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  • Количество слайдов: 75

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Overview Summary • ASRS established in 1976 as an independent, confidential, voluntary reporting system Overview Summary • ASRS established in 1976 as an independent, confidential, voluntary reporting system for aviation at NASA with FAA offering “immunity” to reporters. One of the first lines of defense in identifying safety issues NASA chosen as “Honest Broker” Located at NASA Ames Research Center due to Aviation Human Factors expertise and research—it was recognized that approximately 70% of all accidents are human factors related. • • ASRS database is a national asset of U. S. aviation safety data Utilization, efficiencies, and improvements of the system have been accomplished progressively over the years. L. Connell 3/04

Overview Summary • Unique balance of contractual and financial arrangements between NASA and other. Overview Summary • Unique balance of contractual and financial arrangements between NASA and other. Gov’t Agencies • ASRS has become a model for other aviation systems internationally and also for other operational domains throughout the world • ASRS significantly related to other NASA, FAA, and aviation industry programs • PSRS significantly related to VA National Center for Patient Safety and medical healthcare in general • SIRS significantly related to DHS, TSA, aviation security stakeholders, and other environments. L. Connell 3/04

Code IH Human Factors Research and Technology Division Patricia Jones, Chief (Acting) Code IHH Code IH Human Factors Research and Technology Division Patricia Jones, Chief (Acting) Code IHH Code IHI Human Information Processing Research Branch Human-Automation Integration Research Branch Code IHS System Safety Research Branch Mary Connors, Chief ASRS Program PSRS SIRS Linda Connell Jeff Bixler L. Connell 3/04

ASRS Genesis of Human Factors Research at NASA Ames L. Connell 3/04 ASRS Genesis of Human Factors Research at NASA Ames L. Connell 3/04

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Guiding Principles VOLUNTARY PARTICIPATION Aviation personnel voluntarily submit reports concerning events related to safety Guiding Principles VOLUNTARY PARTICIPATION Aviation personnel voluntarily submit reports concerning events related to safety for the purpose of system alerting, understanding and learning CONFIDENTIALITY PROTECTION Protection of identity is provided by NASA through de-identification of persons, companies, and any other information NON-PUNITIVE FAA will not use, nor will NASA provide, any report submitted for inclusion under ASRS guidelines or information derived therein fo use in any disciplinary or other adverse action. (Advisory Circular 0046 D) L. Connell 3/04

ASRS PURPOSE ALERTS PRODUCTS Identify Deficiencies and Discrepancies Provide Data for Planning and Improvements ASRS PURPOSE ALERTS PRODUCTS Identify Deficiencies and Discrepancies Provide Data for Planning and Improvements L. Connell 3/04

Stakeholders L. Connell 3/04 Stakeholders L. Connell 3/04

Governing Documents • • • Federal Register Notices ‘ 75 & ‘ 76 Federal Governing Documents • • • Federal Register Notices ‘ 75 & ‘ 76 Federal Air Regulation - FAR 91. 25 FAA Advisory Circulars (00 -46 A, B, C, & D) Defines immunity provisions for pilots and others • FAA Facility Operation and Administration Handbook, 7210. 3 T (Air Traffic Controllers) Defines immunity provision for air traffic controllers • Mo. A between FAA and NASA (signed by NASA and FAA Administrators) • Interagency Agreement (signed in ‘ 99 and renewed in’ 04 for an additional 5 years) L. Connell 3/04

Predominant Statements Contained in the Governing Documents • ASRS is voluntary, confidential, and non-punitive Predominant Statements Contained in the Governing Documents • ASRS is voluntary, confidential, and non-punitive safety reporting system with NASA as honest broker • Reports will not be used by or made available to the FAA for disciplinary or enforcement purposes • Limited immunity provisions present from first release of the Advisory Circular AC 00 -46 A • Accidents by NTSB criteria and DOJ criminal offenses wholly excluded • • Time-critical information alerted to FAA and others • Reporting of findings to the public, aviation community, and the FAA Advisory Committee appointed from all elements involved in the operational aspects of the National Aviation System L. Connell 3/04

Event Occurrences Fatal Accidents FAA & NTSB ASRS { { Injury Accidents Precursors Incidents Event Occurrences Fatal Accidents FAA & NTSB ASRS { { Injury Accidents Precursors Incidents Normal Operations ASRS is Complementary to Other Systems of Reporting L. Connell 3/04

