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reporting system.
On December 1, 1974, TWA Flight 514 was inbound
through cloudy and turbulent skies to Dulles Airport in
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Washington, D.C. 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 collided with a Virginia mountaintop,
killing all aboard.
A disturbing finding emerged from the ensuing NTSB
accident investigation. Six weeks prior to the TWA
accident, 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.
Tragically, at the time there existed no method of sharing
the United pilots’ knowledge with TWA and other airline
operators. Following the TWA accident, it was determined
that future safety information must be shared with the
entire aviation community. Thus was born the idea of a
national aviation incident reporting program that would
be non-punitive, voluntary, and confidential.
The FAA and NASA Collaborate
The first step in establishing a national aviation incident
reporting program was to design a system in which the
aviation community could place a high degree of trust.
The FAA Administrator quickly recognized that the
regulatory and enforcement roles of the FAA would
discourage the aviation community from using a new
safety program that depended on voluntary sharing of
safety events. The FAA therefore 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, the blueprint for operating
the newly designated Aviation Safety Reporting System
was set in place: the FAA would fund the program and
provide for its immunity provisions, while NASA would
set program policy and administer operations. The ASRS
program began day-to-day operation in April 1976.
The ASRS Concept Is Proven
The ASRS program has continually demonstrated the
value of “safety lessons learned.” If a system’s users 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.
ASRS Alerts Issued in Feb/March 2006
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 16
Airport facility or procedure 8
ATC procedure or equipment 4
Company policy 2
Total 30
Feb/March 2006 Report Intake
Air Carrier/Air Taxi Pilots 4542
General Aviation Pilots 1515
Controllers 189
Cabin/Mechanics/Military/Other 388
TOTAL 6634
ASRS Safety Products Are AOK
with Program Users
ASRS program users often send us letters
and e-mails telling us how they like, and
use, the various data products produced
by the program, from database Search
Requests to CALLBACK. Along with the
incident reports received by the program,
this feedback helps us to stay wings level
and on course. Here is what recent users
of program materials have to say:
About ASRS Alert Messages:
The information provided via the ASRS was very useful in
determining corrective action.
- Air Traffic Control Tower Manager
The FAA is very committed to the NASA reporting process
and takes these alerts very seriously. We can report that
both issues have been addressed, resolved, and you may
consider them closed.
- FAA Tower Support Specialist
I do appreciate the role that NASA plays in working toward
a safer system and I feel that ASRS reports have played an
important role. I am forwarding this Alert Bulletin up my
chain at the FAA. We also consider the problem to be very
serious! Thank you for your help...
- FAA Air Traffic Manager
About Database Search Requests:
…I want to comment on the outstanding service you
provide and the extreme value of the data….This is the
second time I have used your reports while investigating
causal factors and root causes of aircraft accidents. On
both occasions, the data provided valuable insights that
would not have been gained through any other methods. In
this context, your program is truly unique. We appreciate
　
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