NASA Aviation Safety Reporting System (ASRS) Program Briefing
This presentation provides an overview of NASA's Aviation Safety Reporting System (ASRS).
ASRS↗
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Fatigue, pilot deviations and time of day
The relationships between pilot fatigue, pilot deviations, reported incidents, and time of day are examined. A sample of 200 Aviation Safety Reporting System (ASRS) reports were analyzed from 1985 and 200 reports from 1987, plus 100 reports from late 1987 and early 1988 that were selected because of possible association with fatigue. The FAA pilot deviation data and incident data were analyzed in relation to denominator data that summarized the hourly operations (landings and takeoffs of scheduled flights) at major U.S. airports. Using as numerators FAA data on pilot deviations and incidents reported to the FAA, the rates by time of day were calculated. Pilot age was also analyzed in relation to the time of day, phase of flight, and type of incident.
Baker, Susan P.↗
A taxonomy of decision problems on the flight deck
Examining cases of real crews making decisions in full-mission simulators or through Aviation Safety Reporting System (ASRS) reports shows that there are many different types of decisions that crews must make. Features of the situation determine the type of decision that must be made. The paper identifies six types of decisions that require different types of cognitive work and are also subject to different types of error or failure. These different requirements, along with descriptions of effective crew strategies, can serve as a basis for developing training practices and for evaluating crews.
Orasanu, Judith M.↗
Loss of Situation Awareness in Pilots: Analysis of Incident Reports
Approximately 75% of all aviation accidents and incidents are attributable to human failures in monitoring, managing, and operating system. Tactical decision errors were found to be a factor in 25 of 37 major US air transport accidents between 1978 and 1990. These two facts demonstrate the inability of some pilots to maintain situation awareness. Situation awareness (SA) is defined as 'the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future". Thus, when a pilot loses SA, he or she is unable to ether perceive, comprehend, or project the status of the aircraft. In pilots terms, he or she has 'fallen behind the airplane'. Our study this summer involved an analysis of 190 NASA Aviation Safety Reporting System (ASRS) reports.
Eric B. Villeda↗
Identifying Human Factors Issues in Aircraft Maintenance Operations
Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.
Veinott, Elizabeth S.↗
Ground Taxi Navigation Problems and Training Solutions
Adverse weather conditions can put considerable strain on the National Airspace System. Even small decreases in visibility on the airport surface can create delays, hinder safe movement and lead to errors. Studies of Aviation Safety Reporting System (ASRS) surface movement incidents support the need for technologies and procedures to improve ground operations in low-visibility conditions. This study examined 139 ASRS reports of low-visibility surface movement incidents at 10 major U.S. airports. Errors were characterized in terms of incident type, contributing factors and consequences. The incidents in the present sample were comprised of runway transgressions, taxiway excursions and ground conflicts. The primary contributing factors were Airport Layout and Markings, Communication and Distraction. In half the incidents the controller issued a new clearance or the flight crew took an evasive action and in the remaining half, no recovery attempt was made because the error was detected after the fact. By gaining a better understanding the factors that affect crew navigation in low visibility and the types of errors that are likely to occur, it will be possible to develop more robust technologies to aid pilots in the ground taxi task. Implications for crew training and procedure development for low-visibility ground taxi are also discussed.
Quinn, Cheryl↗
Document retrieval and reporting
ASRES system of computer programs provides for acquisition, storage, retrieval and dissemination of information in form of bibliographic citations of technical documents. Persons with little or no computer experience can operate ASRES. System should be applicable to any definable body of technical literature consisting of up to 32,750 citations.
Perlouch, J. J., Jr.↗
NASA Aviation Safety Reporting System (ASRS)
This presentation presents an overview of NASA's Aviation Safety Reporting System including report processing metrics and outreach activities.