Program Reporting • Reporting to FAA, as specified in Interagency Agreement Bi-weekly telecons Annual Program Reporting • Reporting to FAA, as specified in Interagency Agreement Bi-weekly telecons Annual Report Semi-annual reviews • NASA ASRS Subcommittee of Headquarters Aeronautics Technical Advisory Committee (ATAC) Semi-annual meetings • NASA HQ ATAC Chairman of ASRS Subcommittee invited to present usually once a year or on request L. Connell 3/04

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INCIDENT REPORTER DISTRIBUTION January 1990 - December 2002 L. Connell 3/04 INCIDENT REPORTER DISTRIBUTION January 1990 - December 2002 L. Connell 3/04

ASRS METRICS April 1976 – December 2003 Significant Item Incident Reports Received Quantity 605, ASRS METRICS April 1976 – December 2003 Significant Item Incident Reports Received Quantity 605, 133 Safety Alert Messages Issued 3, 467 Search Requests/Quick Responses 6, 864 CALLBACK Safety Bulletins 291 DIRECTLINE Issues 10 Major Research Studies 59 L. Connell 3/04

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Report Processing L. Connell 3/04 Report Processing L. Connell 3/04

ASRS Expert Analyst Staff • Aviation Operational Expert Analysts perform initial screening identification of ASRS Expert Analyst Staff • Aviation Operational Expert Analysts perform initial screening identification of alerts, initial analyses, database coding, and special studies (e. g. , structured callback interviews and consultation on special safety topics). • Expert Analysts are retired air carrier pilots (Part 121 and 135), retired air traffic controllers, retired maintenance technicians, general aviation pilots, and flight attendants. A minimum of 10 years aviation experience required. • Years of aviation experience of the current analyst staff totals to approx. 390 yrs. An average of 35. 5 yrs experience in aviation. L. Connell 3/04

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Mix and Match Database • Database has 2 Levels of restricted access • Three Mix and Match Database • Database has 2 Levels of restricted access • Three users are allowed to access database Report Processing Coordinator has passwords of 2 Support Staff • Database Password required to open file L. Connell 3/04

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System Hardware • 43 Workstations 11 MAC’s 32 Window PC’s • • 13 Windows System Hardware • 43 Workstations 11 MAC’s 32 Window PC’s • • 13 Windows Servers 1 SGI Server 13 Printers 3 Automated Back up tape drives Cost efficient, relatively low investment in hardware L. Connell 3/04

System Software • Oracle 8 i - relational database platform for ASRS database utilities; System Software • Oracle 8 i - relational database platform for ASRS database utilities; Oracle 9 i for PSRS • • Access, Filemaker • • Microsoft office Database Search Tools Brio Oracle Based - Query Wizard QUORUM/ Perilog (new NASA developed textual search engine) Desktop publishing and website utilities Adobe products, Macromedia products Majority of products - COTS L. Connell 3/04

Network • • • Entire network is connected with Category 5 ethernet cable • Network • • • Entire network is connected with Category 5 ethernet cable • Firewall technology applied All servers connected to network at 100 megabits per second T 1 connection to Ames for incoming and outgoing network traffic L. Connell 3/04

Digital Data Transmission Airline ASAP Program Coordination with ASRS L. Connell 3/04 Digital Data Transmission Airline ASAP Program Coordination with ASRS L. Connell 3/04

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Digital Data Transfer L. Connell 3/04 Digital Data Transfer L. Connell 3/04

Digital Data Transfer Process L. Connell 3/04 Digital Data Transfer Process L. Connell 3/04

BIZTALK Software Translation BIZTALK Software Translation

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ASRS PRODUCTS & SERVICES FOR THE AVIATION COMMUNITY CD ROM L. Connell 3/04 ASRS PRODUCTS & SERVICES FOR THE AVIATION COMMUNITY CD ROM L. Connell 3/04

ALERT MESSAGE PYRAMID Alert Bulletins For Your Information Notices The majority of de-identified alerting ALERT MESSAGE PYRAMID Alert Bulletins For Your Information Notices The majority of de-identified alerting messages are discussed in telecons with FAA and other agencies. L. Connell 3/04

