OIG found that the increase in reported errors was
linked, in part, to a rise in actual errors rather than
increased reporting. For example, the FAA’s air route
traffic control centers (ARTCC) which have had an
automated system in place for years to detect and
investigate reported errors had a 39 percent increase in
operational errors during the same period.
addition, OIG identified other contributing factors to
the rise in the number of operational errors. For
example, almost one quarter of the increase is due to
the revocation of a separation waiver at the Southern
California Terminal Radar Approach Control (TRACON) that
led to the reclassification of many routine approach and
landings as operational errors.
The FAA’s new policies and procedures for collecting,
investigating, and reporting separation losses have the
potential to reduce losses and improve reporting, but
their effectiveness is limited by incomplete data and
implementation challenges. Under the FAA’s new policies,
the FAA uses TARP to detect losses, then examines the
risk of these losses, and identifies corrective actions.
OIG found that the effectiveness of these procedures is
limited by incomplete data and implementation
challenges. Finally, the FAA has recently developed new
corrective action plans to mitigate high-risk separation
However, it is too early to determine the effectiveness
of these plans. In addition, the Agency’s corrective
action plans do not include all safety risks identified
by the FAA and will not address all losses of separation
that air traffic facility officials consider to be high
risk. The FAA concurred with four and partially
concurred with two of OIG’s six recommendations to
improve the Agency’s policies and processes for
identifying and mitigating separation losses.
Department of Transportation’s Office of Inspector
General has made recommendations To improve the FAA’s
policies and processes for collecting, investigating,
and reporting separation losses, and mitigating their
risks, OIG recommend that the FAA:
Include all losses of separation that are reported under
ATSAP, but unknown to air traffic facilities, in its
official count of such events.
Determine the level of staff and expertise needed at the
ATO Service Areas to effectively implement ATO’s new
Orders on investigating losses of separation, audit all
TARP data, and initiate actions to fill those
Determine the extent to which ATO has successfully
implemented its new orders (effective January 2012).
This determination should include reviews of the quality
of separation loss investigation reports, effectiveness
of training, and additional actions or resources needed.
Include high-risk TCAS warning events in its Risk
Analysis Process and System Risk Event Rate when the
separation between two converging aircraft is maintained
at 66 percent or more.
Develop actions to mitigate the following situations
identified in the Risk Analysis Process: (1) poor
recovery from loss of separation and (2) losses of
separation involving on-the-job training.
Utilize analysis of the causal and contributory factors
derived in the Risk Analysis Process including
perception, memory, and training to identify the
underlying reasons for separation losses and develop
mitigation strategies to address those causes.