Increasing safety one report at a time

Some pilots call it a “Get Out of Jail Free” card. Others call it a “Cover Your Butt” card.

But what the Aviation Safety Reporting System (ASRS) is all about is improving safety for all pilots. In our last print issue, we debuted a new feature in which we run a variety of general aviation-related ASRS reports, which differ quite a bit from the NSTB Accident Reports. Most tellingly, the ASRS reports are written by pilots, not bureaucrats, so you get a real feel for what the pilot was feeling and what he or she learned from the incident.

Now the largest aviation reporting system in the world, handling around 61,000 reports each year, ASRS came about as the result of a tragic accident more than 38 years ago.

On Dec. 1, 1974, TWA Flight 514 was inbound to Dulles Airport (IAD) in Washington, D.C., through cloudy and turbulent skies. The flight crew misunderstood an ATC clearance and descended to 1,800 feet before reaching the approach segment to which that minimum altitude applied. The aircraft hit a Virginia mountaintop, killing all aboard.

During the ensuing NTSB accident investigation, it was discovered that a United Airlines flight crew had experienced an identical clearance misunderstanding and narrowly missed hitting the same Virginia mountain during a nighttime approach. The United crew discovered their close call after landing and reported the incident to their company. A cautionary notice was issued to all United pilots.

Unfortunately, at that time, there was no way of sharing that information with other airline pilots.

After the TWA crash, it became obvious to everything in the aviation industry that these close calls and near misses are often the precursors to the worst case scenarios — people dying.

“The NTSB and the industry said to the FAA we need a way we can gather information on events that might occur that are just short of accidents,” said Linda Connell, ASRS program director.

The FAA responded by creating the Aviation Safety Report Program. Not one report was submitted.

While the FAA had good intentions, the industry realized that such a reporting system wouldn’t work, Connell noted. Because the FAA had the power to take away licenses, pilots weren’t going to admit their mistakes.

What was needed was a way to separate the reporting from the regulators and enforcers to a “middle man” or honest broker.

Officials at NASA Ames had just started their human factors research, working with United Airlines in San Francisco on an internal reporting system. When the FAA administrator asked if NASA would become that middle man, the program was born.

According to a well-known story, the framework for the system was developed when four officials — three pilots and a doctor — sat down around a dining room table for four days and came up with a proposal for a voluntary, anonymous reporting system.

When the proposal was submitted, the FAA director said “this is exactly what we need,” then offered immunity from prosecution to those who filed reports.

“That was the big incentive,” Connell said. “The administrator realized that if the FAA says the words, but doesn’t dance the dance, it would fail. We can’t ask people to open up and talk about what really went on, then prosecute them. That would doom it from the beginning. The immunity is an incentive for people to put pen to paper.”

It is NASA’s job to protect the identity of those who respond. A quick look at the ASRS database shows that most identifying information, from airport to type of aircraft, has been deleted.

“The FAA’s job is to keep their hands off of it,” she said, noting “that’s the law — the FAA can’t use information in any disciplinary action.”

Pilots who are involved in an incident can protect themselves from what the government calls an “inadvertent human error” by submitting an ASRS report within 10 days.

“That shows a constructive attitude towards safety by sharing your information,” Connell explained. “There will not be any disciplinary action.”

That assurance has led a huge number of pilots to file reports over the years.

About 60,000 reports are filed each year. Around 62% are airline-related, while 26% are general aviation related. The rest are air traffic, dispatch and other items. In 2010, 10,500 general aviation reports were filed.

The most common reports deal with altitude deviations, near-misses, loss of control, and equipment problems. Interestingly, most of the reports are not tied to a violation of the regulations, Connell said.

“This has matured into a real safety reporting system,” she said. “The safety culture in aviation is very evolved. This is a very educated group who are talking about things that they see that could potentially be links in a chain to an accident.”

In fact, officials note that filing reports helps improve the safety of all pilots.

“By providing information, others can learn,” Connell said. “It improves the system for yourself and your flying compatriots.”

Just how does that work?

When a report is submitted, it is analyzed by two safety experts — “people who have been there, done that and have flown many, many hours,” Connell said.

The report is then “triaged,” with the most serious or hazardous ones getting top priority. In those cases, an alert might be sent out to warn pilots of these hazards.

The analysis also helps identify new issues, such as a traffic problem at an airport or a continued problem with communication during a certain approach.

The data is also used for special studies, as well as by the FAA to determine if changes to traffic patterns, airspace or training is needed. Training organizations, including Embry-Riddle Aeronautical University, also use the information.

The information is also included in the organization’s monthly safety newsletter, “Callback,” which pilots can subscribe to for free online at or by sending a text message to ASRS22828.

Pilots and aviation enthusiasts can also search the ASRS database, inputting any criteria, from types of accidents to model of aircraft to time of day.

When should you file an ASRS report?

“If in doubt, fill it out,” Connell said, noting that criminal activities or a “bona fide” accident by NTSB criteria, which means there was substantial damage or injury, are excluded from the system.

“I’m a GA pilot and I know that if I experience something that might be a potential violation and I’m not clear if I crossed the line, I should send in a report just to protect myself,” she said.

On a more subtle note, writing down what happened is a great learning experience for pilots, she said.

“It gives you the opportunity to learn more about the event and your part in it, which will help you improve as a pilot,” she said.

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