At 11:09 a.m. on Sunday, December 1, 1974, a Boeing 727 operating as TWA Flight 514 was in IMC and inbound to the Washington Dulles International Airport. Due to an ambiguous approach procedure and a misunderstood clearance, the crew descended prematurely to their final approach altitude, which in fact wound up being their final altitude; they collided with the western slope of Mount Weather in Berryville, Va. All seven crewmembers and 85 passengers were killed.

Six weeks earlier, a United Airlines flight had narrowly avoided the same fate during a nighttime approach, discovered their close call after landing, and promptly reported it to Uniteds new Flight Safety Awareness Program. A notice was issued to all company pilots, but thats where it stopped. Back then, there was just no decent way to get the word out throughout the industry.

Kicking Tin
Some good has emerged from these ashes. In much the same way that the Federal Aviation Regulations have often been lessons learned, written in blood, the comments of the NTSB as well as another senior advisory group resulted in the formation of the Aviation Safety Reporting Program (ASRP) on April 30, 1975. They realized that if you want to learn more about aviation incidents, it was best just to ask the people involved. They also knew however that people are usually much more willing to share their hard-learned lessons (rather than pleading the Fifth), if theyre assured of protection from punishment.

By August of that year, a Memorandum of Understanding had been drafted, designating NASA as the broker between the FAA and the aviation community, as well as the operator of the new Aviation Safety Reporting System, funded by the FAA under the umbrella of the three-month old ASRP. In April 1976, the contract for its day-to-day operation was awarded to the Battelle Memorial Institutes Columbus Laboratories, who then engaged the understanding ears of the “old eagles” (retired professional pilots, air traffic controllers, flight surgeons, aviation lawyers and research experts) for the multidisciplinary extraction of those lessons sometimes learned only after the exam.

Since that time, the idea behind ASRS, where people can anonymously report and learn from operational errors, misjudgments and violations, has been emulated by aviation organizations, as well as other industries, worldwide. Their current contractor relationship is with Booz Allen Hamilton.

In case you want to see it spelled out in the Federal Aviation Regulations in black and white, the ASRS immunity provisions are found in FAR 91.25. It prohibits the use of any ASRS report in any disciplinary action or penalty, with the exception of accidents (in which case it goes to the NTSB) or criminal offenses (here, it would land at the Department of Justice).

If the violation was inadvertent or not deliberate, didnt involve an action “disclosing a lack of competency,” you havent been found to commit any other violation within five years prior to the date of occurrences (though one can file reports as often as one chooses), and youve mailed an ASRS form within 10 days after the (possible) violation, they cant touch you. These conditions, and more, are summarized in the sidebar on the next page.

How It Works
ou can read a full description of the ASRS in Advisory Circular AC 00-46D. As the third party, NASA receives safety reports on the Ames Research Center Form 277, one that is familiar to most airline pilots, although pilots are not the only participants. Pilots use the forms “B” version; controllers have a separate “A” version; there is a 277C for cabin crewmembers, and a 277D for maintenance personnel. All users of the NAS can report discrepancies related to aviation safety.

Each form has a tear-off section with all information identifying the reporter. The ASRS program personnel occasionally use it to contact a reporter for additional information needed for a more complete understanding, but it is always removed, time-stamped and usually on its way back to the originator within 72 hours of receipt. No copies are created or maintained. In fact, ASRS security involves secure phones, alarm systems, locked safes and bonded couriers. Since its inception, there has been no breach of confidentiality.

Blank forms can be obtained from FSDOs, FSSs or NASA. It might be a good idea to carry a few with you-you never know when you might need one. Theyre also available on the ASRS programs Web site: . The programs mail address is P.O. Box 189, Moffett Field, CA 94035-0189. (Hint: The “Flash” version of the Web site is pretty cool.)

What You Get
What they give back: The publication most familiar to the pilot community is probably their monthly bulletin Callback, issue #1 of which appeared in July 1979. (The most recent edition, dated October 2006, is issue #322.) The bulletins name was derived from the operating procedure of “calling back” incident reporters by telephone whenever clarification about a particular incident was needed. You can subscribe to it-its free-or you can read it online, both at the above Web site. Callback is currently distributed each month to about 85,000 pilots, controllers and other aviation professionals.

A book about the ASRS, published by Smithsonian Institution Press, was written in 1990 by Rex Hardy, who was also the originator of the Callback bulletin as well as its editor for the first 100 issues. In addition to Callback, the ASRS also publishes ASRS Directline for commercial carriers and corporate operators. A typical recent months “box score” of input showed over 2000 reports coming from air carrier and air taxi pilots; over 600 from general aviation; over 50 from controllers and almost 200 from “cabin/mechanics/military/other.” The ASRS processed its 500,000th report several years ago.

In addition to some 4000 alert bulletins, and several “quick response” studies during accident investigations, airspace redesign, or rulemaking, there have also been several dozen research studies, almost 7000 database searches by government, industry, and academia, and outreach efforts at meetings and conferences.

Not too surprisingly, the majority of incident reports (about 70 percent) involve flaws in information transfer. In the long run, these analyzed incident data have become a valuable safety resource, and even if your “data point” is never correlated or registered, often just the act of putting something down on paper and having to re-think what you did right or wrong, becomes a useful end in itself.

If it didnt exist, the ASRS would have to be created, since it provides such a wealth of operational information. That get out of jail free card aint bad, either!

Jeff Pardo is a freelance writer and editor who holds a Commercial certificate for airplanes, helicopters and sailplanes.


Please enter your comment!
Please enter your name here