Aviation Safety Action Program (ASAP)

Review of ASAP across the industry

In response to requests by airlines to aid them in the management and analysis of their growing ASAP databases an assessment of ASAP programs was completed by the University Of Texas Human Factors Research Project (UTHFRP). This review demonstrated that the committees which are tasked with reviewing ASAP reports (commonly referred to as the Event Review Committee or ERC) are focusing on the development of intervention strategies for those events that are immediately recognized as significant. The list of problems identified and actions taken within individual programs was impressive but limited. Based on a more in depth review of several programs at major commercial airlines concern was raised about the ability of program managers and ERC members to identify longer-term trends that set the stage for future incidents and accidents. Participating ASAP airlines, despite their size and ability to lend resources to their programs, were found to focus primarily on addressing individual pilot errors and lacked the resources needed to complete further investigations. Specifically, our review demonstrated that airlines lacked the tools and knowledge to track and identify trends in ASAP reports over time or identify common factors contributing to the occurrence of events if these factors were not readily apparent. Communication between airlines regarding common identified contributing factors or intervention strategies was found to be coincidental and lacked systematic effort.

Development of a Pilot Reporting Form (Version 1)

During this review process we were, and continue to be, approached by several commercial airlines to aid them in managing, categorizing, and analyzing their growing ASAP databases. In response to these requests we have developed a web-based reporting form to be used by pilots to submit ASAP reports online. This form was designed using the Threat and Error Management Model (TEMM) and was based on findings derived from the Line Operation Safety Audit (LOSA) program database. The goal for developing this form was to test pilots ability to self-report factors contributing to the occurrence of an event using the TEMM categories. It was determined from the implementation of this preliminary form that pilots could reliably use the TEMM categories but required a more technically advanced presentation of the response choices depicted at each stage of the TEMM.

Our involvement with ASAP programs has consistently lead to two conclusions 1) although airlines are beginning to identify common problems, they do not appear to be facilitating the spread of solutions developed in a single program to other airlines and 2) a framework for analysis to identify common underlying problems contributing to disparate events, trend analysis of contributing factors and outcomes, and tracking of corrective actions and intervention strategies.

For further information regarding this program, please contact Michelle Harper, The MITRE Corporation, mharper@mitre.org