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PUBLICATIONS • CALLBACK is ASRS's award-winning monthly safety bulletin that began publication in 1979. PUBLICATIONS • CALLBACK is ASRS's award-winning monthly safety bulletin that began publication in 1979. It has an estimated readership of more than 150, 000. Over 260 issues have been published and distributed throughout the U. S. and to the international aviation community. All issues are available for download at the ASRS website. DIRECTLINE Is another award-winning ASRS publication. This safety journal has an estimated distribution / readership of 20, 000. Ten issues have been published since 1991 with a baseline of three to five articles per issue. All issues are available for download at the ASRS website. L. Connell 3/04

ASRS Home Page http: //asrs. arc. nasa. gov ASRS Database Access at FAA NASDAC ASRS Home Page http: //asrs. arc. nasa. gov ASRS Database Access at FAA NASDAC Site: http: //nasdac. faa. gov

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International Confidential Aviation Safety Systems ICASS L. Connell 3/04 International Confidential Aviation Safety Systems ICASS L. Connell 3/04

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Special Projects L. Connell 3/04 Special Projects L. Connell 3/04

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CROSS-INDUSTRY APPLICATION Patient Safety Reporting System (PSRS) L. Connell 3/04 CROSS-INDUSTRY APPLICATION Patient Safety Reporting System (PSRS) L. Connell 3/04

Medical Performance Factors Medical Performance Factors

VA Staff Invited to Participate VA Staff Invited to Participate

Total Report Intake Total Report Intake

CROSS-INDUSTRY APPLICATION Security Incident Reporting System (SIRS) L. Connell 3/04 CROSS-INDUSTRY APPLICATION Security Incident Reporting System (SIRS) L. Connell 3/04

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 • Shortly after September 11, 2001, the NASA Aviation Safety Reporting System (ASRS) • Shortly after September 11, 2001, the NASA Aviation Safety Reporting System (ASRS) began receiving reports from pilots, flight attendants, and mechanics on aviation security events. NASA ASRS, as the trusted “honest broker” to these communities, has received greater than 500 security reports. • The ASRS promptly established a communications link with the FAA Office of Civil Aviation Security to receive de-identified aviation security reports. With the transfer of Civil Aviation Security responsibilities to the newly established Transportation Security Administration (TSA), the ASRS established a new link for these security incidents after the transition. • NASA and the industry/FAA representatives to the ASRS recognized the need to establish an independent, separate reporting system that focused on the sensitive security information. The TSA workforce and other air transportation personnel who experience security incidents or concerns are expected to contribute. • NASA ASRS performed a review of the security reports and conducted a structured telephon interview to provide an early gap analysis concerning the security data. This work supported by CICT funds provides a strong basis for the continued development of SIRS. L. Connell 3/04

Security Incidents Location Airport Terminal Security Incidents Location Airport Terminal

Security Incidents Location Flight Phase Security Incidents Location Flight Phase

GOAL: Develop and create the ability to provide a national confidentia Security Incident Reporting GOAL: Develop and create the ability to provide a national confidentia Security Incident Reporting System that will serve as a data resource and early warning system for security stakeholders. OBJECTIVES: Provide a confidential, non-punitive reporting environment Gather information on security system events from TSA personnel, airport employees, airline employees, and other aviation system stakeholders Identify vulnerabilities that may not be discernable through other reporting avenues Alert decision makers to potential problems for appropriate follow up action L. Connell 3/04

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SIRS Prototype Development SIRS is expected to be initiated progressively. The ASRS model will SIRS Prototype Development SIRS is expected to be initiated progressively. The ASRS model will be evaluated and replicated as it applies to the environment of aviation security. ***** FY’ 03 -08 • Development of prototype system for event and close call incident reporting related to security • Validation of reporting methodology • Confirmation of utility of providing systems view • Proof-of-concept for the aviation security community L. Connell 3/04

The Model Can Provide - “The First Line of Defense” L. Connell 3/04 The Model Can Provide - “The First Line of Defense” L. Connell 3/04

Confidential Reporting Can Provide the “Big Picture” L. Connell 3/04 Confidential Reporting Can Provide the “Big Picture” L. Connell 3/04

Thank you for your interest and attention L. Connell 3/04 Thank you for your interest and attention L. Connell 3/04

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