Aviation Safety Reporting Program - PowerPoint

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					 Aviation Safety
Reporting Program
       Mark E. Blazy
      Program Manager
  FAA Office of System Safety

                      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)

                      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 earlier—somehow 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.

                      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.
                 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.

•   NASA’s 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.

•   NASA’s system ensures the anonymity of the reporter.

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

                 FAA / NASA
• FAA                      • NASA: five primary
  – Grants Immunity          functions
                           1. Receipt, de-identification, and
  – Provides funding for       processing of incident reports
    NASA’s ASRS            2. Analysis and interpretation of
  – Uses ASRS data to          incident data
                           3. Issue alert messages within a
    enhance safety and         specified time period
    security               4. Disseminate reports and other
                               appropriate information
                           5. Conduct ASRS evaluations and

                            FAA / NASA
FAA                                    NASA
• Title 14 C.F.R.FAR Part
  91, Section 91.25 --ASRP
                                       • NASA is a non-regulatory
   – Prohibition against use of          agency.
     reports for enforcement action.      – They have no authority to
• Federal Register, Vol 41,                 direct corrective action or to
  No. 74 – April 1976                       initiate enforcement action.
   – Describes FAA and NASA            • NASA has sole authority
     use of ASRS Information.
                                          – Make return calls to any
• MOA/IA                                    reporter without the
   – Outlines the roles and                 requirement to inform the
     responsibilities of the FAA            FAA of the information that
     and NASA.                              may identify the reporter.

                    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.

                   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
• Callbacks: The analyst will determine if a callback to the
  reporter for additional information is required.
                      Alert Messages
• Two categories of Alert Messages: Alert Bulletins (AB’s) 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.

                   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.

                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

             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 NASA’s
  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
              ASRS Reports
• Report Intake --    • Full Form Processing
  Annual                Annual
     – 1999: 34,831      – 1999: 9,318
     – 1998: 34,348      – 1998: 8,363
     – 1997: 32,875      – 1997: 8,024
     – 1996: 32,322      – 1996: 7,920
                           • Full form is a
                             comprehensive review
                             of the submitted report.

           Reporting Process
    Initial                     Input Data
               Time Critical
  Screening                       Oracle

                 FAA              NASA
                               issues safety
                    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

               ASRP/ASRS Today
• Original charter to identify deficiencies and discrepancies.
• Since 1976 over 460,00 reports filed.
• 57% of today’s reports identify risks and hazards.
• Continues to be the world’s 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

               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.

             Response to Alerts
• FAA:
  – Aids the FAA in mitigating risks, hazards, or
  – 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.

         FAA / NASA Web Site
• FAA                         • NASA
• http://nasdac.faa.gov       • http://asrs.arc.nasa.gov
  – Includes:                    – Includes:
                                     •   Callback Publications
     • Weather Study
                                     •   Reporting Forms
     • LAHSO
                                     •   Immunity Provisions
     • Aviation Safety Data
       Accessibility Study           •   Cross-link to FAA Web
                                         Site for FAR’s,
                                         Directives, AIM, etc