Flight Safety Information Quarterly Journal Third Quarter 2003 Inside ASRS ASAP The NTSB Major Incidents Major Accidents Reporting Methods: ASRS / ASAP Flight Safety Information Journal Third Quarter 2003 FSI Journal Contents Third Quarter 2003 Reporting Methods: ASRS / ASAP Page Flight Safety Information Journal 3 ASRS Published by www.FSInfo.org 5 ASAP Managing Editor Curt Lewis, PE, CSP 7 The NTSB [email protected] 11 Major Incidents Associate Editor Steven Alcala 13 Major Accidents [email protected] Webmaster Randy Engberg [email protected] About the Picture: The Boeing 747 rolled into a drainage ditch and toppled for- ward causing severe damage to the nose section. 2 Flight Safety Information Journal Third Quarter 2003 Reporting Systems Aviation Safety Reporting Systems (ASRS) What is ASRS? Each report is read, analyzed, and hazards or haz- ardous situations are identified. Once the hazards The Aviation Safety Reporting System (ASRS) was are identified, information is then forward to the established in 1975 in a joint effort between NASA, respective organizations who may then review the who would administer the program, and the FAA, information and take any necessary corrective ac- the original financial supporters of the program. The tions. main purpose of the ASRS is to collect, analyze, and respond to voluntarily submitted aviation safety in- At the same time, analysts will classify the incident cident reports in order to lessen the likelihood of report by the type of hazard presented, and any aviation accidents. According to the NASA ASRS causes, recommendations, or other observations website, the data is used to: will be noted. The de-identified incident report will then be incorporated into the ASRS database. • Identify deficiencies and discrepancies in the National Aviation System (NAS) so that these What about confidentiality? can be remedied by appropriate authorities. • Support policy formulation and planning for, and All ASRS reports are held in strict confidence and improvements to, the NAS. will be de-identified provided there the incident did • Strengthen the foundation of aviation human not involve criminal actions or meets the NTSB’s factors safety research. This is particularly im- definition of an accident. As long as an incident is portant since it is generally conceded that over reported within 10 days of occurrence, the ASRS two-thirds of all aviation accidents and incidents will not be used against a reporter in regards to en- have their roots in human performance errors. forcement actions. The reporter will also be pro- vided with protection against any civil penalties as How does it work? well as any license suspension or revocations. The only exception to this exists when there is an inten- Pilots, air traffic controllers, flight attendants, me- tional violation of the FARs; in this case a person chanics, ground personnel, and others involved in will not be immune from a civil penalty or certificate aviation operations submit reports to the ASRS suspension if the FAA learns of the violation from when they are involved in, or observe, an incident or another source. situation in which aviation safety was compromised; all submissions are voluntary. 3 Flight Safety Information Journal Third Quarter 2003 ASRS - Continued How does ASRS release its findings? ASRS Links NASA releases generalized information regarding NASA’s ASRS homepage: ASRS reports as well as other research studies in http://asrs.arc.nasa.gov several different forms. ASRS reporting forms: • Callback is a monthly safety bulletin that sum- http://asrs.arc.nasa.gov/forms_nf.htm marizes ASRS research studies and related safety information. Additional ASRS reports are FAA policies regarding ASRS can be found via released along with any supporting information Advisory Circular (AC) 00-46C, FAR 91.25, and in • ASRS Directline is a safety bulletin that is peri- the Facility Operations and Administration Hand- odically published for major organizations who book (7210.3M). tend to operate more complex aircraft. - or - visit the FAA webpage at: • When ASRS analysts note any hazardous situa- http://www.faa.gov tions resulting from a report, the analyst may send an alerting message directly to an operator of authority so that corrective actions may be taken. • NASA also keeps a database of all ASRS reports; the reports are classified into certain subject areas for easier searches. Database searches may be requested by persons wanting to obtain information on certain areas of study relating to aviation safety. ASRS Today NASA’s ASRS has become a foundation and inspira- tion to a wide variety of anonymous safety reporting systems including the UK’s Confidential Human Factors Incident Reporting System Programme (CHIRP). The ASRS has received over 300,000 re- ports over the years and has acted on every one. As long as reports submitted, ASRS will continue to be effective in pointing out deficiencies within our na- tional aviation program as well as proposing any new actions that will remediate these deficiencies. 