NASA Aviation Safety Reporting System

NASA

Aviation Safety Reporting System

- Becky Hooey Director, NASA ASRS NASA Ames Research Center Moffett Field, California Becky.L.Hooey@NASA.gov April 22, 2021

Agenda

Ø ASRS Background and Immunity Protection

§ ASRS Processes

§ Applying the ASRS Model to other Domains

ASRS Mission Mandate

ASRS captures confidential voluntary safety

reports, analyzes the resulting aviation safety

data, and disseminates vital information to the

aviation community.

Purpose:

1) Identify deficiencies and discrepancies in

the National Airspace System

2) Provide data for planning and improvements

for the future National Airspace System

Historical Perspective

• In December 1974, TWA Flight 514 crashed into Mt. Weather

on approach to Dulles airport, killing all 92 souls on board, after a pilot - ATC miscommunication.

• Just 6 weeks prior, a UAL 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)

NTSB Identification: DCA75AZ005

Government/Industry Partnership

§ FAA provides funding to and immunity protections § NASA provides program management § The Aviation Community provides advocacy for reporting, feedback, and communications

ASRS Concept & Mission

§ ASRS receives, processes and analyzes voluntarily submitted incident reports from pilots, ATC, dispatchers, cabin crew, maintenance technicians, UAS operators, and others.

§ Reports submitted to ASRS may describe both unsafe occurrences and hazardous situations.

Examples of Report Topics: § Near - mid air collisions, § Airspace violations, § Runway incursions § Confusing airport signage § Charting / navigation issues § Confusing phraseology § Aircraft / Equipment failures § Automation Failures / Over - reliance § Training Aviation Safety Reporting System

ASRS Philosophy

• Focus is on safety problems not people - Emphasis on “WHY” not “WHO” – Understanding contributing factors , often with an emphasis on human factors • Focus on accident and incident precursors or vulnerabilities in a system to s upports proactive mitigation of systemic safety issues .

– System - level learning – Detecting safety issues – sometimes “weak signals” – Sometimes requires large volumes of data on a topic before we have a full understanding • Promote safety culture where people can share and learn from mistakes ASRS is NOT: A Whistleblowing System An Accountability / Enforcement System

ASRS Principles

VOLUNTARY PARTICIPATION

Aviation personnel voluntarily submit reports concerning events related to safety for the purpose of system alerting, understanding and learning

CONFIDENTIALITY PROTECTION

Protection of identity is provided by NASA through de - identification of persons, companies, and any other identifying information

INDEPENDENT

Necessary for trust building and unbiased dissemination of safety information

NON - PUNITIVE

FAA will not use any report submitted for inclusion under ASRS guidelines, or information derived therein, for use in any disciplinary or other adverse action (14 CFR 91.25 & AC 00 - 46F)

ASRS Governing Documents

§ Federal Register Notices ‘ 75 & ‘ 76

Ø Federal Aviation Regulation – 14 CFR 91.25

Ø FAA Advisory Circular (00 - 46 F)

§ Defines immunity provisions for pilots and others § FAA Facility Operation and Administration Handbook,

7210.3R (Air Traffic Controllers)

§ Defines immunity provision for air traffic controllers

§ MOA’s between FAA and NASA

§ Interagency Agreements

§ Renewed every 5 years

Federal Aviation Regulation (14 CFR 91.25)

Prohibition against use of reports for

enforcement purposes

“ The Administrator of the FAA will not use reports

submitted to NASA under the ASRS Program (or

information derived therefrom) in any enforcement

action except information concerning accidents or

criminal offenses which are wholly excluded from the

Program. ”

Legal Immunity Provision

FAA Advisory Circular AC No. 00 - 46 F

Waiver of Imposition of Sanction

The FAA considers the filing of a report with NASA concerning an incident or occurrence involving a violation of 49 U.S.C. subtitle VII or the 14 CFR to be indicative of a constructive attitude . Such an attitude will tend to prevent future violations. Accordingly, although a finding of violation may be made, neither a civil penalty nor certificate suspension will be imposed if: § The violation was inadvertent and not deliberate; § The violation did not involve a criminal offense, accident , or action under 49 U.S.C. § 44709, which discloses a lack of qualification or competency, which is wholly excluded from this policy; § The person has not been found in any prior FAA enforcement action to have committed a violation of 49 U.S.C. subtitle VII, or any regulation promulgated there for a period of 5 years prior to the date of occurrence ; and § The person proves that , within 10 days after the violation , or date when the person became aware or should have been aware of the violation, he or she completed and delivered or mailed a written report of the incident or occurrence to NASA.

