1 The What? Where? and Why? of Voluntary, Non-Punitive, and Confidential Safety Reporting.

1

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.

12

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)

14

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

16

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

27

Why ASRS is Essential for Aviation Safety?

28

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

32

ASRS Processes

Report Processing Flow

33

Electronic and Paper Reports

Incident Reporting ModelIncident Reporting Model

35

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

[email protected]

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.

43

What Can ASRS Do For You?

44

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

47

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