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TheWhat? Where? and Why?
of Voluntary, Non-Punitive, and
ConfidentialSafety Reporting
Linda Connell
NASA ASRS Program Director
Linda Connell
NASA ASRS Program Director
Aviation Safety Reporting SystemAviation Safety Reporting System
3
Where is ASRS Located?
May 20084
Ames Research
Center
Dryden Flight Research Center
Langley Research Center
Glenn Research Center
Jet Propulsion Laboratory
Johnson Space Center
Marshall Space Flight Center
Goddard Space Flight Center
Kennedy Space Center
Home of ASRS
ASRS
Moffett Field - Hangar OneMoffett Field - Hangar One19321932
6
What is Safety Reporting?
ASRS Guiding PrinciplesVOLUNTARY PARTICIPATION
Aviation personnel voluntarily submit reports concerning events related to safety for the purpose of system alerting, understanding and learning
CONFIDENTIALITY PROTECTIONProtection of identity is provided by NASA through de-identification of persons,
companies, and any other information
NON-PUNITIVEFAA will not use, nor will NASA provide, any report submitted for inclusion under ASRS
guidelines or information derived therein for use in any disciplinary or other adverse action (14CFR91.25 & Advisory Circular 00-46D)
INDEPENDENCETrust building and unbiased dissemination of safety information enhanced by report
submissions to organization independent from other directly connected bodies
TWA 514, December 1, 1974TWA 514, December 1, 1974
Aviation Tragedy Leads to Genesis of ASRS
ASRS History
• The ensuing investigation revealed that six weeks prior, a United Airlines crew had experienced an identical ATC misunderstanding and narrowly missed the same mountain.
• At the time there was no method of sharing the United pilot’s experience with TWA and other airline operators.
• This gave birth to the idea of a national aviation reporting program that would enable information sharing.
• In April 1976,NASA and FAAimplemented theAviation SafetyReporting System(ASRS)
NTSB Identification: DCA75AZ005
FAA and NASA Partnership
MOA signed by Administrators for FAA and NASA
. . . To provide information to the FAA and the aviation community to assist them in reaching the goal of identifying and eliminating unsafe conditions to prevent accidents.
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Aviation Safety Reporting
Around the World
13Aviation Safety Reporting System
South KoreaKAIRS (2000)
United StatesASRS (1976)
United KingdomCHIRP (1982)
CanadaCASRP (1985)SECURITAS (1995)
AustraliaCAIRS (1988)REPCON (2006)
RussiaVASRP (1992)
BrazilRCSV (1997)
JapanASI-NET (1999)
TaiwanTACARE (2000)
SingaporeSINCAIR (2004)
FranceREC (1999)
ChinaSCASS (2004)
New ZealandICARUS
South AfricaSASCO
GermanyEUCARE
ASRS Model Applied to International Aviation
Community
ASRS Model Applied
International Confidential Aviation Safety Systems (ICASS)
SpainSNS (2007)
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Other Professions Establish Safety Improvement
Programs Using Confidential Reporting
Confidential Reporting in the U.S Railroad Industry
NASA ASRS and Federal Railroad Administration Interagency Agreement
signed on May 21, 2010
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Patient Safety Reportin
g System
18Aviation Safety Reporting System
Los Angeles Metrolink and Union Pacific Chatsworth - September 12, 2008
Washington MetroFort Totten – June 22, 2009
Human Performance Human Performance Contributions to ErrorsContributions to Errors
THE HUMAN FACTOR
Simplified Event Chain
Detection &Recovery
OperationalSystem
HumanPerformance
Incidents
Accidents
Normal Operations
Incidents
InjuryAccidents
Fatal Accidents
ASRS is Complementary to Other Systems of Reporting
Event OccurrencesEvent Occurrences
{FAA & NTSB
{ASRS
Precursors
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Why ASRS is Essential for Aviation Safety?
