Transcript No Slide Title

The Frontier of Emerging Technologies:
Failures, Fraud, and Financing
American Medical Informatics Association
5th AMIA Health Policy Meeting
Reston, VA
September 1, 2010
Linda Connell, ASRS Director
NASA Aviation Safety Reporting System
Human Systems Integration Division
NASA Ames Research Center
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Home of NASA ASRS
ASRS
Glenn Research Center
Ames Research
Center
Goddard Space
Flight Center
Dryden Flight
Research Center
Jet Propulsion
Laboratory
Langley Research Center
Marshall Space Flight Center
Johnson Space Center
Kennedy Space Center
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Moffett Field - Hangar One
1932
Aviation Tragedy Leads to
Genesis of ASRS
TWA 514, December 1, 1974
ASRS History
•
The ensuing investigation revealed that six weeks prior, a
United Airlines crew had experienced an identical ATC
misunderstanding and narrowly missed the same mountain.
•
At the time there was no method of sharing the United pilot’s
experience with TWA and other airline operators.
•
This gave birth to the idea of a national aviation reporting
program that would enable information sharing.
•
In April 1976,
NASA and FAA
implemented the
Aviation Safety
Reporting System
(ASRS)
NTSB Identification: DCA75AZ005
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ASRS Beneficiaries & Providers
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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
for use in any disciplinary or other adverse action.
(14CFR91.25 & Advisory Circular 00-46D)
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U.S. Aviation Statistics *
•
FAA Certificated Professionals
• Pilots
– Air Carrier
• Air Traffic Controllers
• Mechanics
–
•
Air Carrier
613,746
124,746
14,305
116,310
27,020
Airline
•
Flight Attendants
98,700
______________
•
*2008 US Dept of Labor Statistics
Potential Aviation Reporters
TOTAL(Est.)
•
850,000
Flight Volume
60,000 Flights/Day (Air Carrier, Cargo, Military)
27,178 Flights/Day (General Aviation)
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Monthly Report Intake
1981 – 2009
5,000
• Averaging 4,082
reports per
month, 189 per
working day
• Total Report
intake for 2009
was 48,986
• Anticipated 2010
Report Intake
exceeding 57,000
Smoothed / Forecast
Actual Intake
Series3
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
0
'81
'82 '83
'84 '85
'86 '87
'88 '89
'90 '91 '92
'93 '94
'95 '96
'97 '98
'99 '00 '01
'02 '03
'04 '05
'06 '07
9
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'08 '09
Report Intake 2001 - 2009
Reporter Groups
20% of all reports are matched to unique events
Decreases evident following September 11, 2001 are showing return to pre-9/11 levels
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System Recognition
for Effectiveness
Recent article praises system
• FAA credited for a positive, proactive approach to safety
Proof that government agencies don’t have to act
like big-footed oafs, the FAA (and NASA) has a
system that allows pilots and air traffic controllers
to report problems anonymously, It’s a “Let’s
learn, let’s fix it” sort of culture. The goal is to find
systemic problems and solve them rather than
assign blame. Most errors and mistakes are
caught early, and accidents are rare.
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THE HUMAN FACTOR
Human Performance
Contributions to Errors
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Simplified Event Chain
Operational
System
Human
Performance
Incidents
Detection &
Recovery
Accidents
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Proportion of Event Probabilities
Based on Heinrich Model
Fatal
Accidents
Accidents
Accidents
Precursors
Incidents
Incidents
Normal Operations
Normal Operational Data
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ASRS Purpose
ALERTS
PRODUCTS
Identify
Deficiencies and
Discrepancies
Provide Data
for Planning
and
Improvements
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Incident Reporting Model
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ASRS Products & Services
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ASRS Web Site

