NASA Aviation Safety Reporting System (ASRS) Program Briefing

NASA Aviation Safety Reporting System (ASRS) Program Briefing Becky Hooey, ASRS Director Becky.L.Hooey@nasa.gov

NASA Aviation Safety Reporting System

• 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 .

• With over 48 years of confidential safety reporting, ASRS has received more than 2.1 million reports so far (over 120,000 reports received annually).

When in doubt, fill it out! Contribute to aviation safety https://asrs.arc.nasa.gov

The Genesis of ASRS

st The crash of TWA Flight 514, on December 1 1974 was caused by a misunderstanding between ATC and the flight crew.

• Occurred just six weeks after a United Airlines flight had narrowly escaped a similar fate.

• Unfortunately, in 1974, there was no way for the information that had been communicated within United to be shared with the wider aviation community.

The Genesis of ASRS

AC 00 - 46 Creation of NASA’s ASRS in April 1976 “The FAA determined that…effectiveness would be greatly enhanced if NASA, rather than the FAA, accomplished the receipt, processing, and analysis of raw data. This would ensure the anonymity of the reporter …and, consequently, increase the flow of information… Accordingly, NASA designed and administers the Aviation Safety Reporting System (ASRS)”

ASRS Principles

1. VOLUNTARY

Reporting Incentives When aviation personnel voluntarily submit reports the resulting data are more detailed and descriptive

2. CONFIDENTIAL

VOLUNTARY Protection of identity is provided by regulations and by NASA ‘s de - identification of persons, companies, and other identifying information CONFIDENTIAL

3. NON - PUNITIVE

FAA will not use, nor will NASA provide, any qualifying report submitted to ASRS (or information derived therein) for use in disciplinary or other NON-PUNITIVE adverse action. (14 CFR 91.25 & AC 00 - 46F)

4. INDEPENDENT

NASA serves as the independent third - party; separate from employer and regulator

FAA Advisory Circular 00 - 46F

Use Restrictions. The FAA will not use any reports submitted to NASA under the ASRS (or information derived therefrom) in any enforcement action…except information concerning criminal offenses or accidents which are excluded.

Confidentiality. The FAA will not seek, and NASA will not release or make available to the FAA, any report filed with NASA under the ASRS or any information that might reveal the identify of any party involved in an occurrence or incident reported under the ASRS.

Waiver of Imposition of Sanction. The FAA considers the filing of a report with NASA … to be indicative of a constructive attitude towards safety. 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 … • Inadvertent and not deliberate • Did not involve a criminal offense, accident or action under 49 U.S.C § 44709, which discloses a lack of qualification or competency • No finding of any FAA enforcement action within 5 years prior to date of occurrence • Reported within 10 days of the violation, or first aware of the violation

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 the National Aeronautics and Space Administration under the Aviation Safety Reporting Program (or information derived therefrom) in any enforcement action except information concerning accidents or criminal offenses which are wholly excluded from the Program.”

ASRS Government /Industry Partnership

▪ NASA manages ASRS operations and disseminates safety information ▪ FAA provides funding and immunity protections to reporters as an incentive to report ▪ The Aviation Community provides advocacy for reporting, and extracts lessons - learned to improve aviation safety

Safety Reporting in the USA

In the USA, there are many ways to report safety concerns. Information is

shared among airlines, ASRS, FAA, NTSB. Reports submitted to ASRS

may describe both unsafe occurrences and hazardous situations.

Accidents & Incidents Substantial Damage, Serious Injury, NTSB Flight Control System Failures National Transportation Safety Board Mandatory Occurrence Reporting (MOR) FAA (Also HAZMAT, Bird strike, Lasers, etc.)

Federal Aviation Administration Incidents, Hazards, Close - calls, Rule NASA ASRS Violations, Normal Operations Aviation Safety Reporting System (Accident Precursors) JO 7210.632

ASRS REPORTING METRICS

ASRS Report Intake Profile

Reduced reporting

due to COVID pandemic

impacts on operations

120,000 * 112,816 107,879 106,087 99,010 95,509 100,000 94,302 92,228 91,970 90,100 85,541 80,840 80,000 65,656 60,000 40,000 20,000 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

In 2024, ASRS is forecasting to return to pre - COVID levels

with over 130,000 reports

st.

