Testimony of Linda J. Connell Director NASA Aviation Safety Reporting System Before the Subcommittee on Oversight and Investigations Committee on Veterans’ Affairs House of Representatives July 27, 2000
Mr. Chairman and Members of the Subcommittee, I am pleased to respond to your request for information on the Aviation Safety Reporting System (ASRS). The ASRS is a model for voluntary, confidential, non-punitive safety reporting that has been contributing to aviation safety since 1976. I would like to discuss some aspects of its applicability to the current efforts surrounding the improvement of healthcare within the Department of Veterans’ Affairs (VA), Veterans Health Administration (VHA) and the recent Interagency Agreement between the VA and NASA in May of this year. After the creation of the VHA Expert Advisory Panel on Patient Safety in 1998, NASA was asked to join this prestigious panel and present information on the ASRS. I was very pleased to participate and share the many proactive safety activities that the ASRS is able to perform for aviation. The ASRS is a highly successful and trusted program that has served the needs of the aviation community for 24 years. It is available to all participants in the National Aviation System who wish to report safety incidents and situations. The ASRS was established in 1976 under an agreement between the Federal Aviation Administration (FAA) and NASA. This cooperative safety program invites pilots, air traffic controllers, flight attendants, maintenance personnel, and others to voluntarily report to NASA any actual or potential hazard to safe aviation operations. The FAA‘s Office of System Safety provides most of the ASRS program’s funding. NASA Ames Research Center administers the program, assures confidentiality, receives all reports submitted to the program, and sets policies in conjunction with the FAA and a fifteen member industry Advisory Committee. The ASRS collects and responds to these voluntarily submitted incident reports, using this information to lessen the likelihood of aviation accidents. ASRS data are used to identify aviation system deficiencies for correction by appropriate authorities, support aviation system policy, contribute to planning and improvements, and strengthen the foundation of aviation human factors safety research. ASRS reporters are protected when they report to this system. NASA and the FAA offer those who use the ASRS program two important reporting guarantees: confidentiality and limited immunity. These guarantees, as expressed in Federal Aviation Regulation 14 CFR 91.25 and FAA Advisory Circular 00-46D, are offered because this type of safety information is unique, and its value can only be obtained as a result of the confidence and trust placed in the program by the reporters. A NASA preaddressed and postage-free form, NASA ARC 277A-D, is used by the aviation reporters to submit information. The reports sent to the ASRS are held in strict confidence. More than 470,000 reports have been submitted since the program’s beginning, without a single reporter’s identity being revealed. The ASRS removes all personal names and other potentially identifying information before entering reports into its database. Currently, the ASRS program is receiving approximately 36,000 reports annually. Reporters to ASRS are also guaranteed limited immunity by the FAA. This means that the FAA will not use, nor will NASA provide, information that has been filed with the ASRS in an enforcement action. Fines and penalties for unintentional violations of Federal Aviation Regulations will be waived, as long as violations are reported within 10 days. However, accidents and criminal activities are not protected from enforcement actions, and should not be submitted to the ASRS. In addition to the immunity provisions associated with the ASRS program, reporters often mention other equally important motivations for using the program. The reporters feel increased satisfaction in knowing that they are helping to improve the aviation system by giving safety information to the ASRS, significantly increasing understanding of the factors contributing to safety incidents. I would like to emphasize that the ASRS is a unique safety information system. No other such national reporting system, voluntary or mandatory, delivers the complete standard of confidentiality and anonymity provided by the ASRS program. An indication of the importance of confidentiality is provided by the fact that over 70% of the reports in the ASRS database contain statements revealing human error information. It is not unusual for reporters to discuss their own operational mistakes—mistakes they would never even mention to others (e.g., other Government Agencies or organizations), let alone explain the reasons why the incidents occurred. Confidential incident reporting provides an insight into events from the human perspective that can rarely be obtained through other methods. The successful longevity of the ASRS and its continuing trust and strength arise from several factors. First and foremost is the promise of confidentiality, which is further reinforced by the 24-year history of proven ability to protect the identity of a reporter. The next important factor is the program’s independence, both actual and perceived. NASA’s involvement, as the "honest broker" between the regulator and the reporter, has been a significant reason that the ASRS has been trusted and that the reports received are honest appraisals of the performance of the reporter and others in the aviation system. NASA is a research organization with no regulatory authority and, therefore, is perceived as a safe place to report sensitive, possibly self-incriminating, information. NASA’s distinct position, as an independent Government Agency with a strong influence on aviation safety policy and practice, has been invaluable in instilling trust in the ASRS. Another important factor is the creation of the ASRS Advisory Committee. This body has assisted the ASRS by providing substantial advocacy, guidance concerning ASRS policy, assurance to reporter communities of bona fide confidentiality, and support for improvements in safety as a result of incident reports. This Advisory Committee has been very crucial from the initial steps of the creation of the ASRS and throughout its history. The Advisory Committee attempts to represent all potential reporter communities, as well as other industry organizations and government. Currently, this group exists under the NASA Aero-Space Technology Advisory Committee as the ASRS Advisory Subcommittee. The Advisory Committee has substantially assisted the ASRS in providing another crucial factor important for its success. The importance of feedback to the reporter communities must not be underestimated. The ability of the ASRS program to convert the aviation community’s report input into constructive output is evidenced by the many products produced by the ASRS (see Attachments A & B and http://asrs.arc.nasa.gov ). The ASRS has released 2,500 alert messages concerning potential hazards and important occurrences. Approximately 42% of the alert addressee responses indicate that a follow-up action was taken as a result of the safety alert message. A monthly newsletter, CALLBACK, is distributed to over 88,000 recipients and captures and presents safety information from the incidents received by ASRS. The participation of ASRS at significant safety organizational meetings, conventions, and workshops continues to reinforce the participation by these communities. The reporters can see evidence that information provided is utilized for constructive changes to improve safety. As we begin to