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NASA aviation safety reporting system

During the second quarter of the Aviation Safety Reporting System (ASRS) operation, 1,497 reports were received from pilots, controllers, and others in the national aviation system. Details of the administration and results of the program to date are presented. Examples of alert bulletins disseminated to the aviation community are presented together with responses to those bulletins. Several reports received by ASRS are also presented to illustrate the diversity of topics covered by reports to the system.

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Analysis of Aviation Safety Reporting System Incident Data Associated with the Technical Challenges of the System-Wide Safety and Assurance Technologies Project

The Aviation Safety Program (AvSP) System-Wide Safety and Assurance Technologies (SSAT) Project asked the AvSP Systems and Portfolio Analysis Team to identify SSAT-related trends. SSAT had four technical challenges: advance safety assurance to enable deployment of NextGen systems; automated discovery of precursors to aviation safety incidents; increasing safety of human-automation interaction by incorporating human performance, and prognostic algorithm design for safety assurance. This report reviews incident data from the NASA Aviation Safety Reporting System (ASRS) for system-component-failure- or-malfunction- (SCFM-) related and human-factor-related incidents for commercial or cargo air carriers (Part 121), commuter airlines (Part 135), and general aviation (Part 91). The data was analyzed by Federal Aviation Regulations (FAR) part, phase of flight, SCFM category, human factor category, and a variety of anomalies and results. There were 38 894 SCFM-related incidents and 83 478 human-factorrelated incidents analyzed between January 1993 and April 2011.

Withrow, Colleen A.↗

Kaona: Deep Searching and Curating Data from Aviation Safety Reporting Systems

Context: Several works in the literature have examined how safety narrative databases can be leveraged to share lessons learned. However, less attention has been given to augmenting existing processes for mining these safety reporting system databases. Aim: In this work, we introduce Kaona: An interface that weaves machine learning in existing aviation safety database mining activities. Method: We provide a use case of search, curation and newsletter writing to showcase how Kaona features build on existing processes and on its own to enhance information retrieval, curation and synthesis of narratives. Results: We created two instances of Kaona internally for evaluation, one using publicly available NASA’s ASRS narratives and another using publicly available C3RS narratives. Data ranged from 1998 to 2024. Conclusion: Our tool provides a new way to explore safety narratives, serving to re-imagine how text databases can benefit of novel information retrieval mechanisms in the era of large language models.

ASRS↗

Augmenting Topic Finding in the NASA Aviation Safety Reporting System using Topic Modeling

Context: The NASA Aviation and Safety Reporting System (ASRS) provides various publications to the aviation community (including individual anonymous reports, Callback, Database Search Requests, Directline, and Alerting Messages). Key to these publications are the timely processing of new reports, which is currently done mostly manually by ASRS staff, and which the volume increases yearly. Aim: We investigate whether existing topic modelling techniques are suitable to ease some of the manual effort, and to enhance it with additional visual cues regarding the process of grouping, sense making and labeling incoming (and previous) reports. Method: We evaluate the applicability of WarpLDA topic modelling results combined with three visualization tools, the first two of which have been extended by us in this work for ASRS: Termite, TopicFlow, and LDAVis. Based on the identified limitations in these tools, we propose a methodology for improving them, and evaluate their outputs using ASRS as our test dataset. Results: The user interfaces of Termite, Topicflow and LDAVis were found insufficient for sense-making of the narratives. Moreover, concerns regarding the stability of results due to the inherent randomness of topic modelling, and the lack of a measurable approach for evaluation against the existing ASRS manual workflow were also noted. Conclusion: While many tools to topic modeling and visualization have been proposed, more work is necessary before they can be applied in practical situations to improve existing manual workflows. The methodology presented and applied in this work contribute towards this effort.

ASRS↗

Pre-Departure Clearance (PDC): An Analysis of Aviation Safety Reporting System Reports Concerning PDC Related Errors

Airlines operating in the United States are required to operate under instrument flight rules (EFR). Typically, a clearance is issued via voice transmission from clearance delivery at the departing airport. In 1990, the Federal Aviation Administration (FAA) began deployment of the Pre-Departure Clearance (PDC) system at 30 U.S. airports. The PDC system utilizes aeronautical datalink and Aircraft Communication and Reporting System (ACARS) to transmit departure clearances directly to the pilot. An objective of the PDC system is to provide an immediate reduction in voice congestion over the clearance delivery frequency. Participating airports report that this objective has been met. However, preliminary analysis of 42 Aviation Safety Reporting System (ASRS) reports has revealed problems in PDC procedures and formatting which have caused errors in the proper execution of the clearance. It must be acknowledged that this technology, along with other advancements on the flightdeck, is adding more responsibility to the crew and increasing the opportunity for error. The present study uses these findings as a basis for further coding and analysis of an additional 82 reports obtained from an ASRS database search. These reports indicate that clearances are often amended or exceptions are added in order to accommodate local ATC facilities. However, the onboard ACARS is limited in its ability to emphasize or highlight these changes which has resulted in altitude and heading deviations along with increases in ATC workload. Furthermore, few participating airports require any type of PDC receipt confirmation. In fact, 35% of all ASRS reports dealing with PDC's include failure to acquire the PDC at all. Consequently, this study examines pilots' suggestions contained in ASRS reports in order to develop recommendations to airlines and ATC facilities to help reduce the amount of incidents that occur.