4 Flight Safety Information Journal Third Quarter 2003 Aviation Safety Action Programs (ASAP) What is ASAP? • the event involves criminal actions, substance abuse, controlled substance abuse, or falsifica- The Aviation Safety Action Program (ASAP) is a pro- tion of data. gram designed to give those involved in flight op- • the submitter does not send in the report within erations a method of reporting actual or potential 24 hours of becoming aware of the incident risks within daily operations without fear of legal, • the event involves an intentional disregard for regulatory, or disciplinary action. ASAP aims at en- safety. couraging air carrier and repair station employees • a consensus is not reached concerning the inci- to voluntarily report safety information that may be dent report. critical in identifying potential precursors to acci- dents. Under ASAP, safety issues are resolved If an event is excluded from ASAP, the event will be through corrective actions rather than through pun- referred to the FAA for possible enforcement action, ishment or discipline. Currently, only FAR Part 121 but the content of the report will not be used to ini- air carriers and FAR Part 145 domestic repair sta- tiate / support company discipline or as evidence tions are eligible to participate in ASAP. for FAA enforcement action. How does it work? ASAP vs. ASRS An employee involved in flight operations, such as a According to the Air Line Pilots Association (ALPA), pilot or mechanic, submits an event report concern- less than half of the reports included in NASA’s ing a possible violation of the FARs or any other Aviation Safety Reporting System (ASRS) involved flight safety concern; the report must be filed events where an airmen’s certification might be within 24 hours of the time the employee became placed on the line. Although ASRS provides protec- aware of the situation. tion against civil penalties and license suspension or revocation, it did not provide protection from the The event report is then sent to an Event Review legally binding fact that the reporter might be guilty Committee (ERC) who will then determine whether of a violation of the FARs. Under ASAP, accepted or not to accept the report into ASAP. The three reports are usually closed administratively without a members of the ERC (management representative, finding of guilt. FAA representative, and another third party) must reach a consensus on actions to be taken concern- ASAP is an important addition to NASA’s ASRS pro- ing the ASAP incident report. gram, but it is not meant to serve as a replacement for the ASRS program. Although some programs will If a report is accepted into ASAP, then the ERC will automatically forward events covered under ASAP see that corrective actions are taken in order to pre- to ASRS, it is probably a good idea to file a separate vent the same situation from occurring in the fu- ASRS report. This way the incident reporter will also ture; the employee must also comply with the ERC be covered against any fines or threats of license / recommendations. Additionally, the FAA may re- certificate suspension. Just remember that ASRS spond with a letter of administrative action or a let- reports need to be filed within 10 days of the inci- ter of no action. Basically, all a letter of administra- dent while ASAP reports need to be filed within 24 tive action will either contain a warning or corrective hour s of becoming aware of the incident. action notice, but this record will not become a part of the employee’s permanent record. A report will not be accepted into ASAP if: • the submitter was not an acting employee for the organization. 5 Flight Safety Information Journal Third Quarter 2003 ASAP Report Process Chart This chart illustrates the process that an event filled to ASAP will go through. For more information on ASAP, see the links below. ASAP Links: Advisory Circular (AC) 120-66B FAA ASAP website: http://www1.faa.gov/avr/afs/afs200/afs230/asap/index.cfm 6 Flight Safety Information Journal Third Quarter 2003 The NTSB An Introduction to the NTSB By: Curt Lewis, PE, CSP The Overview: gate based on current emphasis issues or height- The National Transportation Safety Board ened public interest. Regardless of who does the (NTSB) is an independent government agency char- investigation, the NTSB retains the final authority tered with the responsibility to thoroughly investi- on reporting, classification, and determination of gate transportation incidents and accidents. Its pri- the probable cause. mary purpose is to determine the “Probable Cause” In the event of a major or high public inter- of these mishaps and to issue recommendations to est accident, a “Go Team” from Washington, D.C. help prevent further accidents. More specifically, will assemble and arrive at the site as soon as pos- the NTSB has the authority to investigate all avia- sible – usually within six hours.