The Air Traffic Safety Action Program (ATSAP) in the United States has generated a far higher volume of voluntary safety reports from air traffic controllers1 compared with this work group’s historic reporting, new data show. Officials of the Aviation Safety Reporting System (ASRS) say that the candor, details and other subjective attributes of ATSAP report quality also have improved significantly since ASRS began processing copies of these reports on Nov. 12, 2009.
Before ATSAP was launched, ASRS — the 36-year-old program funded by the U.S. Federal Aviation Administration (FAA) and administered by the National Aeronautics and Space Administration (NASA) Ames Research Center — had been the only independent U.S. program to directly receive such reports from controllers.
Controller reports in 2010 and 2011 jumped from about 1 percent of the previous total annual ASRS intake of reports to about 10 percent, says Linda Connell, program director, NASA ASRS. All but a few were submitted via secure websites; ASRS also accepts paper forms. “Everyone has been worried about this workload, but we have handled it through established protocols,” she said.
Direct intake of reports by ASRS from controllers about their errors, safety events and concerns now is much lower than in the past. “There is still some flow of non-duplicative controller reports in 2012 that does not come through the ATSAP mechanism,” Connell said. “We never know whether those controllers still are not aware of ATSAP, or they don’t want to talk about a certain issue through that mechanism.” Direct reports to ASRS are an alternate “open door to assure that the safety information is still obtained,” she added.
ATSAP operates under a relatively new model, labor agreement and FAA policy, with different rules for the confidential and non-punitive treatment of reports accepted, investigated and resolved by local event review committees (ERCs). A neutral third-party ATSAP contractor — CSSI, Inc. — confidentially processes and distributes ATSAP reports to the ERCs and to ASRS. ATSAP itself has been updated by the FAA’s revised voluntary safety reporting programs policy order,2 effective in January.
Under the ASRS model, NASA specialists read and triage all reports within three days (typically 1.14 days in 2012), subjectively determining which of several paths in the process will be assigned to each one. If the report fits ASRS acceptance criteria, the controller who filed the report receives specified protections against FAA disciplinary action, except when events involve criminal activities or accidents.
“In our mission, we stay away from enforcement or corrective action or follow-up,” Connell said. “To the best of our abilities, we provide information that is relevant for somebody else to look at and move forward. If we look at a pilot-initiated report and match it to an ATSAP report about the same event, we can ask, ‘Why did this happen?’ … with rich information to begin to untangle the answer. If people only work with ‘stove-piped’ information, they risk making decisions about the cause in isolation, in a vacuum.” She added that “locked-down” protocols that sometimes are necessary outside ASRS can impede researchers’ access to data.
From 2001 through 2011, ASRS intake included 25,293 direct-to-ASRS and ATSAP reports from controllers, she said. Of these, 17,216 (68 percent) were ATSAP reports — all received near the end of 2009, in 2010 and in 2011. Matching of reports brings together in one database all reporters’ perspectives of an event and different domains of information, Connell said.
Over the 10-year period, the direct-to-ASRS reports totaled 8,077 (32 percent of all controller reports), with the lowest number, 56, in 2011 and the highest number, 1,689, in 2006. Following the transitional year of 2009, the annual total of ATSAP reports reached 8,474 in 2010. In 2011, the program received 7,826 ATSAP reports.
Compared with the FAA Air Traffic Organization’s (ATO’s) ERCs, “ASRS looks at issues using highly trained experts to fully match, evaluate and code events at the national level,” Connell said. “The systems view of our entire process is complementary to what others might do, but it is from a very different perspective.” The aviation safety community thus benefits from multiple data sets and measures, timely identification and alerting about emerging issues, and education about lessons learned, especially those with an important human factors context, she added.
ASRS analysts assign “reported anomaly” types at the intake stage for both ATSAP and direct-to-ASRS reports, said Charles Drew, ASRS program manager for Booz Allen Hamilton, a NASA contractor. These categories are not mutually exclusive.
In 2011, the predominant categories — those to which more than 10 percent of reports were assigned — were “ATC issue–all types” (84.7 percent), “deviation–procedural/published material/policy” (62.2 percent), “airspace violation–all types” (20.5 percent), “deviation–procedural/clearance” (18.3 percent) and “conflict–airborne conflict” (14.6 percent).
ASRS keeps a subset of data — excluding the narrative — from every report received from all aviation work groups (219,092 in 2008–2011) in its internal screening dataset. Analysts then subjectively select a subset of all reports, including the reporter’s narrative, for the Full Form Database accessible online to the public (an estimated 22 percent were controller reports in 2008–2011, compared with an estimated 13 percent of reports from all work groups).3
ASRS does not distinguish ATSAP and direct-to-ASRS reports in the Full Form Database. “Our philosophy, basically, is that we want all information to stand on its own, from whatever source we receive it,” Connell said. “We’re doing our best to select the top layer of the pool of reports for public use. We are a flat-funded program, so at some point we also don’t have the money to select a higher volume.”
An average of four times a week, Connell and Drew issue urgent ASRS Alert Bulletins and non-urgent ASRS For Your Information Bulletins to potentially affected government and industry stakeholders. For the 2008–2011 period, 16.4 percent of alert messages — 87 about air traffic control [ATC] procedures, 42 about ATC equipment and 31 about ATC operations — were based on ATSAP and direct-to-ASRS reports.
In 2011, 201 messages warranted an ASRS alert bulletin from all work groups. The 23 controller-initiated safety issues were:
- Radar data not displayed
- Limited tower visibility
- Similar-sounding fix names in standard instrument departures (SIDs)
- Tower frequency change on published charts
- Two reports of confusion about SIDs
- Missing minimum altitude data on radar displays for instrument flight rules (IFR) operations
- Airport signage, charting and clearance confusion for an area navigation standard instrument arrival (STAR)
- Erroneous alarms from a minimum safe altitude warning system
- False alarms from an airport movement area safety system
- Airspace boundary charting
- A SID anomaly
- Run-up area signage and markings
- Taxiway marking
- Frequent incorrect readbacks of SID assignments
- Tower light-gun functionality
- Equipment handoff
- Turbulence-induced noncompliance with reduced vertical separation minimum
- Taxiway markings visibility
- Confusion from the same fix name in two STARs
- Departure routing confusion from similarly named intersections
- A data-jump anomaly in airport surface detection equipment–model X, and
- A roll capture anomaly on an instrument landing system.
Drew said that the introduction of NextGen technology — such as the En Route Automation Modernization (ERAM) software — entails “inevitable growing pains” that can be detected early by controllers. “In the introduction of ERAM, we’re picking up problems almost like a quality assurance department,” he said.
- This article refers only to controllers but the FAA’s policy applies to “all ATO [Air Traffic Organization] personnel directly engaged in and/or supporting air traffic services and only to events that occur while acting in that capacity.”
- FAA. “Voluntary Safety Reporting Programs (VSRP).” Air Traffic Organization Policy, Order JO 7200.20, Jan. 30, 2012.
- The Full Form Database includes all reports coded as near midair collision, loss of control, critical equipment problem, ground conflict–severe or controlled flight toward terrain.