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Purpose and Mission
Identify deficiencies and discrepancies in the National
Airspace System
Provide data for planning and improvements to the future National Airspace System
ASRS Program Overview
ASRS Purpose
Identify Deficiencies and Discrepancies
Provide Data for Planning and Improvements
ALERTS PRODUCTS
ASRS Alerting Messages 1999 – 2009
154
250
282
213 214
304
208192
342
275
236
0
50
100
150
200
250
300
350
400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Calendar Year
30
31
Monthly Report Intake
• Averaging 4,890 reports per month, 224 per working day
• Total Report intake for 2010 was 58,683
• 60,000 to 62,000 Reports in 2011
0
1,000
2,000
3,000
4,000
5,000
6,000
'81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10
Smoothed / Forecast
Actual Intake
January 1981 – December 2010
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ASRS Processes
Report Processing Flow
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Electronic and Paper Reports
Incident Reporting ModelIncident Reporting Model
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ASRS Summary
Advantage of ASRS as a National Resource
System-Wide Perspective
System-Wide Alerting
Data Processing through Aviation Expert Analysts
Comprehensive and Time Tested Coding Taxonomy
Strong Immunity and Legal Provisions
Information Sharing on Safety/Security
National and International Reputation
Confidential reporting systems have the means to answer the
question why? –
why a system failed
why a human erred
SUMMARY
SUMMARY
WHY CONFIDENTIAL REPORTING WORKS
• When organizations want to learn more about the occurrence of events, the best approach is simply to ask those involved.
• People are generally willing to share their knowledge if they are assured:
• Their identities will remain protected
• There is no disciplinary or legal consequences
• A properly constructed confidential, voluntary, non-punitive, independent reporting system can be used by any person to safely share information
Contact Information
Linda Connell, NASA ASRS/C3RS Director(408) 541-2827 ASRS Office (650) 604-0795 NASA Office
Brian Reilly, C3RS Project [email protected]
ASRS Website:http://asrs.arc.nasa.gov
C3RS Website:http://c3rs.arc.nasa.gov
41Aviation Safety Reporting System
Governing DocumentsGoverning Documents
• Federal Register Notices 1975 & 1976
• Federal Aviation Regulation - 14 CFR 91.25
• FAA Advisory Circular (00-46A, B, C, & D)
• Defines immunity provisions for pilots and others
• FAA Facility Operation and Administration Handbook, 7210.3T (Air Traffic Controllers) and new ATSAP MOU
• Defines immunity provision for Air Traffic Controllers
• Interagency Agreement (signed in 1999 and renewed in 2009 for an additional 8 years)
• IA details such factors as duration, products, expected funding level, termination clause, points of contact, etc.
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What Can ASRS Do For You?
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ASRS Products & Services
ASRS Database Online (DBOL)
DBOL launched August 23, 2006• Over 70,000 total
online queries completed to date
• Over 20,966 queries completed in 2009
Fixed field and text search capability
Data formats (export)• MS Word, Excel, CSV
HTML Experts version (DBOL II)
being proposed
http://asrs.arc.nasa.gov
ASRS Web Site
Completed Fall 2006
• Over 7 million hits in 2009
File an ASRS Report
• Electronic• Print and Mail
Database Online
ASRS Publications
Program Information
Immunity Policies
http://asrs.arc.nasa.gov
Alert Messagesand
Monthly Telecons
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ASRS Alerting Messages 1999 – 2009
154
250
282
213 214
304
208192
342
275
236
0
50
100
150
200
250
300
350
400
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Calendar Year
48
Safety Alerts – Alerting Subjects2006 – Present
111
175
270
421
4
22
22
24
35
52
63
86
0 50 100 150 200 250 300 350 400 450
Security
Aircraft Avionics
Navigation
Aircraft Powerplants
Hazards to Flight
ATC Operations
ATC Equipment
Airport Lighting and Approach Aids
ATC Procedures
Other
Airport Facility Status and Maintenance
Aircraft Systems
n = 1,285
* 2010 data current through November 16.49
37
78
175
28
43
57
61
109
116
285
0 50 100 150 200 250 300
Action not within Addressee's Jurisdiction
Information in AB/FYI Insufficient for Action
Addressee Disputes Factual Accuracy of AB/FYI
Addressee Agrees with AB/FYI, but Unable to Resolve
For Information Only; No Response Expected
Addressee in Factual Agreement but Sees No Problem
Issued Raised by AB/FYI Under Investigation
Action Initiated Before AB/FYI Received
Action Initiated in Response to AB/FYI; Not Completed
Action Taken as a Result of AB/FYI
Alert Responses 1999 – Present
