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From
There to Here, With Your Support
ASRS Celebrates
Its 20th Birthday
An anonymous wit once observed
that "a diplomat is a person who remembers a lady's birthday, but
forgets her age." Putting a more festive (if less discreet) spin
on that advice, CALLBACK is proud to announce both the birthday and age
of the NASA Aviation Safety Reporting System: the program's birthday occurred
on April 15, 1996, a date which also marked the 20th anniversary of ASRS
operations.
As ASRS enters its 21st year, the program has met the test of time, fulfilled
the early hopes of its founders, and achieved many "firsts":
- Processed more than 338,000
total aviation incident reports without violating a single reporter's
confidentiality;
- Issued more than 2,500 alert
messages of all types;
- Responded to more than 4,800
database search requests;
- Performed more than 90 Quick
Response research efforts for the FAA, NTSB, and NASA;
- Published 56 research reports
and papers;
- Returned information to
the aviation community through its two award-winning publications, CALLBACK
(in its 17th year of publication), and Directline, an aviation safety
journal.
In its 20 years of existence,
ASRS has become the world's largest, and longest-operating, incident reporting
program. Without any doubt, it has also saved lives.
Yet as important as all these achievements are, it is not the ASRS as
an organization--but the aviation community it serves--that is the real
story. For at one time, the ASRS did not exist. Many years of effort were
required for the idea of a national reporting system to take root in the
aviation community, and to gather its support and trust.
A Phoenix
from the Ashes
The precipitating event for
the ASRS was a tragedy that occurred on December 1, 1974. On that Sunday
morning, Trans World Airlines (TWA) Flight 514 was inbound to Dulles Airport
through cloudy and turbulent skies, when the aircraft descended to 1,800
feet before reaching the approach segment where that minimum altitude
applied. Flight 514 collided with a Virginia mountain top, with the loss
of all lives on board.
According to the accident report issued by the National Transportation
Safety Board (NTSB), the crew's decision to descend was the result of
inadequate depiction of altitude restrictions on the profile view of the
approach plate, and confusion in interpreting air traffic terminology.
The NTSB investigation uncovered another disturbing, yet provocative,
detail. Six weeks prior to the TWA crash, a United Airlines crew had very
narrowly escaped the same fate, during the same approach, and at the same
location.
United, however, had instituted a new internal reporting program, the
Flight Safety Awareness Program. Under this program, crew members were
encouraged to report anonymously any incident they felt involved a safety
problem for the company. The United pilots involved in the Dulles incident
had reported to their company program the ambiguous nature of the charted
approach.
Other United pilots were made aware of the potential trap, and the FAA
was notified of the circumstances. Unfortunately, there did not exist
at the time any generally accepted method to assure the broad and timely
dissemination of this information to the aviation community.
The NTSB comments on the need for a national incident reporting system,
and the collaboration of aviation industry groups, finally led to significant
action. In May 1975, the FAA issued Advisory Circular 00-46, announcing
the implementation of a confidential, non-punitive incident reporting
program. The FAA assumed a sponsorship role for the new program, but turned
to a neutral and highly respected third party--NASA--to collect, process,
and analyze the voluntarily submitted reports.
Under a Memorandum of Agreement
between the two agencies in August 1975, NASA began operating the newly
designated Aviation Safety Reporting System. Thus the blueprint for the
ASRS was set: FAA would fund the program and provide its immunity provisions,
while NASA would set program policy and administer operations.
ASRS: The
Future
What lies ahead for the ASRS?
Here are some of the activities that ASRS is currently undertaking, with
the advice and support of our advisory oversight group:
- A renewed focus on and expansion
of the ASRS alerting function. A new alerting product, the ASRS Operational
Issues Bulletin, is likely to be distributed through the cooperative
efforts of aviation industry groups this year.
- Continued efforts to find
ways of increasing the participation in the program of the maintenance
and flight attendant communities.
- Conversion of the ASRS database
to widely used commercial off-the-shelf (COTS) software.
- Expansion of Internet services
to make ASRS research publications available to users, as well as additional
issues of its safety publications.
As always, the ASRS program
users and the aviation community are our greatest resources. As you celebrate
with us the 20 years of accomplishment that are the fruit of your support,
we invite you to share with us, and also with your organizations' policy
makers and representatives, your suggestions for increasing the use, and
usefulness, of the ASRS within the aviation community.
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