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Runway incursion problems at a major Northeast airport
An ATC facility’s problems using backup radar (CENRAP)
February 2001 Report Intake
Air Carrier / Air Taxi Pilots 2217
General Aviation Pilots 608
Controllers 52
Cabin/Mechanics/Military/Other 188
TOTAL 3065
Half a Million Incident Reports Later
The ASRS Celebrates Its 25th Anniversary
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.
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.
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.
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
　
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