partially concurs with Recommendation 3. The FAA cannot statutorily require an air

carrier to provide a written root cause analysis. SMS should detect noncompliance and the Agency

can utilize other enforcement mechanisms when certificate holders fail to identify noncompliance

as expected. However, the Agency agrees that additional guidance is needed on the topic of root

cause analysis. As an alternative action, the FAA will publish policy that provides clear

expectations for FAA personnel when requesting the outputs of an air carrier’s SMS processes and

when performing analyses of such information. The FAA plans to implement the alternative

action, publishing revised guidance, by December 31, 2022.

The FAA partially concurs with recommendation 7. While the FAA consistently updates its

Data Collection Tools (DCTs) based on Safety Assurance System (SAS) user feedback, the FAA

does not believe that a specific revision for the SAS DCTs is necessary. However, the Agency

agrees that additional guidance is needed on the use of the DCTs for reviewing SMS. In

particular, the guidance should clarify that the DCTs should not be viewed as limiting and how

investigative personnel can use the existing tools to conduct a thorough assessment. The FAA

will implement the alternative action, publishing revised guidance, by September 30, 2022.

The FAA appreciates this opportunity to respond to the OIG draft report. Please contact H. Clayton

Foushee at Clay[email protected] if you have any questions or require additional information

about these comments.

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