Document
Aviation Safety Reporting System
(ASRS)
-
Becky Hooey, PhD
Director, NASA ASRS
NASA Ames Research Center
Moffett Field, California, USA
Becky.L.Hooey@Nasa.gov
October 20, 2021
Aviation Safety Reporting System (ASRS)
• NASA ASRS is a confidential , voluntary , non - punitive reporting system that receives
safety reports from Pilots, Air Traffic Controllers, Dispatchers, Cabin Crew, Ground
Ops, Maintenance Technicians, and UAS Operators.
• ASRS welcomes reports describing close - calls, hazards, violations, and safety - related incidents.
Sample Report Topics: § Airspace violations § Environmental hazards § Aircraft / equipment issues § Human error/slips/lapses § Airport markings and signage § Miscommunication/misunderstandings § ATC procedures § Near - mid air collisions § Charting/navigation issues § Runway/taxiway/ramp Incursions
• With over 45 years of confidential safety reporting, ASRS has received more than
1.8 million reports so far (~100,000 reports received annually).
• Reports are triaged based on safety content. De - identified reports are entered into
the public online database
http://asrs.arc.nasa.gov
ASRS Genesis
§ In December 1974, TWA Flight 514 crashed into Mt. Weather on approach to Dulles
airport, killing all 92 souls on board, after Flight crew misunderstood an ATC
clearance and descended prematurely below the minimum safe altitude for the area.
§ Just 6 weeks prior, a United Airlines crew had experienced an identical
misunderstanding and narrowly missed the same mountain.
§ The pilots reported to their company, but there was no mechanism to share that
safety information with other airlines
§ In April 1976, NASA and FAA implemented the Aviation Safety Reporting System
(ASRS)
‘TWA 514 was the catalyst for linking a voluntary, confidential, aviation incident reporting program (ASRS) with the NASA Ames Human Factors research program, which leveraged the reporting data for research in areas such as Crew Resource Management, Automation Integration, Fatigue, and Concurrent Task Management’ (CALLBACK, 2011)
ASRS Principles
1. VOLUNTARY 3. NON - PUNITIVE
Aviation personnel voluntarily submit FAA will not use, nor will NASA
reports concerning events provide, any qualifying report
related to safety for the submitted to ASRS (or information
purpose of system derived therein) for use
alerting, understanding in disciplinary or other
and learning adverse action.
( 14 CFR 91.25 & AC 00 - 46F)
2. CONFIDENTIAL
4. INDEPENDENT
Protection of identity is
NASA serves as the
provided by NASA through
independent honest -
de - identification of
broker; separate from
persons, companies,
employer / certificate
and any other identifying
holder / regulator
information
Safety Reporting
§ ASRS is complementary to other systems of reporting and focuses on
precursors to the most severe events
NTSB FAA ASRS § Identify deficiencies and discrepancies in the National Airspace System § Provide data for planning and improvements to the future NAS
ASRS Report Volume Profile
Report Intake
January 1981 – December 2020
§ Over 45 years of
10000
confidential safety
reporting
§ Total intake for 2019 was
107,879
§ Total intake for 2020 was
65,656
• Reflects reduction in flight operations due to COVID '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 '11 '12 '13 '14 '15 '16 '17 '18 '19 '20 1981 2020
Incident Reporter Distribution
January 2020 – December 2020
Dispatch , 2.1% Maintenance , 3.3% Air Taxi FLC , 3.9% Ground , 3.3% Other , 0.3% Air Traffic Control , 4.4% Cabin , 8.4% Air Carrier FLC , 52.9% General Aviation FLC , 21.4% n = 65,656 Reports
ASRS Report Processing
Report Submission : Flight Crew – Airline, Corporate, General Aviation, Rotorcraft, UAS ATC, Dispatch, Maintenance, Ground Ops,
Screen and Triage
Two Expert Analysts read every report within 3 - 5 days for rapid identification Safety Alert Bulletins of safety concerns FAA/NTSB Telecons
Match
Multiple reports from different Online Database reporters involved in same event are combined to provide a richer Callback Newsletter understanding of the event
Code
Industry Meetings Expert Analysts code reports for ease of data extraction
De - Identify
(All ASRS Expert Analysts have at least Case - by - case de - id process 10 years of domain experience as Flight Crew, ATC, Dispatch, and Maintenance) requires operational expertise to protect reporter and third - parties while preserving safety content.
