How Safe Is Our Health Care System?

Safety Models

Linda Connell discussed NASA's Aviation Safety Reporting System (ASRS) for gathering qualitative data on aviation system problems and issues. Reporting is voluntary, is made from a broad population of system users, and covers the full spectrum of safety concerns. The ASRS is the first line of defense by reporting safety incidents that can serve as early warning of potential accidents by others. Since 1988, an average of 2,850 reports have been received per month. ASRS can target specific populations for special study, such as pilots, maintenance personnel, cabin crew, and ramp and gate operators.

The ASRS database includes incident reports, alert messages, findings from research studies, monthly safety newsletters, and quarterly safety bulletins. Alert Bulletins are issued whenever there is a high likelihood of repeat problems. Studies show that 40 percent of users took action in response to an alert bulletin. For Your Information Notices may describe problems where not all details are known but the topic may be of interest to aviation stakeholders.

The ASRS provides a narrative description of an incident reporter's firsthand view of an incident. These realistic descriptions of human performance enhances human factor research in diverse areas.

Benjamin Berman described the mandatory reporting system in commercial aviation. In 1926, The Air Commerce Act charged the Department of Commerce with investigating the cause of aircraft accidents. This legislation was amended in 1934 to require that reports on probable causes of fatal aircraft crashes be made public and banned the use of such reports and related evidence in court proceedings.

The National Transportation Safety Board (NTSB) was created in 1967 within the Department of Transportation (DOT). NTSB's authority was expanded to include all modes of transportation. The NTSB was made completely independent of DOT in 1974 to permit vigorous investigations of accidents involving transportation modes regulated by other agencies of government. The NTSB reports directly to Congress and has no regulatory authority.

The statutory authority of the NTSB requires it to investigate each accident involving a U.S. aircraft other than an aircraft operated by the armed forces or by an intelligence agency of the United States. This authority allows them to access, secure, and retrieve wreckage and obtain information through records and interviews. Operators of an aircraft must notify the nearest NTSB field office immediately when an aircraft accident or other incidents, as defined in rules, occur. Upon investigation, the NSTB identifies "probable cause" and "contributing factors" as well as proximate and latent factors. Rulings on pure pilot error have not been made in many years; findings instead reflect multiple contributing factors.

Voluntary reporting systems also function in the aviation industry through the air carrier and the ASRS.

The following lessons have been learned from the NTSB reporting system regarding human error:

• Errors are ubiquitous on the flight deck.
• Captain-flying is a characteristic of major air carrier accidents but not necessarily incidents.
• There is a need to focus on mitigating the consequences of errors when they do occur.
• There is a need for improvement of error trapping.

Both the voluntary and mandatory systems described above were found to be necessary and worked well together. For example, co-pilots are less likely to directly criticize the pilot and benefit from a voluntary reporting system that focuses on error avoidance and not blame.

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