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 and their effectiveness are needed but currently underdeveloped.

Future Directions

Based on our review of the current state of ASAP programs in the industry, we have identified three areas in which we can support ASAP carriers; 1) Development of a standardized web based system for collection and categorization of voluntarily reported ASAP safety information with a structured focus on the identification of contributing factors, 2) Development of a set of web based tools to aid in the systematic use of this information to develop and track corrective action and interventions strategies, and 3) Establishment of a third party infrastructure to continually monitor, analyze and report on system-level and high risk safety contributing factors and intervention strategies to both individual airlines and the FAA. We propose that the first of these objectives can be achieved by providing pilots with an efficient means to complete detailed, standardized reports of ASAP events. The second objective can be achieved through the development of a set of tools to aid ASAP managers in utilizing the reported information to create corrective actions and intervention strategies that will prevent the event from re-occurring. And in support of the third objective, confidential third-party assistance is needed to identify problems common among individual airlines and facilitate the spread of solutions developed under a single program to other airlines.

It is our long-term objective to develop a set of data collection tools to support analysis of ASAP data across the industry and to provide a third party infrastructure to continually monitor, analyze and report on system-level and high risk contributing factors to both individual airlines and the FAA. We believe that such a program could increase the safety of the National Airspace System by aiding airlines in accomplishing the systematic collection, analysis and reporting of previously unattainable safety information, and through a trusted third party, promote the spread of proactive solutions throughout the industry. Currently we are seeking additional funding from the FAA to further the development of these objectives.

For further information regarding this program contact Michelle Harper at (512) 475-7980 or mlharper@mail.utexas.edu.