Voluntary safety reports by flight attendants prove to be more valuable than expected.
By Wayne Rosenkrans
AeroSafety World, February 2008
(Expanded version of article)
With computer networks ready to pull together diverse safety information, the U.S. Federal Aviation Administration (FAA) during 2008 will keep promoting aviation safety action programs (ASAPs) — including ASAPs for flight attendants — at air carriers and major domestic repair stations. Although introduction of flight attendant versions of this voluntary program is relatively new, benefits from a handful of these ASAPs so far appear to be surpassing the expectations of participants.1 The challenge slowing expansion is persuading people to step beyond outmoded safety programs that discipline employees for inadvertent errors.
In a typical ASAP, the air carrier enters a formal partnership with specially trained FAA aviation safety inspectors and the labor organization of a specific employee group. The partners create an event review committee, a non-threatening environment that invites the certificate holder’s employees to voluntarily submit written reports that may prevent accidents. The mission is to identify and address safety issues wherever evidence leads, regardless of violations of federal regulations by the employee or the company.
“Under an ASAP, safety issues are resolved through corrective action rather than through punishment or discipline,” says FAA Advisory Circular 120-66B, Aviation Safety Action Program (ASAP). “The ASAP provides for the collection, analysis and retention of the safety data that is obtained. ASAP safety data, much of which would otherwise be unobtainable, is used to develop corrective actions for identified safety concerns, and to educate the appropriate parties to prevent a reoccurrence of the same type of safety event.”
FAA Order 8900.1, Flight Standards Information Management System, reminds aviation safety inspectors that ASAPs enable employees to tell what happened “without fear that the FAA will use reports accepted under the program to take legal enforcement action against them, or that companies will use such information to take disciplinary action.” Historically, the former primarily has been a concern of airline pilots and the latter primarily has been a concern of flight attendants.
To make good on these promises and maintain trust, nearly all details of setting up and conducting an ASAP have been prescribed in FAA guidance documents, although participants can diverge from the template in preparing the required memorandum of understanding. Event review committees must determine by “unanimous consensus”2 either that a report is acceptable or it falls under exclusionary exceptions, and learn methods of reviewing ASAP reports and reaching decisions, formulate corrective action and verify its successful completion, and know how the FAA handles exceptional situations such as when the ASAP report is not the sole source of evidence of a regulatory violation.
Committees know when and how to use FAA’s enforcement decision tool and how FAA may conduct an independent investigation of an event disclosed in an ASAP report. They also learn to interpret employee conduct that raises a question of airman competence or qualification, medical certification or other employee competence/qualification issues. The safety risks/threats identified in sole-source reports must be addressed by the committee. A key to the arrangement is that the flight attendant must successfully complete recommended corrective action to be covered by the program’s protections; otherwise he or she can face a reopening of the case and referral for an FAA investigation.
FAA basically expects ASAP reports involving a possible regulatory violation to be accepted if the flight attendant acted as an employee of the air carrier; the report is submitted in a timely manner, such as within 24 hours after the end of a duty day; the alleged regulatory violation is inadvertent and does not appear to involve an intentional disregard for safety; and the event does not appear to involve FAA’s “big five” exceptions — criminal activity, substance abuse, controlled substances, alcohol or intentional falsification.
Without the enforcement-related incentive provided by ASAPs, “important data that might help to correct safety-related systematic deficiencies — and to plan better aviation systems for the future — go unreported,” said John Woodring, cabin safety inspector, FAA Denver Certificate Management Field Office. The rigorous process within ASAPs sometimes enables representatives of airlines, the FAA and flight attendant unions to discover system-level influences on cabin crew behavior that would be missed by focusing only on the individuals involved. For example, in a three-week period, one event review committee received three separate reports from flight attendants who said that that they were standing during landing, instead of being seated in a jump seat with the safety belt and shoulder harness fastened.
“Upon further investigation, the event review committee learned that all three incidents occurred on the same flight segment and involved the same basic circumstances,” Woodring said. “The committee immediately notified the airline safety division of the potential safety issue and requested that the division do a root-cause analysis. … Company procedures were a primary cause of these incidents, and the division took immediate corrective action to mitigate the hazard associated with the identified risk.”
