WASHINGTON — The Government Accountability Office is recommending that the Federal Aviation Administration improve its process for investigating launch mishaps, one that currently relies heavily on launch providers.
In a Dec. 7 report, the GAO recommended that the FAA’s Office of Commercial Space Transportation “comprehensively evaluate” its processes for investigating launch mishaps, including developing criteria for when those investigations should be led by the launch operator.
The report, which examined commercial launch mishaps from 2000 to January 2023, noted that the FAA was the lead agency for investigating all but one of the 50 mishaps during that period. The exception was the October 2014 SpaceShipTwo fatal accident, where the National Transportation Safety Board (NTSB) led the investigation.
The FAA says it decides on a case-by-case basis whether to conduct the mishap investigation itself or allow the launch operator to handle it with FAA oversight. In practice, all 49 investigations were operator-led.
“FAA relies on the operator-led approach, agency officials told us, because, given highly specialized vehicle designs among companies, the agency does not have adequate resources for in-house investigations,” the GAO report stated. Those officials estimated that an agency-led investigation might take 10 to 20 times longer because the FAA lacks the “intimate knowledge of vehicle design” needed to effectively investigate mishaps.
Both FAA and industry support operator-led reviews, which are guided by the FAA to varying degrees based on the nature of each mishap and the experience level of the launch operator. However, the GAO report stated that several unidentified industry stakeholders questioned the independence of company-led investigations as well as their ability to identify broader organization issues versus technical causes of mishaps.
The GAO found that while the FAA says it decides individually who will lead a mishap investigation, it “has no specific criteria among its procedures for making those case-by-case determinations.” That is intended, the FAA argues, to give it flexibility, but the GAO noted that the FAA thus “cannot ensure consistency in its decisions.”
The FAA also has not evaluated the effectiveness of operator-led investigations. “A changing operating environment also underscore FAA’s need to ensure that its mishap investigation process is effective,” the GAO stated, citing the growing number of commercial launches. Without such an evaluation, “FAA cannot be assured that its safety oversight is best achieving agency objectives in an area of critical importance.”
In addition to mishap investigations, the GAO report addressed the ability to share lessons learned about mishaps among agencies and companies. There are no formal mechanism for doing so, the GAO found, but there are informal channels of communication. The FAA is also making another attempt at establishing a lessons-learned database for commercial space transportation after a previous effort at a voluntary system, more than a decade ago, failed because of a lack of industry participation.
In a response to the GAO, Philip McNamara, assistant secretary for administration at the Department of Transportation, which includes the FAA, said the agency accepted the recommendations and would provide a detailed response within 180 days.
The GAO report was requested by the leadership of the House Transportation Committee and its aviation subcommittee. Notably, House oversight of the FAA’s commercial space transportation office has typically been in the jurisdiction of the House Science Committee, not the House Transportation Committee.