Launched
October 2007
• Over 10 million
sessions in 2008

File an ASRS
Report
• Electronic
• Print and Mail




http://asrs.arc.nasa.gov
Database Online
ASRS
Publications
Program
Information
Immunity
Policies
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ASRS Database Online
(DBOL)
•
System initiated
August 23, 2006
More online queries
completed than in
history of ASRS
•
New data export
capability
•
Excel
MS spreadsheet
• CSV
(comma separated value)
For all other
analysis and
database
programs
•
Full Narrative,
Synopsis
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Incident Reporting Model
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Data Exploration Tools
ASRS
Data Query
Data Mining
BRIO
QUORUM/Perilog
ASRS Database Query
Vivisimo
Data Visualization
Other
InSPIRE
Voquette
Starlight
Experimental Software
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ASRS Model Applied to
Aviation & Other Domains
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ASRS Model Applied to
International Aviation
National and International Reputation
ASRS Recognized Model for Proactive Contribution to
Safety & Risk Management Process
• Int’l Confidential Aviation Safety Systems (ICASS)
•
Includes 13 countries modeled after ASRS
• US
• UK
• Australia
• Canada
• Russia
• Taiwan
• France
• Korea
• Japan
• Brazil
• China
• Singapore
• Spain
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International Confidential
Aviation Safety Systems (ICASS)
United Kingdom
CHIRP (1982)
United States
ASRS (1976)
Canada
CASRP (1985)
SECURITAS (1995)
Russia
VASRP (1992)
Germany
EUCARE
France
REC (1999)
Spain
SNS (2007)
Japan
ASI-NET (1999)
South Korea
KAIRS (2000)
China
SCASS (2004)
Taiwan
TACARE (2000)
Singapore
SINCAIR (2004)
Brazil
RCSV (1997)
South Africa
SASCO
Australia
CAIRS (1988)
REPCON (2006)
New Zealand
ICARUS
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ASRS Model Applied to
Other Domains
•
•
•
Patient Safety Reporting System (PSRS)
•
Dept of Veterans Affairs requested that NASA develop a medical reporting
system modeled after the ASRS with external, independent, voluntary,
confidential, & non-punitive features
•
FAA and NASA were highlighted in the Institute of Medicine (IOM) report,
“To Err is Human” in 2000 which was launched nationwide concerning
patient safety efforts.
Confidential Close Call Reporting System (C3RS)
•
Railroad Safety Reporting System was modeled after ASRS
•
Under development at NASA ASRS through collaboration with Federal Rail
Administration and Volpe National Transportation System Center
Firefighters Near Miss Reporting System
•
•
Launched August, 2005 was modeled after ASRS
Development Task Force included FAA and NASA ASRS
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See It. Report It.
Make a Difference.
Confidential Reporting in the U.S Railroad Industry
Unique Aspects of ASRS
Confidential Reporting Model
System-Wide Perspective - capability to identify hazards identified
by aviation personnel and match reports from all segments of aviation
community
•
ASRS was catalyst for recent FAA focus on Teterboro Departures
System-Wide Alerting - both national and international capability to
provide ASRS Alert Messages to industry and government
Data Processing through Aviation Expert Analysts
• ASRS Office staff include Aviation Expert Analysts with a combined
total of 380 years of experience in aviation (air carrier pilots,
corporate pilots, general aviation pilots, air traffic control, and
maintenance)
•
Experts read and review 100% of reports and reliably code
information to databases
Comprehensive and Time Tested Coding Taxonomy
• Fixed Field Codes combined with Narrative Text yields qualitative
data for further secondary analysis techniques (Perilog, special
studies, focused analytic techniques, etc)
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Unique Aspects of ASRS
Confidential Reporting Model
Strong Immunity and Legal Provisions
• Federal Law specifically addressing ASRS (14 CFR 91.25)
• FAA Advisory Circular 00-46D
• ASRS Mandated by Congress in 1980’s
Information Sharing
• Database Search Requests, Database Publically Available, Topical
Studies, Structured Telephone Callback Studies, Collaborations
with Industry and Gov’t (FAA, NTSB, NASA, TSA, etc.)
• Largest source of airline ASAP data collected in central location
National and International Reputation
• ASRS Recognized Model for Proactive Contribution to Safety
Process
• ASRS Model Being Utilized by Other Domains for Safety
Improvements
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SUMMARY
WHY CONFIDENTIAL REPORTING WORKS
• When organizations want to learn more about the
occurrence of events, the best approach is simply
to ask those involved.
• People are generally willing to share their
knowledge if they are assured:
• Their identities will remain protected
• There is no disciplinary or legal consequences
• A properly constructed confidential, voluntary,
non-punitive reporting system can be used by any
person to safely share information
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SUMMARY
Confidential reporting systems
have the means to answer the
question why? –
why a system failed
why a human erred
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Contact Information:
Linda Connell, NASA ASRS Director
[email protected]
(408) 541-2827
Website:
http://asrs.arc.nasa.gov
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