*2024 data includes reports received through October 31

Reporter Distribution

January 2023 – December 2023

Air Taxi Dispatch , Other , Air Traffic Flight Crew , 2.0% UAS , 0.1% Control , 2.6% 0.1% 3.2% Maintenance , 3.3% Ground , 6.3% General Air Carrier Aviation Flight Crew , Flight Crew , 52.1% 14.4% Flight Attendant , 15.7% n = 106,087 Reports

ASRS Highest - Priority Safety Topics

January 2023 – December 2023

1,800 1,614 1,600 1,400 1,200 1,000 Critical Aircraft NMAC Controlled Flight Ground - Loss of Critical Ground Inflight Loss of Equipment Towards Terrain Aircraft Control Conflict Aircraft Control Problem (CFTT)

High - Priority “Bold List” Safety Topics

*Categories are not mutually exclusive.

n = 4,564 Records

ASRS Contributing Factors and Human Factors

January 2023 – December 2023

Contributing Factors

Specific Human Factors

Human Factors 3,107 • Situational Awareness Aircraft 1,954 • Communication Breakdown Procedure 1,880 • Workload Environment - Non Weather Related • Time Pressure Weather • Troubleshooting Airspace Structure • Confusion Airport • Distraction Chart Or Publication • Training / Qualification Software and Automation 268 • Human - Machine Interface ATC Equipment / Nav Facility / Buildings • Other / Unknown Company Policy • Fatigue MEL • Physiological - Other Equipment / Tooling Manuals Staffing Incorrect / Not Installed / Unavailable… Logbook Entry 0 1000 2000 3000 4000 n = 4,564 Records

ASRS Contributing Factors and Human Factors

Communication Breakdown

January 2023 – December 2023

Party 1 Party 2 Count Party 1 Party 2 Count

ATC ATC Dispatch Dispatch Flight Attendant Flight Crew 133 ATC Flight Crew 462 Flight Crew Ground Personnel Ground Personnel Other Maintenance Dispatch Other ATC Flight Crew 5 2 Dispatch Ground Personnel 2 Dispatch Flight Crew Maintenance Ground Personnel Ground Personnel Other Maintenance Flight Attendant Other Flight Crew Flight Crew Ground Personnel 4 Flight Attendant Ground Personnel Maintenance Maintenance Maintenance Other Other ASRS Coding Example

n = 1,571 of 4,564 Records

Each count of one represents communication breakdown Categories are not mutually exclusive.

between two parties Party 1 Party 2

ASRS Contributing Factors and Human Factors Communication Breakdown January 2023 – December 2023 Party 1 Party 2 Count ATC Dispatch Flight Attendant Flight Crew 462 Flight Crew Ground Personnel Maintenance Other ATC Categories are not mutually exclusive.

Dispatch

PROCESSES AND PRODUCTS

The Life of an ASRS Report

ASAP = Airline Safety Action Program Submit Reports ATSAP = Air Traffic Safety Action Program Electronic Airline Print & ATC Submission ASAP Mail ATSAP Screen and Triage Safety Alert Bulletins Expert Analysts read every report within 3 - 5 days for rapid identification of safety concerns FAA/NTSB Telecons Match Online Database Multiple reports for same event are combined to provide a richer CALLBACK Newsletter understanding of the event Industry Meetings Code De - Identify Expert Analysts code reports Personal and carrier for ease of data extraction information, and revealing flight details are removed. Other specific information may be generalized or removed 18

ASRS Safety Products

Incident Reports Received 2,068,784

Custom Safety Alert

7,436

Search

7,632

Messages Requests CALLBACK Database

357,607

Issues Searches (April 1976 – December 2023)

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 .