Possibly — except for the ASAP process — the safety division, FAA and other flight attendants never would have known about these incidents, and no comprehensive investigation would have occurred, he said. “Based on precedent, the company would have assumed it was an employee compliance issue that caused the non-compliance, and therefore would have taken some sort of disciplinary action,” Woodring said.
Based on his experience, absence of trust inhibits communication from flight attendant employee groups to FAA representatives and airlines. “Over time, the flight attendant ASAP has helped break down this distrust,” Woodring said. “ASAP has fostered a growing spirit of partnership [and flight attendants] are realizing that the information provided to the program does drive positive change in company policy,” he said.
The FAA continues to promote ASAPs for flight attendants. For example, the cabin safety benefits have been presented to FAA-industry information-sharing meetings involving the airlines that already have ASAPs for other employee groups and/or flight operational quality assurance programs, and to the Cabin Operations Committee of the Air Transport Association of America, he said.
Conditional Union Support
Candace Kolander, coordinator, air safety, health and security, Association of Flight Attendants–Communications Workers of America (AFA), said that the union supports ASAPs for flight attendants, but on the condition that reports be sent within 10 days to the U.S. National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS). This practice typically protects submitters, if an ASAP report proves unacceptable, and reports become beneficial industrywide. Historically, the apparently slight risk of FAA enforcement action against flight attendants may explain the reluctance of some to submit voluntary safety reports. Unlike pilots’ risk of airman certificate revocation or suspension, for example, “flight attendants don’t have that big question of a violation hanging over their heads all the time,” she said.
Flight attendants’ feedback to AFA about current ASAPs has been positive. “One of the things they are most excited about is addressing concerns in the cabin,” Kolander said. “They want FAA to be given a little ‘heads up’ about concerns that they have not necessarily been able to solve at the air carrier level.”
A classic complaint is that past efforts to balance safety expectations with service expectations resulted in discipline — for example, when a supervisor judged the crewmember’s forceful handling of a safety-related issue with a passenger as conflicting with good customer relations, she said. Such experiences erode willingness to report similar events. “That is one impetus for flight attendants’ willingness to try ASAP,” Kolander said.
Valerie Walker and Jack O’Brien, representatives of the United Airlines Onboard Service Safety Action Program implemented in March 2005, said that ASAP for flight attendants enables airlines “to gain objective feedback relating to the effectiveness of training, policies and processes.” They said that they found that a critical element of success is for the senior leader of the division to “stand up before his/her leadership team and deliver a message supporting the program.”3
Through the ASAP event review committee, the United Airlines Safety Division receives reports from flight attendants, investigates them, provides a weekly update on reports to review, maintains a log of action items, closes out ASAP reports, manages the safety database and interfaces with managers of ASAPs for pilots, dispatchers and maintenance technicians. Walker and O’Brien cited the following program benefits: “increased awareness of cabin safety; a window to what really happens on the line; providing flight attendants a voice in corporate safety; and reports reviewed by safety professionals.”
At Alaska Airlines, the FAA’s template was followed “fairly closely” before the memorandum of understanding was accepted by the FAA in September 2006. Minor changes are expected as this ASAP evolves from a demonstration program to a continuing program in 2008, said Cassandra Bennett-Chaffee, manager, in-flight policy, safety and regulatory compliance.4
Reviewing 200 reports from some of the company’s 2,700 flight attendants the first year was not difficult, she said, contrary to her expectation. “Right off in the first month, we had four potential violations of the Federal Aviation Regulations [FARs], and I worried that I would spend all my waking hours on this program,” Bennett-Chaffee said. “It has become far more manageable because of established patterns. We are looking for trends, we would like to validate whether corrective actions are indeed working.”
ASAP requirements were not difficult to understand or apply after FAA training and observation of internal and external ASAPs, she said. Record keeping also helps maintain consistency in reviews and in consensus decisions. “We have some agreed rules of the road and standardized our letters to reply to flight attendants after we have reviewed a report,” Bennett-Chaffee said.
ASAP protections for submitters encourage event review committee members to be proactive. “To find out about safety-related events, including those that may have required an employee disciplinary measure in the past, we contact individual flight attendants and encourage them to report,” she said. “Our committee has been open and generous in taking reports far past deadline — we firmly believe in the value of learning lessons in a non-punitive environment.” The committee so far has not had difficulty gathering additional facts to aid reviews of ASAP reports.
