Aviation Safety Reporting Program

1
Aviation Safety Reporting Program

• Mark E. Blazy
• Program Manager
• FAA Office of System Safety
• mark.blazy_at_faa.gov

2
ASRP / ASRS

• History
• In 1975 the NTSB recommended FAA create an
  incident reporting system for identifying unsafe
  operating conditions following the TWA B727
  accident near Dulles International Airport,
  December 1, 1974.
• FAA established the Aviation Safety Reporting
  Program (ASRP) in April 1975. Four months later
  the FAA determined that an impartial third
  party without regulatory oversight should serve
  as the repository for safety reports.
• In August 1975 NASA was selected and tasked to
  develop and administer the Aviation Safety
  Reporting System (ASRS)

3
ASRP/ASRS History

• On December 1, 1974, a TWA B-727 was inbound from
  the northwest to land at Dulles International
  Airport in instrument meteorological conditions
  (IMC). The flight descended prematurely below
  the minimum safe instrument altitude striking the
  slope of Mount Weather, VA. All 92 passengers
  and crew on board were killed.
• Investigating the circumstances, the National
  Transportation Safety Board (NTSB) discovered
  that the flight crew misinterpreted information
  on the approach chart. The NTSB then discovered
  that another airline made a similar premature
  descent some six weeks earliersomehow avoiding
  the same fatal error. The earlier incident was
  reported within the company, but it was not
  disseminated to any other airlines for fear of
  enforcement action.

4
ASRP/ASRS History

• This incident served as a catalyst to create an
  incident reporting system. Since one of the
  primary missions of FAA is to promote aviation
  safety, the NSTB made an immediate recommendation
  for the FAA to create a reporting program
  designed to identify unsafe operating conditions.
  In 1975 the FAA instituted the Aviation Safety
  Reporting Program (ASRP), which was designed to
  encourage the identification and reporting of
  deficiencies and discrepancies in the National
  Airspace System (NAS). To encourage reporting,
  the ASRP provides limited immunity from certain
  types of enforcement action.
• Pilots, however, were uneasy and often times
  reluctant to report errors to a regulatory agency
  that could assess fines and revoke licenses.
  Understanding the reluctance to report
  deficiencies or hazards, the FAA determined that
  the effectiveness of the ASRP would be further
  enhanced if an objective, non-regulatory agency
  served as the repository for reported safety
  information. The National Aeronautics and Space
  Administration (NASA) was selected as the
  independent agency.

5
ASRP/ASRS History

• In 1976, FAA and NASA entered into a Memorandum
  of Agreement where NASA would handle the
  collection, analysis, and de-identification of
  safety reports. Although NASA designed and, now
  administers the Aviation Safety Reporting System
  (ASRS), the FAA provides the major funding for
  the ASRS to promote the continued use and
  operation of the system.
• NASAs ASRS is a voluntary incident reporting
  system that is designed primarily to provide
  information to the FAA and the aviation community
  to assist in reaching the goal of reducing and
  ultimately eliminating unsafe conditions in the
  NAS.
• NASAs system ensures the anonymity of the
  reporter.

6
FAA ASRP Primary Objective

• The primary objective
• Obtain all possible information that might assist
  the FAA in evaluating and enhancing safety and
  security.
• ASRP
• Based on free and unrestricted flow of
  information by all users of the airspace system.

7
FAA / NASA Interrelationship

• FAA
• Grants Immunity
• Provides funding for NASAs ASRS
• Uses ASRS data to enhance safety and security

• NASA five primary functions
• 1. Receipt, de-identification, and processing of
  incident reports
• 2. Analysis and interpretation of incident data
• 3. Issue alert messages within a specified time
  period
• 4. Disseminate reports and other appropriate
  information
• 5. Conduct ASRS evaluations and reviews.

8
FAA / NASA Authority

• FAA
• Title 14 C.F.R.FAR Part 91, Section 91.25 --ASRP
  
• Prohibition against use of reports for
  enforcement action.
• Federal Register, Vol 41, No. 74 April 1976
• Describes FAA and NASA use of ASRS Information.
• MOA/IA
• Outlines the roles and responsibilities of the
  FAA and NASA.

• NASA
• NASA is a non-regulatory agency.
• They have no authority to direct corrective
  action or to initiate enforcement action.
• NASA has sole authority
• Make return calls to any reporter without the
  requirement to inform the FAA of the information
  that may identify the reporter.

9
FAA ASRP Policy

• Grants limited immunity from FAA enforcement
  action This means that a person may receive a
  waiver of imposition of a sanction by the FAA.
• Anonymity is assured, in all respects, to the
  extent permitted by law.
• Exceptions to Immunity
• The incident cannot have been deliberate,
  criminal, or resulted in an accident.
• The reporter cannot have been involved in
  enforcement action within the previous five
  years.
• The incident must be reported within 10 days.

