Pilots, maintenance technicians, and most other aviation workers are fully aware that the safety of aviation operations depends on their day-today efforts. But doing the right thing that will keep you, your colleagues, and your customers safe—minute-by minute, throughout each day—isn’t always easy. Human beings make mistakes; we forget; we interpret a supervisor’s direction differently than it was intended.
When operators aren’t aware of those mistakes or deviations, they lose the opportunity to correct them or address the underlying conditions that could contribute to future accidents or incidents. But what if pilots and others could actually report safety-related events or violations without fear of being penalized by the FAA or terminated by their employer? That is possible through the Aviation Safety Action Program (ASAP), facilitated by the Air Charter Safety Foundation in partnership with the FAA.
Since 2012, the ACSF has managed more than half of all ASAP participating companies for the business and general aviation industry.
Under ASAP, aviation employees throughout the company—from maintenance to the flight deck—can submit voluntary reports of safety-related occurrences without fear of losing their job—and without fear of being reprimanded by the FAA and losing their certificate, as long as certain conditions are met. See sidebar for details.
ACSF works alongside aircraft operators and the FAA to receive, review, and respond to ASAP reports. “Having a neutral third party in the discussion helps to develop consensus,” notes the safety manager for an East Coast–based sports organization.
ASAP Brings Big Benefits
ASAP is just one tool used in a robust safety management system (SMS) to improve both an organization’s just culture and reporting culture. We don’t know what we don’t know, which is why the employee hazard reports submitted through ASAP are so powerful. Sharing hazards and other safety issues can prevent others from making the same errors. ASAP’s nonpunitive, solution-oriented focus on safety also supports an organization’s just culture.
The program has posted impressive results so far. As ACSF president, I can attest to the fact that more than 90 percent of our 7,000 ASAP safety reports have been “sole source.” This means more than 6,300 of those safety events may never have been disclosed if it weren’t for ASAP. This level of active participation validates the entire ASAP program.
Beyond the ability to improve safety, ASAP’s solution-oriented approach positively impacts operational efficiencies and policies. For example, after a large regional air ambulance provider reported the inability to reach air traffic control (ATC) in remote areas, its safety manager said, “If someone in the back has a life-threatening medical emergency and we can’t get clearance to get off the ground, that’s a problem.”
The organization developed operational procedures to remedy the issue. As part of their corrective action solution, that company now has a dedicated phone number to obtain departure clearances. Because ASAP reports are shared, that company’s findings will help other operators in this area as well.
The air ambulance company has also uncovered safety-related maintenance issues through ASAP reports. Its safety manager explains, “We identified shortcomings with OEM maintenance manuals, which were updated. And we also drafted content for the AIM [Aeronautical Information Manual, published by the FAA].” ASAP reporting helped to improve the level of safety within the air ambulance company and among different certificate holders and OEMs and led to the FAA adjusting its policies.
ASAP Findings Improve Training
A just culture recognizes that most safety events are caused by honest mistakes, which are often caused by gaps in policies, procedures, or training. Operators have used ASAP information to revise their flight operations and maintenance manuals and close training gaps.
Making such ongoing improvements to company policies and procedures is an important part of an organization’s just culture. “When a pilot isn’t terminated in these instances, we can offer remedial training and take corrective actions to help ensure that these events don’t happen again,” says the air ambulance safety manager.
Participants are encouraged to regularly incorporate information from ASAP reports into their monthly safety newsletters or discussions at team meetings. They may hold training for teams or provide one-on-one corrective training.
Is it Really Nonpunitive?
Over time, as we’ve discovered, one of the biggest reasons why all operators haven’t signed up for the ASAP is that some believe it isn’t truly nonpunitive.
But that belief is quickly discouraged in the wake of these reported events and their positive outcomes. “As a safety manager, my job is not to find blame, it’s to find cause,” said the sports organization’s safety manager. “The benefit of having an ASAP is in the results—of gaining that knowledge of the unintentional error or safety threat. It’s gratifying that we can capture the data and find solutions that oftentimes can prove to be lifesaving.”
While some companies already maintain a safety management system (SMS) with a nonpunitive clause, ASAP provides additional reassurance.
“ASAP was an easy sell to my boss,” says the safety manager for a Part 91 operator. “Our SMS policy has a statement about no retribution, so if a pilot makes an honest error or mistake, the FAA and company cannot take punitive action. And since the ASAP memorandum of understanding is signed by three entities [the employer, the FAA, and the ACSF], it’s a formal promise that adds strength and trust in the program.”
Sharing Data Benefits the Industry
Another key benefit of ASAP is that program participants have access to program findings to help other aircraft operators improve their safety policies and procedures. For example, through ASAP, the air ambulance company identified what to do when an operator has four helicopters arriving in a landing zone and ATC is unavailable. The operator’s corrective action was to work with the FAA and a local ATC to develop a procedure for the first aircraft landing on scene, the second, and so on. These procedures are now available to other operators in that area.
Sharing safety data has big benefits for ASAP participants, enabling them to use lessons learned by others to improve operational efficiencies and even save lives. This is even true of OEMs.
“It doesn’t cost us one extra cent to learn from another’s safety event, and we don’t pay the operators’ costs of experiencing it,” notes the sports organization safety manager.
“We think that ASAP is an invaluable program if it’s understood and managed correctly,” says the operations director of an air-tour operator. “This program is not for people who like to fly under the radar. If you really want to create a just culture and culture of compliance and risk management, ASAP opens up and mitigates those pockets of resistance.”
ASAP in Action: A Case Study
The following actual case study provided by a tour operator shows why ASAP provides value for both the aviation employee and his or her organization.