Aviation Safety Reporting System↗
Cockpit Interruptions and Distractions: Effective Management Requires a Careful Balancing Act
Managing several tasks concurrently is an everyday part of cockpit operations. For the most part, crews handle concurrent task demands efficiently, yet crew preoccupation with one task to the detriment of performing other tasks is one of the more common forms of error in the cockpit. Most pilots are familiar with the December 1972 L1011 crash that occurred when the crew became preoccupied with a landing gear light malfunction and failed to notice that someone had inadvertently bumped off the autopilot. More recently a DC-9 landed gear-up in Houston when the crew, preoccupied with an stabilized approach, failed to recognize that the gear was not down because they had not switched the hydraulic pumps to high. We have recently started a research project to study why crews are vulnerable to these sorts of errors. As part of that project we reviewed NTSB reports of accidents attributed to crew error; we concluded that nearly half of these accidents involved lapses of attention associated with interruptions, distractions, or preoccupation with one task to the exclusion of another task. We have also analyzed 107 ASRS reports involving competing tasks; we present here some of our conclusions from those ASRS reports. These 107 reports involved 21 different types of routine tasks crews neglected at a critical moment while attending to another task. Sixty-nine percent of the neglected tasks involved either failure to monitor the current status or position of the aircraft or failure to monitor the actions of the pilot flying or taxiing. Thirty-four different types of competing activities distracted or preoccupied the pilots. Ninety percent of these competing activities fell into one of four broad categories: communication (e.g., discussion among crew or radio communication), heads-down work (e.g., programming the FMS or reviewing approach plates), responding to abnormals, or searching for VMC traffic. We will discuss examples of each of these four categories and suggest things crews can do to reduce their vulnerability to these and similar situations.
Dismukes, R. K.↗
NASA aviation safety reporting system
During the third quarter of operation of the Aviation Safety Reporting System (ASRS), 1429 reports concerning aviation safety were received from pilots, air traffic controllers, and others in the national aviation system. Details of the administration and results of the program are discussed. The design and construction of the ASRS data base are briefly presented. Altitude deviations and potential aircraft conflicts associated with misunderstood clearances were studied and the results are discussed. Summary data regarding alert bulletins, examples of alert bulletins and responses to them, and a sample of deidentified ASRS reports are provided.
Source record↗
Direct Radiative Effects of Aerosols at the ARM SGP and TWP Sites (DOE ASR Final Report)
This effort has examined and quantified aerosol direct radiative effects (DREs) and associated uncertainties at the Department of Energy Atmospheric Radiation Measurement (ARM) Southern Great Plain (SGP) and Tropical Western Pacific (TWP) sites under both clear and all sky conditions by taking advantage of the advanced ARM long-term comprehensive measurements of aerosol, cloud, radiation, and atmospheric state. This effort has filled the knowledge gap in aerosol DREs at the SGP and TWP under all sky conditions based on the ARM observations.
54 ENVIRONMENTAL SCIENCES↗
NASA ASRS Maintenance Reports - Part Installation Issues
This presentation reviews voluntary safety reports received by NASA's Aviation Safety Reporting System pertaining to safety issues related to incorrect part installation.
Doyle, Dennis↗
Human factors in aviation operations: The hearback problem
This report covers a study of ASRS reports wherein ATC controllers failed to monitor adequately (hearback) incorrect readbacks of ATC clearances. A total of 417 reports received over a period of 29 months from April 1981 through July 1983 comprised the study data set. Factors examined were: the reasons for a flight crew's getting clearances incorrectly, the operating factors that caused controllers to mishear or not hear the correct readbacks, and consequences of the various types of hearback misses. The principle conclusion of the study takes the form of a precaution to flight crews that a controller's not challenging a readback does not necessariliy mean the readback is correct and that flight crews must explicitly question any doubtful or unusual aspects of clearances rather than depending on controllers to detect readback errors.
Monan, William P.↗
Performance Data Errors in Air Carrier Operations: Causes and Countermeasures
Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.
countermeasures↗
“Terrain, Terrain Pull-up!” Air Carrier Controlled Flight Toward Terrain Incidents Reported to the NASA ASRS
The Aviation Safety Reporting System (ASRS) in a partnership between the National Aeronautics and Space Administration (NASA), the Federal Aviation Administration (FAA), participating carriers, and labor organizations. It is designed to improve the National Airspace System by collecting and studying reports detailing unsafe conditions and events in the aviation industry. Employees are able to report safety issues or concerns with confidentiality and without fear of discipline. Safety reports highlighting controlled flight toward terrain incidents as reported to the NASA ASRS.
confidential reporting↗
Annual Summary Report (FY 2025) Composite Analysis for Low-Level Waste Disposal in the Central Plateau of the Hanford Site
In accordance with DOE M 435.1-1, Radioactive Waste Management Manual, requirements, the U.S. Department of Energy (DOE) Hanford Field Office (HFO) prepared this Annual Summary Report (ASR) for fiscal year (FY) 2025 for the Hanford Site Composite Analysis (CA) reported in DOE/RL-2019-52, Composite Analysis for Low-Level Waste Disposal in the Hanford Site Central Plateau (FY 2020) (hereinafter referred to as the Hanford Site Composite Analysis). The preparation of this ASR follows the technical specifications provided in DOE-STD-5002-2017, Disposal Authorization Statement and Tank Closure Documentation.
12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