10
ASRS Operations

• Reporting Forms Reporters are encouraged to use
  NASA FORM 277. Other written reports may be
  used.
• ASRS Form 277 After the NASA review the top
  portion of the form is detached and returned to
  the reporter.
• Top portion of form The only record of the
  incident report with the reporter's name. Should
  be maintained by the reporter.
• Reports NASA will review, code, and enter
  information into database. Two analysts will
  examine each full-form report.
• Callbacks The analyst will determine if a
  callback to the reporter for additional
  information is required.

11
Alert Messages

• Two categories of Alert Messages Alert Bulletins
  (ABs) and For Your Information (FYI) notices.
  NASA imparts safety alerts to the FAA and
  industry for investigation and/or corrective
  action.
• Alert Bulletins (AB) Early warning reports
  issued by NASA to inform the FAA, the NTSB, and
  the aviation industry of air, equipment, ground,
  or any other safety or security hazards.
• For Your Information (FYI) notices Notices
  issued by NASA that inform the FAA and aviation
  industry of conditions that may be sufficient for
  hazards or indicate an adverse safety or security
  trends.

12
ASRS Operations

• Data Searches
• Search Requests
• Processing of database searches and analyses for
  specific or general information. (e.g., wake
  turbulence, digital avionics hardware and
  software problems, TCAS II Incident, Airport Ramp
  Safety Incidents, and LAHSO). No costs
  associated. Timeframe Approximately 3 weeks.
• Structured Callbacks
• A quantitative and qualitative research tool that
  can be used to describe inferential and
  descriptive statistics and data. NASA will, in
  conjunction with the specific requestor, develop
  methodologies and research questionnaires.

13
ASRS Operations

• Quick Responses
• Detailed data research projects on specific
  subjects. Timeframe Approximately 2-4 weeks.
• Topical Research
• In-depth data collation performed over extended
  period frequently lasting several months or
  years. Comprehensive examination of operational
  safety issues.

14
NASA Publications

• Directline Periodic publications (available on
  the internet) that contains technical information
  directed to specific groups or organizations in
  the aviation community.
• Callback Not to be confused with NASAs
  research criteria called Structured Callback.
  CALLBACK is a monthly safety bulletin (available
  on the internet) that includes excerpts of
  research studies and related aviation safety
  information.

15
ASRS Reports

• Report Intake -- Annual
• 1999 34,831
• 1998 34,348
• 1997 32,875
• 1996 32,322

• Full Form Processing Annual
• 1999 9,318
• 1998 8,363
• 1997 8,024
• 1996 7,920
• Full form is a comprehensive review of the
  submitted report.

16
Reporting Process
Initial Screening
Review Time Critical Reports
Input Data Oracle
FAA
Alert Messages Response
NASA issues safety alerts
Industry
FAA/NASA Alert Teleconference
17
Reporter Breakdown by Category

• 1999 1998
• Air Traffic Controller 730 Air Traffic
  Controller 844
• Air Carrier 23258 Air Carrier 22802
• Air Taxi 1072 Air Taxi 1308
• General Aviation 8023 General Aviation
  7866
• Mechanics 687 Mechanics 436
• Flight Attendants 737 Flight Attendants
  662
• Other 324 Other 430

18
ASRP/ASRS Today

• Original charter to identify deficiencies and
  discrepancies.
• Since 1976 over 460,00 reports filed.
• 57 of todays reports identify risks and
  hazards.
• Continues to be the worlds largest and longest
  operating voluntary aviation incident reporting
  program.
• Graphical User Interface (GUI).
• ASRP outreach U.S. colleges and universities with
  avionics, aviation safety or other aviation
  related programs.
• Purpose Greater understanding of the program
  and system

19
ASRS Data benefits

• Data used to identify
• Possible causes of pilot and controller errors.
  This led, in part, to prevention strategies like
• Crew resource Management (CRM) AC revision to
  improve decision making and coordination efforts.
• Help in the establishment of FAA/ARAC group for
  new autopilot airworthiness criteria.
• Aided FAA in ATC separation criteria for avoiding
  wake turbulence accidents and incidents.
• Airport ramp safety.

20
Response to Alerts

• FAA
• Aids the FAA in mitigating risks, hazards, or
  deficiencies.
• Aids the FAA in conducting safety risk
  assessments, I.e., LAHSO and Runway Inclusions.
  
• ASRS data was used as pointers to the problem and
  used as examples to indicate possible factors
  involved.
• Extends to all FAA offices Air traffic, flight
  standards, aviation security, etc. ASRS cannot
  be the only source for statistically meaningful
  analysis.

21
FAA / NASA Web Site

• FAA
• http//nasdac.faa.gov
• Includes
• Weather Study
• LAHSO
• Aviation Safety Data Accessibility Study

• NASA
• http//asrs.arc.nasa.gov
• Includes
• Callback Publications
• Reporting Forms
• Immunity Provisions
• Cross-link to FAA Web Site for FARs,
  Airworthiness Directives, AIM, etc