Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN.

Contributor - Safety

Stuart “Kipp” Lau

Safety reporting in aviation has a long history. In the U.S., the concept of voluntary safety reports dates to the 1970s with the rollout of NASA’s Aviation Safety Reporting System (ASRS). Today, with the adoption of a modern safety management systems (SMS) and other voluntary aviation safety programs, there are more opportunities for pilots and other employees to report safety hazards.
“NASA ASRS is a voluntary, confidential, non-punitive reporting system that receives safety reports from pilots, air traffic controllers, cabin crew, ground operations, dispatch, and maintenance,” said&nbsp;NASA ASRS director Becky Hooey. The growth of the system has been impressive. According to Hooey, “NASA ASRS has received over 1.8 million safety reports since its inception in 1976.&nbsp;Compared to the first year when ASRS received about 100 reports, ASRS report intake has grown approximately one-thousand-fold, with an all-time high of 108,000 annual reports submitted in 2019.” Today, roughly 20 percent of all NASA ASRS reports are submitted by general aviation pilots.
Over the past two decades, many business aviation operators in the U.S. have voluntarily implemented SMS&nbsp;and Aviation Safety Action Programs (ASAP) to collect safety-critical information from pilots; often those reports are input into NASA ASRS. In addition, there are now more than 20 corporate/business operators participating in the FAA's Aviation Safety Information Analysis and Sharing (ASIAS), which aggregates safety data from sources such as ATC radar plots, flight data, and ASAP to improve the National Airspace System.
Gathering information from frontline employees, analyzing that data, and sharing those results are foundational for a modern proactive aviation safety program. A healthy SMS largely relies on hazard reporting and other data sources to reduce operational risk. Safety reporting metrics are a strong indicator of an effective SMS; a high number of reports is indicative of a good reporting culture. A better measurement of an effective SMS is how those organizations promote safety by sharing safety report information both internally and externally with other operators.
<h2>Varied Pulses</h2>
To get a pulse on the health of safety reporting in business aviation, AIN surveyed several safety practitioners involved in business aviation. These included&nbsp;NASA ASRS, Air Charter Safety Foundation (ACSF), and two SMS implementation and training specialists—Baldwin Aviation and Wyvern.
The general sentiment on safety reporting in business aviation was mixed. According to ACSF president Bryan Burns, “The reporting culture in business aviation overall is strong.” An example of this strength is the amount of participation in ACSF's organization-based ASAP. Burns adds, “With over 200 members participating in ASAP, we would expect to see differences in reporting cultures, with some operators being more active than others.&nbsp;We always like to see more reporting, but we feel that our members have embraced the open reporting culture that improves safety in their operation.”<img alt="Don Baldwin, Andrew Day, Bryan Burns" data-entity-type="file" data-entity-uuid="da4c0e01-4b47-4f41-9f96-61252f86e2a6" src="/sites/default/files/headshots2.jpg" width="1800" height="901" loading="lazy">
Other organizations, such as safety risk management and training provider Wyvern, have observed a recent uptick in safety reporting. “Generally, we see the overall health of charter and bizav reporting culture as healthy and improving," said Wyvern COO Andrew Day. "With the additional challenges that Covid-19 has brought over the last 24 months, this factor seems to have led to a much higher use of the hazard reporting system, spawning more widespread (non-Covid) use of the hazrep (a Wyvern hazard report) system by crewmembers.&nbsp;Meaningful hazreps are on the rise across the industry, which is indicative of an improving reporting culture.”
Noting a difference in the reporting and sharing of safety information between airline and business aviation operators, Baldwin Aviation president Don Baldwin said,&nbsp;“Airlines have been very successful with reporting and sharing through ASIAS. Business aviation is a bit different in that many are quite hesitant to share their information but love to see [reports from] others.” Baldwin Aviation has identified other challenges, he added.&nbsp;“If they do share, business aviation operators typically have to overcome internal barriers with their legal departments.&nbsp;Many are reluctant to allow their aviation departments to participate due to liability and the nature of safety information.”&nbsp;
<h2>Recent Events</h2>
Over the past 24 months, major challenges affected the business aviation community. Two of the most prominent issues have been the global Covid-19 pandemic and the telecom industry’s rollout of new 5G networks. An additional safety issue—circle-to-land operations—has emerged as a threat to flight safety with two fatal accidents within the past 12 months.
