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

2. Aviation Safety Reporting System
Linda Connell
NASA ASRS Program Director

3. Where is ASRS Located?

4. Home of ASRS ASRS 4 Ames Research Center Glenn Research Center
Dryden Flight Research Center
Langley Research Center
Glenn Research Center
ASRS
Jet Propulsion Laboratory
Johnson Space Center
Marshall Space Flight Center
Goddard Space Flight Center
Kennedy Space Center
May 2008 4 4

5. Moffett Field - Hangar One
1932

6. What is Safety Reporting?

7. ASRS Guiding 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 information
NON-PUNITIVE
FAA 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)
INDEPENDENCE
Trust building and unbiased dissemination of safety information enhanced by report submissions to organization independent from other directly connected bodies

9. Aviation Tragedy Leads to Genesis of ASRS
TWA 514, December 1, 1974

10. NTSB Identification: DCA75AZ005
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 FAA implemented the Aviation Safety Reporting System (ASRS)
NTSB Identification: DCA75AZ005

11. 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

13. ASRS Model Applied to International Aviation Community
United Kingdom
CHIRP (1982)
Russia
VASRP (1992)
Canada
CASRP (1985)
SECURITAS (1995)
New Zealand
ICARUS
South Africa
SASCO
Germany
EUCARE
Japan
ASI-NET (1999)
South Korea
KAIRS (2000)
France
REC (1999)
United States
ASRS (1976)
Spain
SNS (2007)
China
SCASS (2004)
Taiwan
TACARE (2000)
Singapore
SINCAIR (2004)
Brazil
RCSV (1997)
Australia
CAIRS (1988)
REPCON (2006)
International Confidential Aviation Safety Systems (ICASS)
Aviation Safety Reporting System

14. Other Professions Establish Safety Improvement Programs Using Confidential Reporting14

15. Confidential Reporting in the U.S Railroad Industry
NASA ASRS and Federal Railroad Administration Interagency Agreement signed on May 21, 2010
Confidential Reporting in the U.S Railroad Industry

16. Patient Safety Reporting System

18. Aviation Safety Reporting System
Los Angeles Metrolink and Union Pacific Chatsworth - September 12, 2008
Aviation Safety Reporting System

19. Washington Metro
Fort Totten – June 22, 2009

20. Human Performance Contributions to Errors
THE HUMAN FACTOR
Human Performance Contributions to Errors

25. Simplified Event Chain
Operational
System
Human
Performance
Incidents
Detection &
Recovery
Accidents

26. ASRS is Complementary to Other Systems of Reporting
Event Occurrences
Fatal Accidents {
FAA & NTSB
Injury
Accidents
Precursors
Incidents {
ASRS
Normal Operations
ASRS is Complementary to Other Systems of Reporting

27. Why ASRS is Essential for Aviation Safety?

28. Purpose and Mission
ASRS Program Overview
Identify deficiencies and discrepancies in the National Airspace System
Provide data for planning and improvements to the future National Airspace System

29. ASRS Purpose ALERTS PRODUCTS Identify Deficiencies and Discrepancies
Provide Data for Planning and Improvements
ALERTS
PRODUCTS

30. ASRS Alerting Messages 1999 – 200930

31. Monthly Report Intake
January 1981 – December 2010
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 31 31

32. ASRS Processes

33. Report Processing Flow
Electronic and Paper Reports 33

34. Incident Reporting Model

35. ASRS Summary

36. 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

37. SUMMARY
Confidential reporting systems have the means to answer the question why? –
why a system failed
why a human erred

38. 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

40. Brian Reilly, C3RS Project Manager
Contact Information
Linda Connell, NASA ASRS/C3RS Director
(408) ASRS Office
(650) NASA Office
Brian Reilly, C3RS Project Manager
ASRS Website:
C3RS Website:

41. Aviation Safety Reporting System

42. Governing Documents Defines immunity provisions for pilots and others
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, T (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? 43

44. ASRS Products & Services

45. 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

46. http://asrs.arc.nasa.gov ASRS Web Site Over 7 million hits in 2009
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

47. Alert Messages and Monthly Telecons47

48. ASRS Alerting Messages 1999 – 200948

49. Safety Alerts – Alerting Subjects 2006 – Present49
* 2010 data current through November 16.

50. Alert Responses 1999 – Present