Agenda

§ ASRS Background and Immunity Protection

Ø ASRS Processes

§ Applying the ASRS Model to other Domains

ASRS Report Processing Flow

Direct Reports (Electronic and Paper) ASAP and ATSAP Reports B DO NOT REPORT AIRCRAFT ACCIDENTS AND CRIMINAL ACTIVITIES ON THIS FORM.

ACCIDENTS AND CRIMINAL ACTIVITIES ARE NOT INCLUDED IN THE ASRS PROGRAM AND SHOULD NOT BE SUBMITTED TO NASA.

ASRS General Report Form

ALL IDENTITIES CONTAINED IN THIS REPORT WILL BE REMOVED TO ASSURE COMPLETE REPORTER ANONYMITY.

( SPACE BELOW RESERVED FOR ASRS DATE/TIME STAMP) IDENTIFICATION STRIP: Please fill in all blanks to ensure return of ID strip to you.

NO RECORD WILL BE KEPT OF YOUR IDENTITY. This section will be returned to you.

TELEPHONE NUMBERS where we may reach you for further details of this occurrence: HOME Area _______ No. ______________________ Hours _________________ Hours _________________ No. ______________________ WORK Area _______ TYPE OF EVENT/SITUATION https://asrs.arc.nasa.gov/report/ NAME ____________________________________________________ ________________________________________ ________________________________________ ADDRESS/PO BOX _________________________________________ electronic.html DATE OF OCCURRENCE ___________________ __________________________________________________________ (MM/DD/YYYY) CITY __________________________ STATE _____ ZIP ____________ LOCAL TIME (24 hr. clock) _________________ (HH:MM) PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.

REPORTER FLYING TIME (in hours) CERTIFICATES & RATINGS ATC EXPERIENCE † Captain Student FPL † Single Pilot † † Flight Instructor † † Developmental Total Time hrs † )LUVW2ႈFHU yrs † Sport/Rec † Multiengine † Instructor radar † SLORWÀ\LQJ yrs hrs † Instrument non-radar † Private † Trainee Last 90 Days † SLORWQRWÀ\LQJ Dispatcher: yrs Commercial † † Flight Engineer supervisory yrs † † relief pilot hrs Time in Type yrs † check airman † Other: † ATP † Other: military AIRSPACE CONDITIONS / WEATHER ELEMENTS LIGHT / VISIBILITY ATC / ADVISORY SVC.

† dawn † night fog † snow † Ramp † Center † Class A † Class E † VMC † † daylight † dusk hail thunderstorm † † † Ground † FSS ID Strip † Class B † Class G † IMC † Tower † UNICOM † haze/smoke † turbulence Ceiling feet † Class C † Special Use † Mixed † TRACON † CTAF † icing † windshear Visibility miles ATC Facility † Marginal † rain † other: † Class D † TFR RVR feet Name: AIRCRAFT 1 AIRCRAFT 2 Your Aircraft Type (Make/Model) Operating Other Operating (e.g. B737, Not "N#", Flt#", etc.): FAR Part: Aircraft: FAR Part: Operator † air carrier † fractional † military † air carrier † fractional † military † air taxi † FBO † personal † air taxi † FBO † personal other: † corporate † government † other: † corporate † government † Mission † passenger † cargo/freight † ferry † passenger † cargo/freight † ferry † personal † training † other: † personal † training † other: Flight Plan † VFR † SVFR † none † VFR † SVFR † none Report Narrative † IFR † DVFR † IFR † DVFR Flight Phase † taxi † climb † ¿QDODSSURDFK † taxi † climb † ¿QDODSSURDFK † parked † cruise † missed/GAR † parked † cruise † missed/GAR † WDNHRႇ † descent † landing † WDNHRႇ † descent † landing † initial climb † initial approach † other: † initial climb † initial approach † other: Route † airway (ID): † STAR (ID): † visual approach † airway (ID): † STAR (ID): † visual approach in Use † direct † oceanic † none † direct † oceanic † none † SID (ID): † vectors † other: † SID (ID): † vectors † other: If more than two aircraft were involved, please describe the additional aircraft in the "Describe Event/Situation" section.

