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Keynote Address for the 30th Anniversary Celebration NASA Aviation Safety Reporting System, San Carlos, CA
Robert L. Sumwalt
NASA Aviation Safety Reporting System, 30th Anniversary Celebration, San Carlos, CA

Good evening. I am pleased to be part of this celebration, as we honor one of the aviation industry’s treasurers. NASA Aviation Safety Reporting System (ASRS) is the world’s largest repository of aviation human factors information. Considering that the vast number of aviation mishaps involve human factors, I believe ASRS is a tremendous asset and resource to enhance aviation safety. 

Dr. Charlie Billings and Charles Drew have given a good historical perspective of ASRS as well as current and future initiatives. So, let me move slightly away from that theme and tell you briefly how ASRS has been meaningful to me as a pilot, writer, safety analysis and researcher. Then I’ll briefly tell you some ways that ASRS has been helpful to the National Transportation Safety Board.

First, I’ll tell you that as a pilot, ASRS has been very much appreciated! Yes, you can imagine that with some 14,000 flight hours, there may have been a time or two that I reached for those trusty ASRS reports to spill my guts about some situation that concerned me. I’ll leave the details to your imagination, but suffice it to say that I always kept a few of the ASRS forms in my flight bag - just in case they were needed.

I began using ASRS data as a writer for Professional Pilot Magazine. One of the articles that I was working on involved altitude deviations. I called ASRS and spoke to Vince Mellone. In talking to Vince I learned that altitude deviations composed the majority of reports submitted to ASRS.

Vince sent me a package containing 150 reports involving altitude deviations. As I read each report narrative, I tried to determine the underlying problem and then categorize each one. This one was due to a mis-set altitude alerter. This one was due to the pilots reading back the clearance but the controller not catching the erroneous readback. This one was because neither pilot was adequately monitoring the aircraft’s flightpath. This one due to confusing 10,000 and 11,000 feet. You get the picture.

The idea of course, was that if we could determine five or six basic factors that led to altitude deviations, then we could develop intervention strategies for each of those problem areas.

As fate would have it, within a week of my completing the article for Professional Pilot, USAir announced that the company and ALPA had formed an altitude awareness committee to look for ways to combat this growing problem at USAir. Since I had just completed this work that pretty well described my thoughts on the issue, I faxed the article to one of the leaders on the committee. The next thing I know, I was on the committee.

Within a few months, USAir had developed our altitude awareness program. The program was largely based on analysis of ASRS data, but we also used other ASRS products, as well. Among them was Bill Monan’s contractor report on Hearback/ Readback error and Don George’s Directline article that explained that 10,000 feet and 11,000 feet were the most commonly confused altitude pairs.

Overall, the USAir altitude awareness program was attributed with a 70 percent reduction in altitude deviations at USAir. And because of the successes of that program, the program has been emulated by operators all over the world – not just airlines but business operators, as well.

Also significant – and this part was certainly not because of me - but to show the overall significance of the USAir Altitude Awareness program - is that this program formed the foundation for collaboration between labor, company and regulator. The idea emerged that these three entities could – no – SHOULD – work together to collect information in a non-jeopardy way. And of course, this was the forerunner of today’s ASAP and FOQA programs in terms of collaborating, collecting and analyzing data in non-jeopardy way.

Shortly after the altitude awareness program was formed I contacted Bill Reynard to tell him how useful ASRS data was in establishing the architecture of our program. He and I chatted and one thing led to another. Somewhere along the line it was suggested that I contact Loren Rosenthal about my becoming an ASRS research consultant. I very much value the relationship with this office and the great people here. Further, I think we produced some good projects. The one I think we got the most mileage from was a study that we completed in 1997 which discussed problems with inadequate flight crew monitoring skills. Co-authors on that project were Rowena Morrison and Elisa Taube.

That project laid grounds for an industry push to improve flightcrew monitoring skills. Our paper cited the wisdom of changing the term Pilot Not Flying to Pilot Monitoring. Within the past four years, the industry has seen that transformation. FAA now recognizes the term Pilot Monitoring and Boeing has changed all of its manuals to reflect the new term.

I also had the pleasure to work on a project with Key Dismukes and Grant Young where we analyzed 107 ASRS reports to look at Interruptions and Distractions. We published our findings in Directline. That article was widely reproduced.

As you see ASRS has proved to be invaluable for me, not only as a pilot, but as a writer, safety analyst and researcher.

But, I’ll switch gears now and tell you that ASRS has long assisted NTSB in our efforts to investigate aviation accidents. In recent years, the ASRS team has provided NTSB with search requests within the first few hours of an investigation. These search requests are based on the ASRS staff’s experience in aviation and their insights into potentially relevant issues based on initial reports or accident circumstances. Since 1995 ASRS has generated 117 Search Requests for NTSB.

ASRS has also provided us with other ASRS products, as well. An example of this is the ASRS Study of Pilot Response to Unexpected Roll Events – a study that was performed in connection with our investigation of the accident involving USAir flight 427 outside of Pittsburgh, PA in 1994.  

ASRS data allows us to put the circumstances of the accident in context as we explore whether a particular failure is isolated to the events of that day or representative of a more systemic problem.

I have a letter here addressed to Linda Connell from NTSB Chairman, Mark V. Rosenker. In his letter, Chairman Rosenker sends his congratulations on behalf of the Safety Board. His letter states, in part: “Your staff’s efforts are not only greatly appreciated, but they are extremely useful, as well. Like NTSB, I know that your organization is totally committed to improving aviation safety. Your commitment saves lives and I hope you and your staff can take time to realize what a treasure we have here in this country by having ASRS.”

The work that ASRS does really does make a difference. Each year ASRS collects more than 40,000 reports. And as I read through the list of Alert Bulletins, I am impressed with the fact that not only do your products effectively pinpoint problems within our aviation system, but most importantly, through cooperation with FAA and other organizations, these problems are resolved.

Also noteworthy is that ASRS has been able to achieve its accomplishments with some interesting funding challenges. If ASRS has been able to achieve all of the things mentioned tonight by Linda Connell, Dr. Billings and by Charles Drew, then just imagine what it could do if they had a bit more funding!

In closing, I want to congratulate ASRS for 30 years of service to the industry. But, I realize that ASRS in itself, is just an office. It is the people who have made ASRS what it is today. Tonight we can all celebrate because each of us has been part of ASRS’s rich history and success. 

There is a phrase that I’ve come to appreciate: “Out of tragedy comes triumph.”

ASRS exemplifies that phrase. There was a tragedy with TWA flight 514 on December 1, 1974. And from that tragedy, tonight we celebrate triumph … 30 years of NASA’s Aviation Safety Reporting System.

Thank you for allowing me to be part of this celebration.