Issue Number 204
June 1996
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

From There to Here, With Your Support

ASRS Celebrates Its 20th Birthday

An anonymous wit once observed that "a diplomat is a person who remembers a lady's birthday, but forgets her age." Putting a more festive (if less discreet) spin on that advice, CALLBACK is proud to announce both the birthday and age of the NASA Aviation Safety Reporting System: the program's birthday occurred on April 15, 1996, a date which also marked the 20th anniversary of ASRS operations.

As ASRS enters its 21st year, the program has met the test of time, fulfilled the early hopes of its founders, and achieved many "firsts":

  • Processed more than 338,000 total aviation incident reports without violating a single reporter's confidentiality;
  • Issued more than 2,500 alert messages of all types;
  • Responded to more than 4,800 database search requests;
  • Performed more than 90 Quick Response research efforts for the FAA, NTSB, and NASA;
  • Published 56 research reports and papers;
  • Returned information to the aviation community through its two award-winning publications, CALLBACK (in its 17th year of publication), and Directline, an aviation safety journal.

In its 20 years of existence, ASRS has become the world's largest, and longest-operating, incident reporting program. Without any doubt, it has also saved lives.

Yet as important as all these achievements are, it is not the ASRS as an organization--but the aviation community it serves--that is the real story. For at one time, the ASRS did not exist. Many years of effort were required for the idea of a national reporting system to take root in the aviation community, and to gather its support and trust.

A Phoenix from the Ashes

The precipitating event for the ASRS was a tragedy that occurred on December 1, 1974. On that Sunday morning, Trans World Airlines (TWA) Flight 514 was inbound to Dulles Airport through cloudy and turbulent skies, when the aircraft descended to 1,800 feet before reaching the approach segment where that minimum altitude applied. Flight 514 collided with a Virginia mountain top, with the loss of all lives on board.

According to the accident report issued by the National Transportation Safety Board (NTSB), the crew's decision to descend was the result of inadequate depiction of altitude restrictions on the profile view of the approach plate, and confusion in interpreting air traffic terminology. The NTSB investigation uncovered another disturbing, yet provocative, detail. Six weeks prior to the TWA crash, a United Airlines crew had very narrowly escaped the same fate, during the same approach, and at the same location.

United, however, had instituted a new internal reporting program, the Flight Safety Awareness Program. Under this program, crew members were encouraged to report anonymously any incident they felt involved a safety problem for the company. The United pilots involved in the Dulles incident had reported to their company program the ambiguous nature of the charted approach.

Other United pilots were made aware of the potential trap, and the FAA was notified of the circumstances. Unfortunately, there did not exist at the time any generally accepted method to assure the broad and timely dissemination of this information to the aviation community.

The NTSB comments on the need for a national incident reporting system, and the collaboration of aviation industry groups, finally led to significant action. In May 1975, the FAA issued Advisory Circular 00-46, announcing the implementation of a confidential, non-punitive incident reporting program. The FAA 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, NASA began operating the newly designated Aviation Safety Reporting System. Thus the blueprint for the ASRS was set: FAA would fund the program and provide its immunity provisions, while NASA would set program policy and administer operations.

ASRS: The Future

What lies ahead for the ASRS? Here are some of the activities that ASRS is currently undertaking, with the advice and support of our advisory oversight group:

  1. A renewed focus on and expansion of the ASRS alerting function. A new alerting product, the ASRS Operational Issues Bulletin, is likely to be distributed through the cooperative efforts of aviation industry groups this year.

  2. Continued efforts to find ways of increasing the participation in the program of the maintenance and flight attendant communities.

  3. Conversion of the ASRS database to widely used commercial off-the-shelf (COTS) software.

  4. Expansion of Internet services to make ASRS research publications available to users, as well as additional issues of its safety publications.

As always, the ASRS program users and the aviation community are our greatest resources. As you celebrate with us the 20 years of accomplishment that are the fruit of your support, we invite you to share with us, and also with your organizations' policy makers and representatives, your suggestions for increasing the use, and usefulness, of the ASRS within the aviation community.