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Larry, as I do not know what your level of familiarity with ASRS is,
the responses here are for benefit of readership and assume a basic
awareness that a program exists...

On Jun 17, 11:49 am, Larry Dighera wrote:

Are you saying that you were the one who prompted the use of "Web Beacons" by ASRS?
KBL: Nope. That seems to be an area you are familiar with. I'd
recommend contacting the folks at ASRS if you think there will be
problems with perception. I know they would value your input.

Or are you referring to other "improvements?" If so, what might they be?
KBL: Electronic report submission, searchable online database and
availability of electronic Callback. But as you have brought up, those
may not be "improvements" in the eye of every beholder. Maybe the Feds
having name address SSN and medical data was enough?


Why does ASRS find it necessary to pay to track the CallBack readership's activities?
KBL: Pleas call Chuck Drew and ask him. Or the FAA, it is their
program.


KBL: Just a solid 30 year old program that gathers information on
events to improve safety of the National Airspace System.

I'm aware of that. That's not an issue I raised.
KBL: You're correct. Sorry about that. I misinterpreted the tone of
your post and level of ASRS program awareness.

KBL: Only 35 percent of the reports deal with non-conformance to FARs
and most of those the FAA would never have been aware of.

What do the other 65% deal with? Non-conformance with FAOs? NMACs? Company policies? Military regulations?
KBL: The other reports deal with hazards that have been identified,
human and material factors that would not otherwise be reported to
regulators and manufacturers. Lessons learned that one might want to
share with their fellow airmen. Otherwise known as "There I Was"
stories. Not everything has to be an accident, incident or deviation
from FARs to be of interest to the safety community. In fact, as you
know, it is most likely a confluence of multiple latent factors that
leads up to a mishap, an active failure of the system. The more of
these factors we can identify and mitigate, the better the performance
of the system.

KBL: I talk with the folks there and there is nothing higher on their
list of priorities than protecting the identity of reporters.
If their priorities were any other way, they'd soon be out of work
for lack of participants.
KBL: Pretty much how it went the first year of ASRS when the FAA was
running it. NASA took over and they had more reports in the first few
months than the entire previous year.

KBL: It is too bad that we live in a blame society, because there is a
lot of information we will never know about because of that blame
culture and the litigious nature of our society.
It's just an inherent aspect of the system. There are a lot of things in life that are unfortunate due to mutually exclusive compromises. If you remove the right to litigate, you may learn some information, but justice will not be served.

KBL: Justice may make us feel better about the system and feeds
lawyer's families, but in many cases it does nothing to address the
small failures. Blame someone and move on. I am thinking of good
people doing work in demanding situations where active deficiencies in
the system develop into failures. Did we fix anything so that the next
crew does not discover the same hazards with more disastrous
circumstances? Having done this for 30 years I have seen many a good
investigation derailed once a "probable cause" is identified and we
have someone to wear the blame banner.
I believe Thomas Kuhn's "Structure of Scientific Revolution" does a
good job of explaining why we act the way we do, assigning blame and
quantifying safety to reassure ourselves. I personally believe that
there must be a balance between quantity and quality, art and science,
production and protection when you are operating a system, managing
quality, improving performance and investigating failures. If we do
not move "beyond probable cause" we will not have a shot at further
reducing the current mishap rate. It will take imagination and change
from current blame game to accomplish this. If we do not, and the rate
stays where it currently is, we will see more mishaps as international
air travel numbers increase.
For those interested in the future of safety systems, I recommend "The
Limits of Expertise: Rethinking Pilot Error and the Causes of Airline
Accidents" by DIsmukes, Berman and Loukopolos
http://www.amazon.com/Limits-Experti.../dp/0754649652
and also recent books by Sidney Dekker "Ten Questions About Human
Error: A New View of Human Factors and System Safety"
James Reason is another good resource.

ICAO is mandating Safety Management Systems for member state airlines
by 2009. In order for SMS to succeed, you have to have employee
participation. That requires a "trust" culture and sharing of
information in order to identify hazards and improve the system. If
information is shared solely for the benefit of the lawyers, the
quantity and quality of the information will be thin and value of SMS
will be marginalized.


I suggest they lose the "Web Beacons" unless there is some redeeming benefit; it seems counter to their image of impartiality.

I may begin using some of the CallBack stories as seed material for discussion here in the future.

Great! A good question would be "What parts of the system could have
better supported the pilot/dispatcher/supervisor/regulator...in their
decision making process? IOW "Why" did they make "poor decisions" or
exercise "poor judgment", as the mishap reports cheerily point out?
Bad info in a lot of cases, or mistimed information.
Anyway, off to pull weeds!

Thanks Larry for all of the great info you have posted since 2001. It
has generated some great discussion and that's what this is all about!
If you're ever in DFW give me a holler and we'll get some BBQ.

Kent