ASRS Safety Products
Submit
De - Identified Reports
Screen
Match
Industry Database Telecons Newsletter Alerts/FYI Meetings* InfoShare 12 editions ~ 36 Safety ~ 120 - 160 Up to 36,000
Code
published CAST items database Alerts/FYI GA - JSC searches per discussed notices
De - Identify
32,000+ year by ASRS UAST with FAA/ issued per users subscribers ICASS NTSB year CAST = Commercial Aviation Safety Team: GA - JSC = General Aviation - Joint Steering Committee UAST = Unmanned Aircraft Safety Team • Air Carriers • FAA • Individuals ICASS = International Confidential Aviation • Academia • Flight Schools • NASA Safety Systems • Media • Research • NTSB • Labor Groups • Industry Groups • DOD • Airports • DHS • Manufacturers
Safety Products: ASRS Database
Direct access to search de - identified reports in the ASRS database is
available through ASRS Database Online (DBOL)
https://asrs.arc.nasa.gov/
Special Report Sets
§ Collections of records on
specific safety topics
§ Contain at least 50 records
each
§ 30 sets available
Contact us for help in Searching the Database Aviation Safety Reporting System
Safety Products: Alert/FYI Notices,Telecons
# issued
Category Examples
in 2020 Aircraft Systems 18 Brakes Locked on Takeoff, Flight Control Anomalies, Navigation 11 Database Errors, Similar Sounding Fix Names Airports Facility Status and Mx 46 Runway, Taxiway, Ramp signage and markings, and charting ATC Procedures 16 SID, STAR, RNAV Procedures Hazards to Flight 12 Obstacles on or near approach path, Solar panel glare Airport Lighting Approach Aids 5 Unlighted Tower, PAPI Lights Aircraft Avionics 5 FMS / Database Anomalies, Navigation Software ATC Operations 8 Non - standard Taxi Phraseology, staffing ATC Equipment 10 Glideslope Unreliable, Radio Coverage Hazardous Material (HazMat), Maintenance On - time Departure Other 29 Pressure, COVID 160 Alert Bulletins and FYI notices issued in 2020
Examples of Safety Alerting Success
§ Arrival Charting: Altitude noted on chart was 2000 ft when it should have been 3000 ft. Flight Crew confirmed error and re - programmed FMC which was “not ideal when descending into an unfamiliar airport” Chart Publisher "...we revised the ZZZ Arrivals Chart … we missed updating that specific altitude .
The two Charts will be revised in the next two weeks... A Chart Change Notice has already been issued. ” § Runway Light Intensity: In - pavement Runway LED lights were too bright, negatively affecting pilots’ night vision at flare. Blooming around LED lighting was a source of distraction.
Airport Operations: “In coordination with ATC, the airport tested various in - pavement light settings. Pilots were made aware of the settings check and were asked to comment upon rollout.
Consensus was reached on a preferred setting. Default in - pavement lighting settings have been changed to the lower, preferred step .” § Aircraft Wing Oscillations: Pilot reported wing oscillations after experiencing light chop/turbulence at FL400 in aircraft equipped with after - market winglets .
FAA: …”We found 40 some similar incidents ... The prevalence of incidence of aircraft with winglets has dramatically affected these events. The pursuit of subject incidents has resulted in data and risk analysis that has resulted in Aircraft Certification (AIR) initiating their Continued Operational Safety programs using the Corrective Action Review Board process to consider mitigating response to these events…”
Safety Products: CALLBACK Newsletter
Over 32,000 Subscribers Month Issue Issue Title / Topic (2020) 480 January The “Whether” of Winter Weather 481 February What Would You Have Done?
