Aviation Safety Reporting Program

1. Aviation Safety Reporting Program Mark E. Blazy Program Manager FAA Office of System Safety mark.blazy@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 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.

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. • 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.

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 Grants Immunity Provides funding for NASA’s 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. FAA / NASA Interrelationship

8. 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. FAA / NASA Authority

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 NASAFORM 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 (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.

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 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 information.

15. 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. ASRS Reports

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 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

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 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 FAR’s, Airworthiness Directives, AIM, etc FAA / NASA Web Site