Typically, reports have been timely; the ASAP allows reports to be submitted only via a secure online form. In contrast, the company’s mandatory cabin safety reports — requiring a written report for any of 20 reasons listed in the flight attendant manual, such as defective safety equipment — involve intake of a much higher volume via telephone, paper forms and online reporting.
The ASAP supplements mandatory cabin safety reports, which flight attendants cannot monitor. In comparison, products of committee meetings twice a month include the quarterly ASAP report to FAA and a monthly ASAP bulletin securely distributed on line to all flight attendants at the airline. “Verbatim deidentified ASAP reports in the monthly bulletin are high value … the lessons learned have been amazing,” Bennett-Chaffee said. “Some flight attendants say that a policy or procedure was not clear to them until they read somebody else’s report and then they say, ‘I realized why I need to follow the procedure in the manual.’”
Beyond words, ASAP-related actions by the airline have high visibility. “We see flight attendant manual changes and sometimes daily changes in procedures,” she said. Since the ASAP was established, the company’s cabin supervisors also have been reporting improved adherence to written procedures. The program provides the option of either automatic forwarding of ASAP reports to ASRS or no forwarding. In the first year, about half of the reports were forwarded — with each employee’s written permission — including the flight attendant’s name, address and telephone number, enabling ASRS analysts to follow up before deidentifying the report.
Latricia Foulger, director, InFlight, SkyWest Airlines, said that under an FAA-funded collaborative project between the airline and the Universal Technical Resource Services Aviation Consulting Group, flight attendants explain the cause and outcome of the event in their ASAP report. “Sometimes, contact by our event review committee will be for the sole purpose of counseling the flight attendant in proper procedures,” Foulger said. “ASAP reports are selected for publication based on the severity or frequency of the safety concern. No names are divulged. The committee produces ASAP Circulars that are issued to each flight attendant through a bimonthly newsletter as well as posted on a company intranet giving details of the event and the committee’s conclusion and recommended preventive measures.”
American Airlines representatives Shannon Stewart and Penney Pollard told cabin safety professionals that “earning and keeping trust should be a primary goal of the [ASAP] program.” Numerous safety reports generated by an ASAP for flight attendants help validate that “employees trust the process,” they said. An effective ASAP will “establish a culture of self-reporting within your company in which your employees provide a realistic snapshot of your operation,” they said.5
Success requires thorough research, timely and high-quality responses to ASAP safety reports, consistent products from the program and continuing education. Specifically, ASAPs can improve training of flight attendants to cover areas of deficiency and generate specific feedback to the submitter and other flight attendants “so they may benefit from reported events and avoid the same threats,” Stewart and Pollard said.
ASRS Magnifies Impact
In 2007, reports received from 68 ASAPs at 32 U.S. airlines surpassed the total ASRS reports received directly from air traffic controllers, dispatchers, flight attendants, maintenance technicians and pilots, said Linda Connell, program director of ASRS at the NASA Ames Research Center. “We are the largest repository of ASAP information,” Connell said. As of December 2007, three airlines with six ASAPs for flight attendants were submitting their reports to ASRS. Data for total intake of reports “absolutely show increasing interest” from flight attendants in voluntary safety reporting, she said.
“Our purposes are to identify deficiencies and discrepancies in the aviation system as a whole and to provide data for planning and improvements,” Connell said. “The first is a short-term purpose. Every report has to be read by two expert analysts within three days of the time we receive it to identify time-critical deficiencies and discrepancies — the hazards. We then spend time evaluating each report and selecting reports for additional processing from predetermined categories of high-value safety information.”
Time-critical reports are analyzed, deidentified/sanitized and distributed quickly to affected parties as Alert Bulletins reflecting the highest-level hazards. Reports used in alert messages and the high-value selections normally are processed for addition to the ASRS Online Database, which can be accessed and searched at NASA ASRS <asrs.arc.nasa.gov> and FAA Aviation Safety Information Analysis and Sharing <www.asias.faa.gov>. About half of all reports, and 75 percent of ASAP reports, arrive in a digital format.
