Aviation Safety Action Plan


In the last issue we discussed the NASA ASRS reporting system in detail and discussed how it allowed, for the first time, data collection regarding potential safety issues and trends that didn’t necessarily result in an accident and require an investigation to figure out what happened in the accident; so that regulations or accepted practices could be updated accordingly.

The ASRS tool proved to be very effective for the FAA because it allowed them to analyze trends and identify problems using standard statistical methods, but more importantly, it allowed them to see potential trends before they resulted in an accident rather than the historical norm, which was after the fact.

Since one of the common realities of accidents is that most of the causal factors in any accident have occurred many times before, but not all at the same time, which allowed the previous accidents to be avoided; this analysis of factors became critical to moving aviation safety to the next level.  However, due to its very widespread implementation (covering anybody who might file an ASRS) and a potential lack of participation if the event was undetected by other parties (as in the case of no ATC involvement), it was soon realized that there might be a better way to implement the same concept at a more specific level.

After seeing the effectiveness of ASRS, the FAA quickly set to work on a more formal reporting system specifically designed for operators in an effort to enhance the identification of trends that might lead to a major aviation disaster.  A good example of this type of disaster might be a runway over-run as a result of an unstable approach caused by excessive speed, and in fact, there were several of this type of incident in the years preceding the release of the ASAP program.  The thought process of the safety teams at the time was that if there was one accident as a result of an unstable approach, there must me many other such incidents that didn’t result in an accident and thus went undetected.  Indeed, after ASAP’s implementation, it was found that this was in fact true and that for every incident that occurred there were usually hundreds of similar events that occurred prior but didn’t result in an accident or incident.

On January 8th, 1997 the FAA released Advisory Circular 120-66 laying the foundation for what would become the modern ASAP system.  The actual implementation of the system was fairly complex for the air carriers, but was functionally very straight forward and easy to understand for the people who would be using it on a daily basis.

ASAP formally became a program that was outlined by the operator (an airline for instance) and then was agreed upon by the FAA through a Memorandum of Understanding or MOU.  Once the MOU was codified with the FAA, the specific ASAP program for that operator became operational and ASAP became a formal part of the way the operator conducted business.

The premise of ASAP is very similar to ASRS, in that it is a formal data collection system used to identify problems and trends and pro-actively address issues prior to them becoming an accident in order to improve the level of safety.

Also similar to ASRS, data tracking and classification tools had to be developed in order to track and catalogue the reported data so that it could be used effectively, although this doesn’t necessarily affect the people reporting to ASAP.

Also similar to ASRS, ASAP provides some level of protection for those reporting issues in order to encourage widespread participation, which maximizes the level of effectiveness of an ASAP program.

So how does an ASAP program work?  Most people who have reported through ASRS or ASAP know that whenever something happens that should be reported, they file a report and they get a series of letters and responses back either telling them they need to do something (remedial training, testing, or other assigned work) to close the case, or in most cases, the case is simply closed with some feedback on how it could have been prevented.  In very rare cases, there is some enforcement action on the part of the FAA, but that will be discussed later in the article.  While this seems simple enough, many people probably wonder what is behind the ASAP curtain and what happens to that report when they file it.

First, ASAP will have guidelines for reporting.  In order to encourage maximum participation and in exchange for the FAA’s agreement of protection under the ASAP program, there is a window that is considered for “timely reporting” of events.  This will vary by program, but will often resemble a 24-hour period after the end of a trip in the case of a pilot, for instance.  If any reports are filed within this defined window, then the reports will not be excluded from ASAP on the basis of timeliness.  There are some allowances for filing outside of this window, but it should be noted that if it is determined that the person had knowledge of the event and it was not filed in a timely manner, it may be excluded from ASAP protection.  It is always best to file reports as soon as practical and within the time-line prescribed for inclusion.

Once the report is filed it will become either a sole-source report, or a non-sole source report.  Sole-source just means that it was the only report filed on the event and there is no other evidence available regarding the event.  Non-sole-source means that there is other information on the event, such as an altitude deviation where an ATC controller may have also filed a report, and the FAA subsequently followed up on the report by pulling ATC tapes, logs, and got a statement from the controller regarding the event.

Email Your Safety Thoughts To Scott.Stahl@aerocrewnews.com

In the event of a sole-source report, they reports will typically be included regardless of the time-line, but it is still advisable to file them within the time limit specified in the program’s MOU.  If the report was not sole source, and was not filed in a timely manner, then the ASAP Event Review Committee will determine if the person who did not report in a timely manner had a reasonable expectation of being aware of the event and being able to report it in a timely manner.  This will then be considered when determining if the event should be included in ASAP or not.

Once the event is reported, it proceeds to the ASAP Event Review Committee, which will typically consist of 1 member from each represented group.  There will typically be an FAA ERC representative who is specifically trained for that function, a member representing the company, and a member representing the employee group that is being reviewed.

This committee will sit down and review the events submitted to them and will then use all evidence to weigh the outcome of the event and whether any further action is necessary.  It should be noted that the ERC must come to a consensus on the event and in the cases where consensus isn’t reached, the FAA ERC member has the final say in what the outcome will be.

The reports protected by ASAP will be those reports that:

Those non-sole-source reports submitted that have “sufficient evidence” for violation under 14 CFR will be closed with administrative action.  Those non-sole source reports without sufficient evidence for violation will be closed with a FAA Letter of No Action.

Sole-source reports included in ASAP will be closed with no action.

Reports that demonstrate a lack of qualification or raise questions of lack of qualification will be addressed by the ERC and have appropriate action recommended.

If an event is excluded from ASAP, then it will be referred to the FAA for appropriate enforcement action, but it should be noted that the majority of reports are included as long as they are submitted in a timely fashion to the ASAP ERC.

Of course, since the intent of ASAP is to gather data on human error, mistakes, unintentional violations, and other events that need to be understood in order to further aviation safety and not to protect people from willful non-compliance, there is a list of things that will automatically be excluded from ASAP protection if encountered by the ERC:

They include:

  1. Willful disregard for safety or willful violation of regulation.
  2. Any event which appears to include:
    1. Criminal activity
    2. Substance Abuse
    3. Controlled Substances
    4. Alcohol
    5. Intentional falsification
  3. Any report which was not filed in a timely manner and the ERC couldn’t reach consensus on whether or not to include it in the ASAP program.
  4. Reports of events that occurred while not acting as an employee of the Certificate Holder covered under the ASAP program.  This means that reporting of events when not working (such as flying a private airplane) is not allowed.

If a sole-source report is not excluded due to these conditions, it will be included in ASAP.

Also, if it is later determined that a report was not filed in a timely manner by an employee that should be included in the ASAP event, the ERC will attempt to determine if the non-reporting employee should have or could have known about the event and if it is determined that they didn’t, or couldn’t and the event has been accepted into ASAP, they will be given a 24-hour window within which to make their report.

The final step of the ASAP program after everything has been collected, included or excluded, reviewed, and a determination made, is to take the data that is included in these reports to identify areas of concern, trends, and problems in the operation to attempt to correct them.  This is done through policy review, training, recurrent training, news-letters and any other means a company may have available to communicate with the employee group.  This typically forms the basis for issues covered in recurrent, CBT’s, upgrade training, etc. and is a primary system for the correction of problem trends in an operation, which has helped move air safety to the level we are seeing today.


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