Number 260
April 2001
Half a Million Incident Reports Later
The ASRS Celebrates Its 25th Anniversary
On April 15, 2001, the world’s largest confidential voluntary aviation reporting system, the NASA Aviation Safety Reporting System (ASRS), will celebrate its 25th year of operation. Just prior to this anniversary, the ASRS will reach another milestone – the processing of its 500,000th aviation incident report. The ASRS was founded in 1976 through a Memorandum of Agreement between the Federal Aviation Administration (FAA) and National Aeronautics and Space Administration (NASA). The longevity and success of the ASRS program is a remarkable example of how cooperation between government agencies can create an effective agent for safety improvements against the backdrop of changing times. The FAA quickly recognized that its regulatory and enforcement roles would discourage the aviation community from using the new program. It therefore asked NASA to act as the independent third party that would administer the program and fulfill the role of an honest broker attending to the interests of both sides. NASA, a research organization with no regulatory or enforcement role, saw a unique opportunity to enhance its research capability through access to the human factors data generated by the new system. NASA accepted the proposal to support the FAA in its mission to eliminate unsafe conditions in the national aviation system, and the ASRS began operation in 1976. The FAA provides funding for all ASRS program operations, while NASA administers the program and supplies “in-kind” funding support.
Origins of the FAA / NASA Partnership
Progress often comes at a price, and the founding of the ASRS was no exception. A tragic and potentially avoidable airline accident was the direct motivation for establishing a national aviation incident reporting system. On December 1, 1974, TWA Flight 514 was inbound through cloudy and turbulent skies to Dulles Airport in Washington, DC. The flight crew misunderstood an ATC clearance and descended prematurely to the final approach altitude, below the minimum safe altitude for the area through which they were flying. The aircraft collided with a Virginia mountain top, killing all aboard. A disturbing finding emerged from the NTSB accident investigation. Six weeks earlier, a United Airlines flight crew had experienced an identical clearance misunderstanding and narrowly missed hitting the same mountain during a nighttime approach. The United crew discovered their close call after landing and reported the incident to their company’s new internal reporting program. A cautionary notice was issued to all United pilots. Unfortunately, at the time there existed no method to share this knowledge with TWA and other airline operators. Following the TWA accident, it was determined that such safety information must in the future be shared with the entire aviation community. Thus was born the idea of a national aviation incident reporting system.
The Role of the ASRS Advisory Committee
A major factor in the success of the ASRS has been the involvement of the entire community of aviation stakeholders in the form of an industry-government Advisory Committee to NASA. The FAA Office of System Safety provides a representative that is a standing member of this group. At the very beginning of the program, Committee representatives were actively involved in program development and oversight, and became strong advocates for the ASRS with their professional organizations and unions. The widespread acceptance and use of the ASRS program in aviation circles is due largely to their efforts. Today, the NASA/ASRS Advisory Committee continues to offer its guidance, aviation expertise, criticism, and advocacy in semiannual meetings. This ensures that the major ASRS stakeholders are informed about program developments, and that NASA and the FAA, in turn, are aware of stakeholder views and important industry trends.
Safety Depends on “Lessons Learned”
The great strength of confidential reporting systems is that they are a means of converting incident information into a resource for improving the safety of aviation operations, and protecting the welfare of all participants. As the ASRS has demonstrated for many years, if a system’s users – the people at the “sharp end” of day-today operations – are encouraged to report the safety problems they encounter to a program they can trust, safety goals will be reached much sooner than if we never hear the stories of those lessons learned.
Two Agencies, One Purpose
The first step was to design a system in which the aviation community, both individually, and collectively, could place a high degree of trust.