1,938+

Queries completed each month

375,045+

Queries completed since DBOL launch in July 2006 Aviation Safety Reporting System

ASRS Safety Alerting Program

Report Submitted Corrective Action ASRS Issued Safety Alert to ASRS Airbus Response : “Having checked the diagrams referenced in the ASRS report, and also further to follow up with the supplier of the identified affected engine nacelle and diagram, we can Synopsis: A320 Maintenance confirm that the orientation of Technician reported that the the shown backshells in the incorrect part was listed in the referenced documentation Illustrated Parts Catalog (IPC) does not accurately reflect the and needs to be corrected and installation on the aircraft. We updated. The installation of the have therefore taken steps to incorrect part as instructed in the current IPC could lead to possible update the referenced documentation , which will be malfunction of the aircraft’s thrust updated for the May 2024 reverser system.

revisions. ” ASRS Report # 2022066

CALLBACK Safety Newsletter

▪ CALLBACK is a monthly publication - distributed by email and all issues are available on our website ▪ We encourage sharing and re - distribution ▪ Subscription is free and available via the ASRS website.

Scan to Sign Up for CALLBACK

33,200+

Total number of email subscribers for 2023

741,822+

CALLBACK views for 2023 (HTML and PDF) Aviation Safety Reporting System

UAS Safety in Sight

▪ UAS Safety In Sight is an Unmanned Aircraft System (UAS) specific publication distributed by email.

▪ Subscription to UAS Safety In Sight is free and available via the ASRS website.

Sign up for UAS Safety in Sight

1,100+

Total number of email subscribers as of 2024

11 Issues

Published to date Aviation Safety Reporting System

How are ASRS Reports Used?

Common Examples

FAA Wake Encounters Long - term study to assess wake vortex encounters and assess the impact of changes to dynamic separation criteria HAZMAT Understand types of incidents and contributing factors for outreach, education Airport Operations Provide compilation of reports of airport ramp light issues in the U.S. (SR 7343) 5G Interference Continued monitoring of impact of deployment of 5G C - Band on flight operations NTSB Participation in NTSB Roundtable to review industry - wide safety issue of runway incursions, their contributing factors, and additional mitigations to reduce frequency To inform accident investigations , looking at precursor events to shed light on possible human factors involvement Airlines To educate pilots about new routes ( Share local folklore about airport ops) Equipment Provide compilation of reports on B737 AUTO SLAT and SPD LIM Fail Related Manufacturers Incidents (SR 7343) Airports To address confusing signage, faded paint/markings, inadequate markings for construction Chart To identify and correct discrepancies between chart and actual airspace/airport ; Manufacturers Rectifying missing or confusing charting Aviation Safety Reporting System 24

ASRS Current Safety Issues

Low Altitude Events Reconfiguration of ATC N90 TRACON Operations at Non - Towered Airports

Low Altitude events

▪ Reports describe low altitude events in 2024 ▪ Reported events spanned 119 unique airports ▪ Majority occurred in Daylight VMC

ATC Reconfiguration

Background: On July 28, 2024, PHL TRACON was assigned to control

the EWR area. This was previously controlled by N90 TRACON.

LGA Class B EWR Class B JFK Class B Area Involved – 10,000 MSL and below

ATC Reconfiguration

Issues and concerns expressed in ASRS reports ▪ Controllers that previously used in - person communication to facilitate traffic coordination are no longer in same room • Timeliness of inter - facility coordination for point outs/hand - offs in complex airspace resulting in loss of separation and airborne conflicts • ATC personnel adapting to changes in ATC equipment configuration used to coordinate movement of flights across different airspaces ▪ Controllers experienced stress resulting from physical relocation and adapting to new facility, in turn impacting work performance ▪ Pilots received clearances that added workload and complexity to an already challenging flight environment

Operations at Non - Towered Airports

▪ ASRS analysis showed a majority of

Aircraft Operation Total Count*

interactions among aircraft involved a

Types

Near Mid - Air Collision or Ground

Personal 584

Conflict

FBO Corporate 64

▪ Most incidents resulted in pilots taking

Air Carrier

evasive action to avoid a collision

Air Taxi

▪ Issues related to interaction between

Military

Turbojet and Non - Turbojet aircraft

Government Other • Aircraft power performance differences • Different levels of pilot experience • Schedule pressure (Turbojet) versus recreational flight operations • Passengers on larger aircraft n = 875 Records

More Information at ASRS Website

https:// asrs.arc.nasa.gov