Montalyo, Michael L.↗

Wire Rope Inspection Report Safety Division, Code 360

The purpose of this report is to review Federal Regulations, Voluntary Consensus Standards (VCS), and best practices associated with WRI requirements within the government and industry. This report provides an analysis to NASA Headquarters regarding the limited risks that wire ropes present to the Agency based on the interpretation of Section 29 CFR 1910.179 (m) of the Occupational Safety and Health Administration (OSHA) requirements that allow inspections of OHC wire rope based on the operational status of the crane. This report also provides details and recommendations for the reduction of personnel exposure to safety risk associated with working at heights while inspecting wire rope on inactive lifting devices.

Wire Rope↗

NASA Aviation Safety Reporting System

Problems in briefing of relief by air traffic controllers are discussed, including problems that arise when duty positions are changed by controllers. Altimeter reading and setting errors as factors in aviation safety are discussed, including problems associated with altitude-including instruments. A sample of reports from pilots and controllers is included, covering the topics of ATIS broadcasts an clearance readback problems. A selection of Alert Bulletins, with their responses, is included.

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Apollo experience report: Safety activities

A description is given of the flight safety experiences gained during the Apollo Program and safety, from the viewpoint of program management, engineering, mission planning, and ground test operations was discussed. Emphasis is placed on the methods used to identify the risks involved in flight and in certain ground test operations. In addition, there are discussions on the management and engineering activities used to eliminate or reduce these risks.

Rice, C. N.↗

NASA aviation safety reporting system

Reports describing various types of communication problems are presented along with summaries dealing with judgment and decision making. Concerns relating to the ground proximity warning system are summarized and several examples of true terrain proximity warnings are provided. An analytic study of reports relating to profile descents was performed. Problems were found to be associated with charting and graphic presentation of the descents, with lack of uniformity of the descent procedures among facilities using them, and with the flight crew workload engendered by profile descents, particularly when additional requirements are interposed by air traffic control during the execution of the profiles. A selection of alert bulletins and responses to them were reviewed.

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NASA aviation safety reporting system

A decline in reports concerning small aircraft was noted; more reports involved transport aircraft, professional pilots, instrument meteorological conditions, and weather problems. A study of 136 reports of operational problems in terminal radar service areas was made. Pilot, controller, and system factors were found to be associated with these occurrences. Information transfer difficulties were prominent. Misunderstandings by pilots, and in some cases by controllers, of the policies and limitations of terminal radar programs were observed.

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NASA aviation safety reporting system

An analytical study of reports relating to cockpit altitude alert systems was performed. A recent change in the Federal Air Regulation permits the system to be modified so that the alerting signal approaching altitude has only a visual component; the auditory signal would continue to be heard if a deviation from an assigned altitude occurred. Failure to observe altitude alert signals and failure to reset the system were the commonest cause of altitude deviations related to this system. Cockpit crew distraction was the most frequent reason for these failures. It was noted by numerous reporters that the presence of altitude alert system made them less aware of altitude; this lack of altitude awareness is discussed. Failures of crew coordination were also noted. It is suggested that although modification of the altitude alert system may be highly desirable in short-haul aircraft, it may not be desirable for long-haul aircraft in which cockpit workloads are much lower for long periods of time. In these cockpits, the aural alert approaching altitudes is perceived as useful and helpful. If the systems are to be modified, it appears that additional emphasis on altitude awareness during recurrent training will be necessary; it is also possible that flight crew operating procedures during climb and descent may need examination with respect to monitoring responsibilities. A selection of alert bulletins and responses to them is presented.

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NASA aviation safety reporting system

A sample of reports relating to operations during winter weather is presented. Several reports involving problems of judgment and decisionmaking have been selected from the numerous reports representative of this area. Problems related to aeronautical charts are discussed in a number of reports. An analytic study of reports involving potential conflicts in the immediate vicinity of uncontrolled airports was performed; the results are discussed in this report. It was found that in three-fourths of 127 such conflicts, neither pilot, or only one of the pilots, was communicating position and intentions on the appropriate frequency. The importance of providing aural transfer of information, as a backup to the visual see and avoid mode of information transfer is discussed. It was also found that a large fraction of pilots involved in potential conflicts on final approach had executed straight-in approaches, rather than the recommended traffic pattern entries, prior to the conflicts. A selection of alert bulletins and responses to them by various segments of the aviation community is presented.

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NASA aviation safety reporting system

The study deals with 165 inadvertent operations on or into inappropriate portions of the aircraft areas at controlled airports. Pilot-initiated and controller-initiated incursions are described and discussed. It was found that a majority of the pilot-initiated occurrences involved operation without a clearance; controller-initiated occurrences usually involved failure to maintain assured separation. The factors associated with these occurrences are analyzed. It appears that a major problem in these occurrences is inadequate coordination among the various system participants. Reasons for this, and some possible solutions to various aspects of the problem, are discussed. A sample of reports from pilots and controllers is presented. These relate to undesired occurrences in air transport, general aviation, and air traffic control operations; to ATC coordination problems; and to a recurrent problem in ASRS reports, parachuting operations. A sample of alert bulletins and responses to them is presented.

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NASA aviation safety reporting system

Knowledge of limitations of the Air Traffic Control system in conflict avoidance capabilities is discussed. Assumptions and expectations held by by airmen regarding the capabilities of the system are presented. Limitations related to communication are described and problems associated with visual approaches, airspace configurations, and airport layouts are discussed. A number of pilot and controller reports illustrative of three typical problem types: occurrences involving pilots who have limited experience; reports describing inflight calls for assistance; and flights in which pilots have declined to use available radar services are presented. Examples of Alert Bulletins and the FAA responses to them are included.

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