Aviation’s Best Kept Secret

The PRICE: At 11:09 AM on Sunday, December 1, 1974, TWA 514 was IMC and inbound to Virginia’s Dulles Airport and due to an ambiguous approach procedure and a misunderstood clearance, the crew descended prematurely to their final approach altitude. The Flight collided with a mountaintop and all aboard perished. Six weeks earlier, a United Airlines flight had narrowly avoided the same fate during a nighttime approach, discovered their close call after landing, and promptly reported it to United’s new Flight Safety Awareness Program. A notice was issued to all company pilots, but that’s where it stopped. Back then, there was just no good way to get the word out.

The RESULT — ASRS: In much the same way that the Federal Aviation Regulations have often been lessons learned, written in blood, the comments of the NTSB resulted in the formation of the Aviation Safety Reporting Program on April 30, 1975. They realized that if you want to learn more about aviation incidents, it’s best to ask the people involved. They also knew that people are usually much more willing to share their hard-learned lessons if they’re assured of protection from punishment. By August of that year, a Memorandum of Understanding had been drafted, designating NASA as the broker between the FAA and the aviation community, as well as the operator of the new Aviation Safety Reporting System. Funding for the system came by way of the FAA under the umbrella of the three-month old ASRP. In April 1976, the contract for its day-to-day operation was awarded to the Battelle Memorial Institute’s Columbus Laboratories. They then engaged the understanding ears of the ‘old eagles’ (retired professional pilots, air traffic controllers, flight surgeons, aviation lawyers, and research experts) for the multidisciplinary extraction of those lessons sometimes learned only after the exam. Since that time, the idea behind ASRS, where people can anonymously report and learn from operational errors, misjudgments, and violations, has been emulated by aviation organizations, as well as other industries, worldwide.

STAYING SAFE — In More Ways Than One: Immunity provisions are spelled out in Section 91.25 of the FARs. The rules prohibit the use of any ASRS report in any disciplinary action or penalty, with the exception of accidents (in which case it goes to the NTSB) or criminal offenses (a matter for the Department of Justice.) There are some notable exceptions…

  • The violation must be inadvertent or not deliberate,
  • It must not involve an action ‘disclosing a lack of competency’,
  • You must not have been found to commit any other violation within five years prior to the date of occurrence (though one can file reports as often as one chooses),
  • And you’ve mailed an ASRS form within 10 days after the (possible) violation.NOTE: Filing an ASRS form is considered by the FAA to be indicative of a ‘conservative attitude’ and if you meet the requirements above, they can’t touch you.

    WHAT YOU GIVE… A full description of the ASRS is contained in Advisory Circular 00-46D. As the third party, NASA receives Safety Reports on the Ames Research Center Form 277 that is familiar to most airline pilots, although pilots are not the only participants. (Pilots use the ‘B’ version; ATC personnel have a separate ‘A’ version; there is a 277C for flight attendants, and a 277D for maintenance personnel.) Each form has a tear-off section with all information identifying the reporter. ASRS program personnel occasionally use it to contact a reporter for additional information if that is deemed necessary for a more complete understanding. The contact information section is always removed, time-stamped and is usually on its way back to the originator within 72 hours of receipt. No copies are created or maintained. In fact, ASRS incorporates secure phones, alarm systems, locked safes, and bonded couriers to keep information safe. Since its inception, there has been no breach of confidentiality.

    IS LESS THAN WHAT YOU GET: CALLBACK issue #1 appeared in July 1979. The April 2001 issue of CALLBACK, #260, marks the 25th anniversary of the ASRS. The bulletin’s name was derived from the operating procedure of ‘calling back’ incident reporters by telephone whenever clarification about a particular incident was needed. A typical recent month’s “box score” of input showed over 2000 reports coming from air carrier and air taxi pilots; over 600 from general aviation; over 50 from controllers, and almost 200 from “cabin/mechanics/military/other”.

    Treasure Trove … With A Common Thread
    The ASRS recently processed their 500,000th report. In addition to about 4,000 alert bulletins, and several “quick response” studies during accident investigations, airspace redesign or rulemaking reports, there have also been several dozen research studies, 6,000 database searches by government, industry, and academia, and outreach efforts at meetings and conferences. Not too surprisingly, the majority of incident reports (about 70%) involve flaws in information transfer.

    BOTTOM LINE: The analyzed incident data housed by the ASRS have become a valuable safety resource for pilots around the world. But even if your “data point” is never correlated or registered, the act of simply being forced to re-think what you did right or wrong by putting something down on paper is a useful end in itself. …That get out of jail free card ain’t bad, either!

    Note: ASRS also publishes Directline for commercial carriers and corporate operators. All ASRS products are accessible from their homepage at http://asrs.arc.nasa.gov/. Any friends that are still not online can find reporting forms at FSDOs and FSSs, and can contact ASRS at: POB 189, Moffett Field, CA 94035.