The Reported Incident: On one air-tour flight, a chip light flickers. Standard policy requires landing the helicopter as soon as possible. The light continues to flicker and then turns solid. By this time, the pilot is 10 minutes from base. He turns around and heads back to the base, choosing not to land anywhere closer, despite many available options.
The light turns out to be faulty and not a serious issue. But positive outcome aside, there are still questions about the pilot’s decision to fly for 10 minutes with the chip light on.
The director of operations reviews the company’s just culture policy, and he considers the pilot’s decision to be reckless. That is, until the pilot explains that decision.
The ASAP Investigation: The pilot tells the ASAP Event Review Committee (ERC) that he previously had flown in Alaska with a chip light on and wasn’t able to set down, so he is comfortable flying with it illuminated. Also, the pilot relates that the tour company had previously told him ‘If you’re going to land, make sure you land somewhere that it doesn’t end in the news.” With further investigation by the ERC, what looked like reckless behavior turned into a company procedural issue.
The Outcome: As a result of the ASAP investigation, that tour operator has embraced more conservative aeronautical decision-making and changed its communication and training protocols. There’s no longer a “go, no matter what” attitude. “Now, we tell them that you can take off and turn around,” the operator notes. “And you can cancel the flight; we’ll applaud that decision. The ASAP has gotten us closer to the mindset that we don’t need ‘macho’ in any way.”
The ASAP process helped the operator to focus on deeper issues than the actions of one pilot. “This ASAP reporting helped us really look at what sort of attitudes are in the pilots’ minds when we train them. And we have to pay attention to what we say during training,” he says. “When the pilots are in the air, we want them to only make aeronautical decisions. We encourage them to have a far more conservative mindset when flying tours.”
Is ASAP Worth It?
The last word in this is best summed up by those who have used ASAP. “It’s an extremely beneficial program, and anyone who’s not using ASAP is doing themselves a significant disservice,” notes the Part 91 operator.
“ASAP more than pays for itself,” says the tourism operator. “And it’s brought items to our attention that might otherwise have fallen through the cracks.”
New to Safety? Start Here
For those operators who’ve yet to implement a safety management system (SMS), the ASCF is here to help by providing education, mentorship, resources and tools. Our teams will take operators through the process of how to set up a SMS and get started with the ACSF’s Aviation Safety Action Program. As an added bonus, ACSF members who participate in the ASAP will get free access to the actively managed web-based ACSF SMS Tool, which helps teams manage all aspects of safety. The ACSF SMS Tool will, among other things, allow flight departments to document aviation safety data, perform risk assessments and assign corrective actions. The platform also serves as an internal reporting program and offers multiple reporting options for each safety event. Users can voluntarily submit reports for an ASAP Event Review Committee meeting and export reports to the FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) system. For more information, visit acsf.aero/ acsf-sms-tool.
By Bryan Burns
How to Join ASAP
Register. ACSF members can register at acsf.aero/asap-program. Note: An annual fee is required based on the fleet size and number of participants enrolled in the program.
Sign MOU. ACSF will organize the co-signing of a memorandum of understanding (MOU) between all three parties—your operation, your local FAA flight standards district office (FSDO), and the ACSF. Once the MOU is finalized, ACSF will work with you to begin your program participation.
Enroll in e-Learning. Your ASAP representative will be able to enroll all participating company members in the online training, which explains more about the program rules and how to submit a report.
ASAP Is. An Aviation Safety Action Program (ASAP) fosters a voluntary, cooperative, nonpunitive environment for the self-reporting of any events or concerns that could affect the safety of a flight. Flight department employees (pilots, aviation mechanics/engineers, dispatchers, schedulers, etc.) use ASAP to self-identify and report significant safety concerns and issues.
Types of Reportable Events. Reportable events may include (but are not limited to) operational deficiencies, noncompliance with regulations, or deviations from company policies and procedures. Examples include flying an unstable approach, airspace violations, altitude or route deviations, logbook errors, and OEM aircraft design/configuration issues.
Events Not Accepted by ASAP. The FAA takes no action against an employee who submits a report that is accepted as being appropriate for the ASAP process. However, not all events reported to ASAP are protected from punitive action.
An employee’s report may be dismissed from the ASAP if his or her actions demonstrate an intentional disregard for company safety policies or the federal aviation regulations, or if he or she is involved in criminal activity, substance abuse, or the intentional falsification of information. When an employee’s report is dismissed from the ASAP, the events contained in that report may be evaluated by the employer or the FAA for further disciplinary action.
ASAP Resolution Process. Each ASAP report is investigated by an organization’s event review committee (ERC), which typically meets every two to three months or as needed. An ERC consists of three members: a management representative from the operator, an employee representative (pilot, mechanic, dispatcher, as appropriate), and a qualified FAA inspector from the appropriate flight standards district office. A representative from the Air Charter Safety Foundation (ACSF) is also present as a neutral third-party ASAP facilitator.
Committee members work together to review, analyze, and resolve the reported safety event. Using consensus and a non-disciplinary approach, the committee determines corrective actions that address all causal factors related to the event, including training gaps or ambiguities in company policies.
After the ERC determines to its satisfaction that all corrective actions have been properly completed, the ERC notifies the submitter that the report is closed.
ASAP Benefits: Employees of a participating ASAP organization have access to a nonpunitive reporting system that encourages them to submit safety events that might otherwise never be reported. Participating companies can take advantage of a structured, collaborative process to resolve those events and address all causal factors, while strengthening their just culture. De-identified information from ASAP reports is also available to other organizations participating in the ACSF ASAP, and those companies are encouraged to use that data, including all corrective actions taken, to inform their training programs and develop mitigation strategies for their operations. In addition, ACSF publishes a quarterly ASAP newsletter.