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pilots.
Unfortunately, at the time there existed no method to
share this knowledge with TWA and other airline
operators. Following the TWA accident, it was determined
that such safety information must in the future be shared
with the entire aviation community. Thus was born the
idea of a national aviation incident reporting system.
Two Agencies, One Purpose
The first step was to design a system in which the
aviation community, both individually, and collectively,
could place a high degree of trust.
Number 260 April 2001
ASRS Feedback
to the Aviation Community
A reporting system’s information output directly reaches
the system’s users, enables a learning process to take
place, and helps ensure that corrective actions will be
appropriate and effective. What has the ASRS produced
that contributes to safety “lessons learned”?
Alert Bulletins and For Your Information Notices –
a crucial ASRS mission is to serve as a “front line” for
alerting on safety issues that affect many aviation users,
or pose a significant safety hazard. The ASRS has issued
approximately 4,000 alerting messages of all types to the
FAA manufacturers and aviation community authorities
since the program’s inception. Twice a month the ASRS
has teleconferences with the FAA Office of System Safety
on the most important alerting items seen in its recent
report flow.
Quick Response Studies – Another important ASRS
mission is to support government organizations such as
the FAA, NTSB, and Congress during rule-makings,
procedure and airspace design efforts, accident
investigations, and other ad hoc circumstances. Recent
Quick Response efforts include a study of passenger
misconduct incidents and runway incursion events
involving pilots.
Operational Research – ASRS has conducted and
published 57 research studies since the program’s
inception. ASRS research has always been designed to
examine human performance issues in real-world
operations.
Database Search Requests – Information in the ASRS
database is available to interested parties at no cost. To
date more than 6,000 database searches have been
performed in support of government, industry, academic
and other requests.
Publications – The ASRS has developed two
publications, CALLBACK and ASRS Directline, to provide
feedback to its constituencies. CALLBACK’s goal is to
educate a broad aviation audience in safety issues by
using a “lessons learned by others” approach in a monthly
safety bulletin format. ASRS Directline is published
periodically to meet the needs of the operators and flight
crews of complex aircraft, such as commercial carriers and
corporate fleets. Articles focus on subjects of special
interest to this group.
Program Outreach – NASA and ASRS staff members
participate in important aviation industry meetings and
conferences to interact directly with stakeholders across the
system and stay in touch with current aviation issues and
concerns. The ASRS web site (http://asrs.arc.nasa.gov) has
become an increasingly important resource for program
outreach. Program users can find reporting forms, recent
issues of the ASRS publications, data report sets on
frequently requested topics, and much other program
information for downloading at the ASRS site.
The ASRS Reporting Model
There is a growing recognition that the ASRS model of
safety incident reporting is a proven and effective way
to complement accident investigations, mandatory
event reporting, and other information gathering
systems.
The idea behind the ASRS has been emulated by
aviation systems worldwide, and is now catching on in
industries outside aviation such as maritime, nuclear
power, and medicine. That idea is fairly simple and
straightforward:

When organizations and industries want to learn
more about safety incidents and why people did
what they did, the best approach seems to be to
simply ask the participants.

People are generally willing to share their
knowledge if they are assured their identities will
remain anonymous and the information they
provide will be protected from disciplinary
consequences.

A properly structured confidential, voluntary, nonpunitive
incident reporting system can be used by
any person to share this information.

Such a system has the means to ask, and
frequently answer, the question of why. There is no
substitute for knowing why a system failed or why
a human erred.

A voluntary incident reporting system cannot
　
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