The Covid-19 pandemic not only impacted our personal lives but also disrupted many aviation operations. According to NASA’s Hooey, “ASRS received over 2,000 Covid-related reports from all aspects of aviation operations including&nbsp;pilots, air traffic controllers, cabin crew, ground operations, dispatchers, and maintenance technicians.” Pilot proficiency, ATC procedures, and staffing levels were common issues related to the pandemic.
Likewise, Wyvern noted a significant increase in hazard reporting during the pandemic. According to senior director of risk management and flight leader program manager Alec Blume, “During the past 24 months, there has been a significant uptick in hazard reporting activity related to Covid-19, with these submissions being the driver of a 60 percent increase in hazard reporting activity within the Wyvern&nbsp;client base.&nbsp;Of note, many organizations undertook management-of-change [MOC]&nbsp;exercises related to external Covid-19 concerns, with several more mature organizations running MOC on internal countermeasures within their operation.”
“Anecdotally, we have seen reports on events that may indicate issues related to staffing," said ACSF's Burns, "recency of flights resulting in 'rusty'&nbsp;skills, and increased workloads as the public has sought alternatives to flying the major airlines. In some sense, the impacts of the pandemic are starting to fade as increased flying has brought the proficiency of the industry back to near pre-pandemic levels.”&nbsp;
More recently, there has been a lot of fanfare and confusion surrounding the rollout of Verizon’s and AT&amp;T’s new 5G networks and their potential impact on aviation safety. Ironically, there have been few 5G reports, according to the ACSF and Baldwin Aviation. “There has been some recent hazrep activity related to the C-band 5G rollout," said Wyvern's Blume, "most related to the frequent notam&nbsp;changes. All 5G hazreps have occurred within the U.S., with zero 5G hazreps from clients outside the U.S.”
<h2>Emerging Threats</h2>
In July 2021, a Bombardier Challenger 605 crashed near the Truckee-Tahoe Airport (KTRK) in Truckee, California. Both pilots and four passengers were killed in the crash following an attempt to “circle to land” from an instrument approach.
Five months later, in December 2021, a Learjet 35A crash killed all four occupants near Gillespie Field (KSEE) in El Cajon, California; the pilots of this aircraft were attempting to fly a visual approach requiring a turning&nbsp;maneuver at night in low visibility conditions. The official circle-to-land approach was not authorized at night, and the pilots canceled their IFR clearance before attempting the visual approach. 
<figure style="margin:0;">
<div style="margin-bottom:5px;"><img alt data-entity-type="file" data-entity-uuid="d9036873-c658-4455-97f0-5ea5a14259bc" src="/sites/default/files/nbaa2013_mw_0033.jpg" width="2100" height="1050" loading="lazy"></div>
<figcaption style="font-size:1.5rem;line-height:1.2;font-style:italic;">Photo: Barry Ambrose</figcaption>
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Each accident is classified by the NTSB as an “active” investigation. While the final reports of each crash will not be issued for months, circle-to-land maneuvers are now a hot topic in the business aviation community. Much of the conversation focuses not only on the nuances of the maneuver but also, according to some reports, focus on how the circle-to-land maneuver&nbsp;is trained and the limitations of flight simulators.
“As a result of recent circling approach-related accidents [Truckee, Gillespie], many operators have collaborated through Wyvern&nbsp;to inquire what others are doing to mitigate risk related to this high-risk but infrequently performed maneuver," said Day. "Some sharing of specific crew-training scenarios&nbsp;designed to enhance crew proficiency have been implemented, as well as a review of internal flight risk analysis tool [FRAT]&nbsp;modifications to incorporate an identification and control of risk related to airports/approaches that are determined to pose a higher-than-normal risk.”
