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

1. 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 Glenn Research Center ASRS AmesResearchCenter Goddard Space Flight Center Dryden Flight Research Center Jet Propulsion Laboratory Langley Research Center Marshall Space Flight Center Johnson Space Center Kennedy Space Center May 2008 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. 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 FAAimplemented theAviation SafetyReporting 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 ASRS Model Applied South Korea KAIRS (2000) United States ASRS (1976) Taiwan TACARE (2000) Canada CASRP (1985) SECURITAS (1995) Japan ASI-NET (1999) Singapore SINCAIR (2004) Brazil RCSV (1997) Russia VASRP (1992) United Kingdom CHIRP (1982) China SCASS (2004) Spain SNS (2007) France REC (1999) Germany EUCARE Australia CAIRS (1988) REPCON (2006) South Africa SASCO New Zealand ICARUS International Confidential Aviation Safety Systems (ICASS) Aviation Safety Reporting System

14. Other Professions Establish Safety Improvement Programs Using Confidential Reporting 14

15. 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. 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

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

26. Fatal Accidents { FAA & NTSB Injury Accidents Precursors { Incidents ASRS Normal Operations Event Occurrences 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

30. ASRS Alerting Messages 1999 – 2009 30

31. Monthly Report Intake 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 January 1981 – December 2010 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. Contact Information Linda Connell, NASA ASRS/C3RS Director (408) 541-2827 ASRS Office (650) 604-0795 NASA Office linda.j.connell@nasa.gov Brian Reilly, C3RS Project Manager brian.f.reilly@nasa.gov ASRS Website: http://asrs.arc.nasa.gov C3RS Website: http://c3rs.arc.nasa.gov

41. Aviation Safety Reporting System

42. Governing Documents • 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, 7210.3T (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 totalonline 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 http://asrs.arc.nasa.gov

46. ASRS Web Site • 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 http://asrs.arc.nasa.gov

47. Alert MessagesandMonthly Telecons 47

48. ASRS Alerting Messages 1999 – 2009 48

49. Safety Alerts – Alerting Subjects2006 – Present n = 1,285 49 * 2010 data current through November 16.

50. Alert Responses 1999 – Present