About 20 percent of the total report intake eventually is included in the ASRS Online Database. This includes all reports deemed to involve high-severity events such as controlled flight toward terrain and “special study” events sought by FAA, NTSB or industry researchers, such as runway incursions and wake vortex encounters. The deidentified reports not chosen for the ASRS Online Database remain in the ASRS Screening Dataset, an internal processing step used by ASRS staff.
Connell considers ASRS and ASAPs as complementary, neither a sufficient replacement for the other. A past disadvantage of ASAPs was separation of programs by employee group so that events and concerns became “stove-piped” (segregated) within and among airlines instead of being aggregated, she said. FAA and NASA are addressing this, realizing that some aviation safety specialists prefer ASAP reports because they involve internal investigations, corrective actions and permanent access to a record, protected from public disclosure by federal law, with only the submitter’s name deleted. Underscoring this point, the FAA said, “The value of ASAP for safety enhancement lies in its capacity to retain specific information on individual events, including, for example, specific information on aircraft make, model and series.”6 The value of ASRS is its ability to aggregate safety information while avoiding the “stove-piping” problem, Connell said.
Under the FAA’s Voluntary Aviation Safety Information-Sharing Process, work has been under way since 2004 to develop a “technical process to extract deidentified data from any participating airline flight operations quality assurance [program] or [ASAP], aggregate it through a distributed database and make it accessible to appropriate industry stakeholders for analysis.”7 FAA therefore encourages ASAPs to develop data acquisition, event categorization and risk analysis methods that gradually will enable voluntary national sharing of ASAP information from multiple programs, a common taxonomy (classification scheme) tailored to the types of events, and classification of corrective actions for flight attendants and other specific employee groups. In May 2008, the Voluntary Aviation Safety Programs Conference in San Diego will include presentations on how ASAP, ASRS and related programs can be integrated into an airline’s safety management system (SMS) and how voluntary safety information can be shared by airlines and the FAA.
An ASAP for flight attendants does not guarantee that safety issues will be resolved permanently, or even that flight attendants will participate. To the extent that deeper safety awareness empowers flight attendants, however, they are in a better position to prod airlines and the FAA to examine issues objectively and involve cabin crews in solutions.
- As of December 2007, the FAA had accepted 10 memorandums of understanding authorizing ASAPs for flight attendants at Alaska Airlines, Eos Airlines, Horizon Air, PACE Airlines, Pinnacle Airlines, Skyway Airlines, SkyWest Airlines, Swift Air Group, United Airlines and USA3000 Airlines.
- Ganter, John H.; Dean, Craig D.; Cloer, Bryon K. Fast Pragmatic Safety Decisions: Analysis of an Event Review Team of the Aviation Safety Action Partnership. Sandia National Laboratories. Report no. SAND2000-1134. May 2000. Researchers said, “Potential corrective action can be visualized as a steel ball on [a tilt table]. In order for this potential action to be implemented, the ball must pass through a hole at the center: the zone of unanimous consensus. The representatives must cooperate in achieving a reasonably balanced table.”
- Walker, Valerie; O’Brien, Jack. “Safety Action Program in a Flight Attendant Environment.” In proceedings of the 23rd annual International Aircraft Cabin Safety Symposium. Oklahoma City, Oklahoma, U.S.: Southern California Safety Institute, 2006.
- Bennett-Chaffee, Cassandra. “Value of the Cabin Crew Aviation Safety Action Program (ASAP) at Alaska Airlines.” Paper and presentation to the Air Transport Association of America. October 2007.
- Stewart, Shannon; Pollard, Penney. “Cabin ASAP: The International and Non-Labor Perspective.” In proceedings of the 23rd annual International Aircraft Cabin Safety Symposium.
- FAA. Order 8000.82, Designation of Aviation Safety Action Program (ASAP) Information As Protected From Public Disclosure Under 14 CFR Part 193. Sept. 3, 2003.
- Chidester, Thomas R. Voluntary Aviation Safety Information-Sharing Process: Preliminary Audit of Distributed FOQA and ASAP Archives Against Industry Statement of Requirements. FAA Office of Aerospace Medicine. Report DOT/FAA/AM-07/7. April 2007.