Tell Us Your Story

LOCATION CONFLICTS Altitude: (single value) † MSL † AGL Estimated miss distance in feet: horiz vert as evasive action taken? † Ye s † No W Distance: and/or Radial (bearing): from: “ The usefulness of incident reporting lies in the Was TCAS a factor? † TA † RA † No ATC Fac † † Airport insights that can be gained from careful study of the Did terrain warning system activate?

† Intersection † NAVAID † Yes † No narratives submitted, in all their contextual richness, OMB No. 2700-0172 Exp 7/31/2022 NASA ARC 277B (May 2009) GENERAL not in quantitative knowledge one can gain from Aviation Safety Reporting System counting adverse events. ” (Charlie Billings)

ASRS Report Processing Flow

Screening for Safety Alert Messages

§ All reports are screened by

two subject matter experts

within 3 days

§ ASRS Expert Analysts are

pilot, ATC, dispatch, and

maintenance qualified, each

with over 30 years experience

§ ASRS Assistant Analysts are

pilots and flight instructors with

commercial and instrument

ratings

4 ASRS has issued over 6,800 Safety Alerts and FYI messages

ASRS Report Processing Flow

ASRS Report Matching

§ Provides information from more than one person’ s

perspective on a single event

100%

ASRS Report Processing Flow

Comprehensive and Time - Tested Coding Taxonomy

ASRS Report Coding by SMEs

Comprehensive and Time - Tested Coding Taxonomy

Report Processing Flow

Report De - Identification

§ ASRS returns the

Identification Strip to the

mailing address provided.

§ ID Strip serves as the

proof - of - submission

§ Manual, context -

dependent , de - id of

report narratives and

fixed - field codes

§ Some fields are

generalized (date/time)

Report Processing Flow

ASRS Report Records Are Public: § Direct request to ASRS Office via website “Contact Us”, email, or phone § Direct Access to Database Online (DBOL) ASRS Database

ASRS Database Online

Direct access to search de - identified reports in the ASRS

database is available through ASRS Database Online

(DBOL) at https://asrs.arc.nasa.gov/search/database.html .

Database Users Gov’t Operations FAA Air Carriers NASA Airport NTSB Unions DHS Aircraft Manufacturers Military Equipment Manufacturers Safety Orgs Research AOPA Research Orgs GAMA Academia Over 21,000 Database Searches are NBAA Media conducted each year HAI Legal Individuals

Report Processing Flow

ASRS Data Products

§ These products and services fulfill the program ’ s

mission to disseminate safety data

ALERT QUICK ASRS CALLBACK SPECIAL MESSAGES RESPONSES DATABASE NEWSLETTER STUDIES Safety information Rapid data analysis The public ASRS Monthly newsletter Studies/Research issued to by ASRS staff on Database Online and with a lessons learned conducted on safety organizations in safety issues with data available in format, available via topics of interest in positions of authority immediate operational Database Report Sets website and email. cooperation with for evaluation and importance generally or Search Requests aviation organizations.

possible corrective limited to government full filled by ASRS actions. agencies. staff.

ASRS Special Studies and Topic Areas

COVID (FAA AVP) General Aviation (FAA AVP) UAS (FAA AUS - 430) COVID - Related ASRS Reports FAA, Aviation Safety 2020 Wake Vortex (FAA AJP) HazMat (FAA AXH - 1) NextGen/Human Factors (FAA ANG - C1)

Agenda

§ ASRS Background and Immunity Protection

§ ASRS Processes

Ø Applying the ASRS Model to other Domains

ASRS Model Application Areas

§ International Confidential Aviation Safety Systems (ICASS) § 12 other countries have ASRS - type reporting systems Aviation Safety Reporting System

ASRS - Model Application Areas

Important Characteristics of ASRS

• Voluntary reporting

• Independent / trusted third party

• Non - Punitive - Strong immunity and legal provisions

• Confidential - Secure data confidentiality protections

• Reports screened and coded by aviation domain experts

• Rapid system - wide alerting and data sharing

• National publicly available repository of safety reports

https://asrs.arc.nasa.gov/ Becky Hooey, Director , NASA Aviation Safety Reporting System (ASRS) Becky.L.Hooey@nasa.gov