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The Frontier of Emerging Technologies:Failures, Fraud, and Financing

American Medical Informatics Association5th AMIA Health Policy Meeting

Reston, VASeptember 1, 2010

Linda Connell, ASRS DirectorNASA Aviation Safety Reporting System

Human Systems Integration DivisionNASA Ames Research Center

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Ames Research

Center

Dryden Flight Research Center

Langley Research Center

Glenn Research Center

Jet Propulsion Laboratory

Johnson Space Center

Marshall Space Flight Center

Goddard Space Flight Center

Kennedy Space Center

Home of NASA ASRSHome of NASA ASRS

ASRS

Moffett Field - Hangar OneMoffett Field - Hangar One19321932

Aviation Tragedy Leads to Aviation Tragedy Leads to Genesis of ASRSGenesis of ASRS

TWA 514, December 1, 1974TWA 514, December 1, 1974

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ASRS HistoryASRS 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 FAAimplemented theAviation SafetyReporting System(ASRS)

NTSB Identification: DCA75AZ005

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ASRS Beneficiaries & Providers ASRS Beneficiaries & Providers

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Guiding PrinciplesGuiding Principles

VOLUNTARY PARTICIPATIONAviation personnel voluntarily submit reports concerning events

related to safety for the purpose of system alerting, understanding and learning

CONFIDENTIALITY PROTECTIONProtection of identity is provided by NASA through de-

identification of persons, companies, and any other information

NON-PUNITIVEFAA 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 *U.S. Aviation Statistics *

• FAA Certificated Professionals• Pilots 613,746

– Air Carrier 124,746• Air Traffic Controllers 14,305• Mechanics 116,310

– Air Carrier 27,020

• Airline• Flight Attendants 98,700

______________

• Potential Aviation ReportersTOTAL(Est.) 850,000

• Flight Volume60,000 Flights/Day (Air Carrier, Cargo, Military)27,178 Flights/Day (General Aviation)

*2008 US Dept of Labor Statistics

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Monthly Report IntakeMonthly Report Intake1981 – 2009

• 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

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

'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 '08 '09

Smoothed / ForecastActual IntakeSeries3

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Report Intake 2001 - 2009Report Intake 2001 - 2009Reporter GroupsReporter Groups

Decreases evident following September 11, 2001 are showing return to pre-9/11 levels

20% of all reports are matched to unique events

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System Recognition System Recognition for Effectivenessfor 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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Human Performance Human Performance Contributions to ErrorsContributions to Errors

THE HUMAN FACTOR

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Simplified Event Chain

Detection &Recovery

OperationalSystem

HumanPerformance

Incidents

Accidents

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Accidents

Incidents

Normal OperationsNormal Operational Data

Incidents

Accidents

FatalAccidents

Precursors

Proportion of Event Probabilities Based on Heinrich Model

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ASRS PurposeASRS Purpose

Identify Deficiencies and Discrepancies

Provide Data for Planning

and Improvements

ALERTS PRODUCTS

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Incident Reporting ModelIncident Reporting Model

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ASRS Products & ServicesASRS 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

Database Online ASRS

Publications Program

Information Immunity

Policieshttp://asrs.arc.nasa.gov

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ASRS Database Online ASRS Database Online (DBOL)(DBOL)

• System initiated August 23, 2006More online queries

completed than in history of ASRS

• New data export capability

• ExcelMS spreadsheet

• CSV(comma separated value)

For all other analysis and database programs

• Full Narrative, Synopsis

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Incident Reporting ModelIncident Reporting Model

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Data Exploration Tools

BRIO

ASRS Database Query

Voquette

Experimental Software

Other

InSPIRE

Starlight

Data MiningData Mining

QUORUM/Perilog

Vivisimo

Data QueryData Query

Data VisualizationData Visualization

ASRS

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ASRS Model Applied to Aviation & Other Domains

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National and International ReputationASRS 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

ASRS Model Applied to International Aviation

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International Confidential International Confidential Aviation Safety Systems (ICASS)Aviation Safety Systems (ICASS)

South KoreaKAIRS (2000)

United StatesASRS (1976)

United KingdomCHIRP (1982)

CanadaCASRP (1985)SECURITAS (1995)

AustraliaCAIRS (1988)REPCON (2006)

RussiaVASRP (1992)

BrazilRCSV (1997)

JapanASI-NET (1999)

TaiwanTACARE (2000)

SingaporeSINCAIR (2004)

FranceREC (1999)

ChinaSCASS (2004)

New ZealandICARUS

South AfricaSASCO

GermanyEUCARE

SpainSNS (2007)

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• 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

ASRS Model Applied to Other Domains

See It. Report It.Make a Difference.

Confidential Reporting in the U.S Railroad Industry

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Unique Aspects of ASRSUnique Aspects of ASRSConfidential Reporting ModelConfidential 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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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

Unique Aspects of ASRSUnique Aspects of ASRSConfidential Reporting ModelConfidential Reporting Model

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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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Confidential reporting systems have the means to answer the

question why? –

why a system failed

why a human erred

SUMMARY

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Contact Information:

Linda Connell, NASA ASRS DirectorLinda.J.Connell@nasa.gov

(408) 541-2827

Website:http://asrs.arc.nasa.gov