ASRS Recently Issued Alerts On…
Opening of CL-65 cabin oxygen access panels inflight Fokker 100 uncommanded pitch-up during initial climb A300 passenger entertainment system electrical box fire Runway incursion problems at a major Northeast airport An ATC facility’s problems using backup radar (CENRAP)
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://asrs.arc.nasa.gov/
February 2001 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2217 608 52 188 3065
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_260.pdf
April 2001
Half a Million Incident Reports Later
The ASRS Celebrates Its 25th Anniversary
On April 15, 2001, the world’s largest confidential voluntary aviation reporting system, the NASA Aviation Safety Reporting System (ASRS), will celebrate its 25th year of operation. Just prior to this anniversary, the ASRS will reach another milestone – the processing of its 500,000th aviation incident report. The ASRS was founded in 1976 through a Memorandum of Agreement between the Federal Aviation Administration (FAA) and National Aeronautics and Space Administration (NASA). The longevity and success of the ASRS program is a remarkable example of how cooperation between government agencies can create an effective agent for safety improvements against the backdrop of changing times. The FAA quickly recognized that its regulatory and enforcement roles would discourage the aviation community from using the new program. It therefore asked NASA to act as the independent third party that would administer the program and fulfill the role of an honest broker attending to the interests of both sides. NASA, a research organization with no regulatory or enforcement role, saw a unique opportunity to enhance its research capability through access to the human factors data generated by the new system. NASA accepted the proposal to support the FAA in its mission to eliminate unsafe conditions in the national aviation system, and the ASRS began operation in 1976. The FAA provides funding for all ASRS program operations, while NASA administers the program and supplies “in-kind” funding support.
Origins of the FAA / NASA Partnership
Progress often comes at a price, and the founding of the ASRS was no exception. A tragic and potentially avoidable airline accident was the direct motivation for establishing a national aviation incident reporting system. On December 1, 1974, TWA Flight 514 was inbound through cloudy and turbulent skies to Dulles Airport in Washington, DC. The flight crew misunderstood an ATC clearance and descended prematurely to the final approach altitude, below the minimum safe altitude for the area through which they were flying. The aircraft collided with a Virginia mountain top, killing all aboard. A disturbing finding emerged from the NTSB accident investigation. Six weeks earlier, a United Airlines flight crew had experienced an identical clearance misunderstanding and narrowly missed hitting the same mountain during a nighttime approach. The United crew discovered their close call after landing and reported the incident to their company’s new internal reporting program. A cautionary notice was issued to all United pilots. Unfortunately, at the time there existed no method to share this knowledge with TWA and other airline operators. Following the TWA accident, it was determined that such safety information must in the future be shared with the entire aviation community. Thus was born the idea of a national aviation incident reporting system.
The Role of the ASRS Advisory Committee
A major factor in the success of the ASRS has been the involvement of the entire community of aviation stakeholders in the form of an industry-government Advisory Committee to NASA. The FAA Office of System Safety provides a representative that is a standing member of this group. At the very beginning of the program, Committee representatives were actively involved in program development and oversight, and became strong advocates for the ASRS with their professional organizations and unions. The widespread acceptance and use of the ASRS program in aviation circles is due largely to their efforts. Today, the NASA/ASRS Advisory Committee continues to offer its guidance, aviation expertise, criticism, and advocacy in semiannual meetings. This ensures that the major ASRS stakeholders are informed about program developments, and that NASA and the FAA, in turn, are aware of stakeholder views and important industry trends.
Safety Depends on “Lessons Learned”
The great strength of confidential reporting systems is that they are a means of converting incident information into a resource for improving the safety of aviation operations, and protecting the welfare of all participants. As the ASRS has demonstrated for many years, if a system’s users – the people at the “sharp end” of day-today operations – are encouraged to report the safety problems they encounter to a program they can trust, safety goals will be reached much sooner than if we never hear the stories of those lessons learned.
Two Agencies, One Purpose
The first step was to design a system in which the aviation community, both individually, and collectively, could place a high degree of trust.
ASRS Recently Issued Alerts On…
Opening of CL-65 cabin oxygen access panels inflight Fokker 100 uncommanded pitch-up during initial climb A300 passenger entertainment system electrical box fire Runway incursion problems at a major Northeast airport An ATC facility’s problems using backup radar (CENRAP)
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://asrs.arc.nasa.gov/
February 2001 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2217 608 52 188 3065
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_260.pdf
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