482 March Adventures in Ground Operations 483 April RNAV (RNP) Approaches User Feedback, October 2021 484 May A Day in the Life of a Maintainer “CALLBACK 501 looks at reported ETOPS 485 June The COVID - 19 Confrontation incidents that reveal a spectrum of ETOPS. Thank you for highlighting this subject, 486 July The Old Threat From a New Enemy especially the article "Fuel, Pumps, and ETOPS", 487 August What Would You Have Done?
which brings up several issues. As an ex - Airline Pilot, and FAA Inspector who was involved in 488 September MEL Missteps multiple Part 121 ETOPS Certifications and operations , this is a topic which should receive 489 October Late Clearance Changes much more attention .” 490 November Airmanship and Automation 491 December VFR Flight into IMC
https:// asrs.arc.nasa.gov /publications/ callback.html
Aviation Safety Reporting System
Special Studies and Focus Areas
ASRS Watch List: 737 Max, UAS, Cabin Fumes, GPS Interference (as of October 2021)
Wake Vortex (FAA AJP) HazMat (FAA AXH - 1) NextGen/HF (FAA ANG - C1)
• Screening and FullForm Processing • Weekly summaries of Wake • 100% FullForm Processing • RNAV/RNP Approaches Incidents at RECAT airports • Secondary Coding to understand • Metroplex Procedure Complexity • Supplemental Question Set (SQS) incident types, contributing factors • Arrival/Approach Transition • Quarterly data summaries • Outreach to Ground Ops • Secondary Analysis shared with prepared for FAA Personnel to build safety culture FAA/Industry Groups General Aviation (FAA AVP) COVID (FAA AVP)
UAS (FAA AUS - 430)
• 100% Fullform Processing • Launched UAS Reporting form • De - identification of 100% of GA • Weekly reporting to FAA Aviation in April 2020 reports Safety Management • 100% FullForm Processing • Over 40,000 reports available for • Alerts/FYI notices, Telecons • Outreach, Education and analysis by FAA, GA JSC, industry • Newsletters Safety Culture
COVID - Related Safety Products
Submit
ASRS COVID - Related Safety Products
56 Weekly updates to FAA Aviation Safety Management Team
Screen
Match
Industry Database Telecons Newsletter Alerts Meetings 2,270 COVID ICASS 3 editions 6 COVID - 10 COVID -
Code
reports ASRS TSG related FAA/ related to related Alert processed InfoShare COVID: June, NTSB Bulletins
De - Identify
July, August telecons https://asrs.arc.nasa.gov
Incident Reporting Model
§ ASRS is a closed loop ASRS process that supports Triaging System Safety and Human Coding Factors Reporter callbacks § Government / Industry are De - identification provided information that Reports Alerting may result in corrective actions Input Analysis by Process ASRS Domain Experts Reporters Corrective Industry Database Actions & Mitigations Publication of Synthesis Findings & Research ASRS/ FAA/ Industry FAA/ Industry Search Requests Risk Identification Learning Secondary Analysis Safety Assessment Special Studies Safety Enhancement Adapted from: Prioritization Aviation Safety Reporting System
Important Characteristics of ASRS
• Voluntary reporting
• Confidential - Secure data confidentiality protections
• Independent / trusted third party
• Non - Punitive - Strong immunity and legal provisions
• Reports screened and coded by aviation domain experts
• Emphasis on incident/accident precursors and human factors
• Rapid system - wide alerting and data sharing
• National publicly available repository of safety reports allows for
further analysis, research and learning
“ The usefulness of incident reporting lies in the insights that can
be gained from careful study of the narratives submitted, in all
their contextual richness, not in quantitative knowledge one can
gain from counting adverse events. ”
Dr. Charlie Billings. Co - Developer of the ASRS Model
https://asrs.arc.nasa.gov/
Becky Hooey, Director , NASA Aviation Safety Reporting System (ASRS) Becky.L.Hooey@nasa.gov