apply the aviation model to the VHA and its current quality improvements efforts, it is noteworthy that the ASRS model has already been widely accepted by other aviation systems around the world. There are currently seven countries that have begun operating voluntary, confidential incident reporting systems. In addition to the United States, participating nations include the United Kingdom, Australia, Canada, Russia, Taiwan, and Korea. These countries have preserved the concepts of voluntary and confidential reporting as key characteristics necessary to assure the filing of reports. Although most countries have provisions for "use immunity" (i.e., prohibition from use in enforcement action), none have "transactional immunity" (i.e., waiver of disciplinary action). All countries are, however, very aware of the necessity of confidentiality for the continuing viability of their systems. The vital role of confidentiality was graphically demonstrated when one nation’s system collapsed, due to a dramatic decrease in reporting after a reporter’s identity was revealed. In assuring protection of a reporter’s identity, methods for de-identification of reports are crucial. The ASRS employs aviation experts as its report analysts. These people are, in fact, retired aviation professionals, including pilots, air traffic controllers, flight attendants, and mechanics—all of whom have had lengthy careers in aviation. Analysts examine each report and maximize the pertinent safety information available within the report. The ASRS system (as opposed to one which has anonymous reporting) has the capability of contacting incident reporters and obtaining additional information, as well as discussing safety events with reporters. When these interactions occur, it is a matter of event reporters talking with individuals having comparable professional training and experience—pilots talking to pilots, controllers talking to controllers, etc. This collegiality produces an increase in the validity of the data. Analysts are able to find out the "why" of the event, not just a terse description. Consequently, the narrative section of the report record is quite complete in its description of the event, as well as the inclusion of key words and coding to facilitate subsequent retrieval from the electronic database. In addition to providing expertise and quality assurance, ASRS analysts are able to reliably remove information that might identify a reporter. The ASRS places its highest priority on this protection. The goal is to remove enough information to protect the reporter while at the same time preserving the safety message, in the actual words of the person reporting. This process of de-identification also relates to other topics of interest, such as the public release of information and legal discovery. The ASRS database includes only the information that has been determined to be most important. Due to limited resources, the ASRS performs a type of triage to determine which reports will be fully analyzed for inclusion in the database. Once these data are placed in the database, it is accessible to the public through the ASRS Search Request process, an internet site managed by the FAA (http://nasdac.faa.gov/safety_data), or through a private CD-ROM product available on the market. The ASRS has accomplished over 5,800 database searches for government agencies, students, research organizations, international organizations, aircraft manufacturers, etc. The FAA is the top requester of the ASRS information. Often, we are asked for information through the Freedom of Information Act (FOIA), but recourse to this statute is not needed, since NASA’s ASRS database is already openly available. As for legal issues, incidents reported to ASRS rarely involve negligence and liability, often inherent in more serious events, such as accidents. After being rapidly de-identified, a narrative may be augmented in various ways. For example, analysts may add additional clarifying language. Also, a report from one reporter (e.g., a Captain) will be paired with other reports (e.g., a First Officer) describing the same event. Through such procedures, the content of the original report may to a certain extent be altered. Accordingly, ASRS has been informed that such alteration renders a report "hearsay evidence," due to its lack of an identifiable source, and therefore of less interest in legal proceedings. In some cases, for example, database reports have actually been used to defend a pilot. Instead of using information against an individual, data may be used to illustrate a potential system flaw that may also have victimized a number of other persons. Therefore, when event reporters do choose to share their experience with the ASRS, they are not faced with the added threat of complicating their own, or their employers’, legal position. The de-identification process has been quite effective in driving out fear of incident reporting. It is important to note that the ASRS is not an investigative system. The information contained in reports is evaluated carefully by experts, but the confidentiality requirements of the system make it impossible to obtain third party verification. The information relating to the existence and character of a phenomenon is relayed to the appropriate organizations in a manner that permits and encourages them to investigate the safety issue further and seek a solution. Alternatively, they may implement interim procedures to accommodate the phenomenon until a solution can be identified and instituted. We firmly believe that the ASRS incident database is the most authoritative source of human performance information that exists in aviation today. This program is a paradigm that can be utilized in many other disciplines. The current NASA/ASRS effort to establish a new external reporting system with the VHA, entitled the Patient Safety Reporting System (PSRS), will be a challenge as well as an opportunity. The ASRS model will serve as a starting point for the proposed voluntary reporting system. However, the significant operational and structural differences between the health care environment and the field of aviation may present challenges for the PSRS system. It may well be necessary to develop VHA approaches that differ from those employed by the ASRS, but the salient characteristics of the ASRS will be captured so as to provide the maximal relevant information. The three-year agreement between the VA and NASA will explore how such differences impact the implementation of confidential and de-identified patient safety-related reporting within the VA health care system. This approach is intended to provide the most efficient path to discovering the benefits of voluntary, confidential reporting in health care settings. The VA and NASA are uniquely positioned to embrace this challenge. The opportunity for both NASA and the VA is to gain new insights into the nature of human performance in the complex and dynamic environment of medicine, exploring the best means of optimizing safety in patient care. Potential benefits have not only an immediate application to VA/VHA care of veterans but also long-term relevance to health care in general. Thank you for providing me with this opportunity to present information on the Aviation Safety Reporting System, outlining our accomplishments in the effort to bring about improvements in aviation safety. NASA will be pleased to provide any further information that you may request. Mr. Chairman, Members of the Subcommittee, this concludes my testimony. I will be happy to respond to your questions.
NASA/ASRS RESEARCH IMPACT: A PARTIAL LISTING
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