URGENT: Information please! Aviation Safety Reporting System

From:         Pete Mellor <pm@csr.city.ac.uk>
Date:         06 Aug 93 02:53:45 PDT
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                        INFORMATION REQUIRED ON ASRS

In his book "Normal Accidents", Charles Perrow refers to an autonomous, 
no-penalty, Air Safety Reporting System managed by the National Transportation 
Safety Board (NTSB) in the US. He cites the existence of this database, and 
its use for early detection of design problems. 

According to John J. Nance, "Blind Trust" (Quill William Morrow, New York, 
1986), p.275, the *Aviation* Safety Reporting System was set up by NASA on 
behalf of the FAA in 1975. The FAA guaranteed immunity to any pilot 
who filed a report on the ASRS, but NASA could manage the system independently 
and additionally guarantee anonymity. Around 1978 the immunity provisions were 
substantially restricted, as a result of a campaign for "pilot accountability" 
by Administrator Langhorne Bond. Nance believes that it is precisely the 
*lack of* an "autonomous, no-penalty" reporting system that is responsible 
for the lack of safety information in the US, as compared to the UK, where 
the CHIRP system is available. He specifically cites the fact that, although 
the tendency of the Boeing 737 to "pitch up/roll off" when taking off under 
icing conditions was well known since 1971, and was responsible for the crash 
of Palm 90 into the Potomac on 13th January 1982, in the intervening 10 years 
not one report of "pitch up/roll off" was filed by US pilots, although many 
such incidents were reported from Europe. He speculates that the incidents 
did occur, but went unreported since a report could result in the pilot 
being disciplined for taking off with the aircraft in an unsafe condition. 

Are these two authors talking about the same system? 

If so, which one of them is right? 

Any other information on ASRS or CHIRP, particularly with authoritative 
references, would be more than welcome. 

This is not asked out of idle curiosity. The SHIP project is producing a 
report which discusses the use of reporting systems for incidents in avionics 
and industrial control systems, and we have unearthed these contradictory 
statements. Obviously, we want to get our facts right, and we only have today 
(and possibly the weekend) to churn out the final draft, hence the urgency. 

Many thanks. Please reply direct to me (even if you also post to the list). 

Peter Mellor, Centre for Software Reliability, City University, Northampton 
Sq., London EC1V 0HB, Tel: +44(0)71-477-8422, JANET: p.mellor@csr.city.ac.uk