<h2>Sharing Information</h2>
In aviation, there is a lot to be learned from sharing information between operators. This is especially important for smaller operators with a lower number of flight cycles, such as a corporate flight department or charter operator.
NASA ASRS is a great source of information. According to NASA’s Hooey, “One of the unique features of the NASA ASRS is the ability to broadly share safety reports within the aviation community. Reports that are submitted to the NASA ASRS are first de-identified to protect the reporter’s identity and then these de-identified reports are shared in a number of ways including the ASRS Safety Alert Bulletin and For Your Information Notices. These are distributed to the FAA, equipment manufacturers, ASAP managers, and groups like the NBAA to share with their membership.
“In 2021, NASA ASRS issued 215 Safety Alert Bulletins/For Your Information Notices including topics such as airport lighting and signage issues, aircraft and equipment malfunctions, navigation and charting confusions, avionics anomalies, and more,” Hooey said. “In the past 10 years, over 180 of the Safety Alert Bulletins/For Your Information Notices that NASA has published were based on reports submitted by the business aviation community.” In addition, NASA publishes “Callback,” its popular monthly newsletter that is presented in a lessons-learned&nbsp;format.
The NASA ASRS database can be searched by the public. “NASA ASRS enters all of the fully de-identified reports into a publicly available database where operators can search for topics of interest,” Hooey added. “For example, one could search for reports on a specific aircraft make/model, hazards experienced at a particular airport, or factors that contribute to incidents such as fatigue, poor crew resource management, and loss of situational awareness.”
In addition to NASA ASRS, Don Baldwin said, “There are several options, ASRS being most popular and then ASIAS. Several regional associations have started their own sharing programs that member companies can participate in. In the Part 91 world there are a few regional safety groups that meet regularly to share safety information.”
Operators that participate in FAA-approved ASAP and flight operational quality assurance (FOQA) programs can participate in ASIAS and biannual FAA InfoShare meetings. According to ACSF’s Burns, “The InfoShare meetings are a great venue to learn from the experiences of other operators. The pandemic has impacted the ability to participate in these in-person events, but hopefully we will be able to return to those in-person events more consistently in the future.” Burns added that there are a number of other worthwhile events.&nbsp;“For all operators, there are many different regional and national events to discuss safety. The ACSF Safety Symposium, Business Aviation Safety Roundtable, Bombardier Safety Standdown, Flight Safety Foundation Business Aviation Safety Summit, and NBAA Safety National Safety Forum are but a few of the excellent opportunities to talk shop with the leading safety minds in our industry.”
Beyond those more formal events, some SMS service providers share aggregated information amongst their userbase. “The Wyvern&nbsp;Wingman and Flight Leader programs provide a healthy environment to facilitate the cross-pollination of aggregated hazard information," Blume said, "as well as industry best practices from individual operator experiences. This meaningful transfer&nbsp;of knowledge seems to be on the rise across the industry.”
From a 35,000-foot view, most safety practitioners are satisfied with the level of reporting in business aviation, but by nature, these individuals have a chronic unease. As Wyvern’s Day said, “Overall, the state of hazard reporting in charter and bizav is reasonable, but like all things relative to SMS, can be improved upon. One area that seems to have had a positive impact on increasing hazard reporting is the more frequent use of postflight debrief tools.&nbsp;These tools have helped to drive crews into the hazard reporting system, which helps to break down the 'workload'&nbsp;barrier.”
“As we all know, there is always room for improvement when it comes to safety," concluded ACSF's Burns. "One of the main areas we can improve as an industry is in the voluntary adoption of safety management systems, and the ASAP and FDM programs to feed data into those SMSs. As an industry, we need to continue our efforts to educate, encourage, and support operations without SMSs&nbsp;to embrace the value of these programs.”

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