NASA aviation safety reporting system

Reports describing various types of communication problems are presented along with summaries dealing with judgment and decision making. Concerns relating to the ground proximity warning system are summarized and several examples of true terrain proximity warnings are provided. An analytic study of reports relating to profile descents was performed. Problems were found to be associated with charting and graphic presentation of the descents, with lack of uniformity of the descent procedures among facilities using them, and with the flight crew workload engendered by profile descents, particularly when additional requirements are interposed by air traffic control during the execution of the profiles. A selection of alert bulletins and responses to them were reviewed

NASA aviation safety reporting system

An analytical study of reports relating to cockpit altitude alert systems was performed. A recent change in the Federal Air Regulation permits the system to be modified so that the alerting signal approaching altitude has only a visual component; the auditory signal would continue to be heard if a deviation from an assigned altitude occurred. Failure to observe altitude alert signals and failure to reset the system were the commonest cause of altitude deviations related to this system. Cockpit crew distraction was the most frequent reason for these failures. It was noted by numerous reporters that the presence of altitude alert system made them less aware of altitude; this lack of altitude awareness is discussed. Failures of crew coordination were also noted. It is suggested that although modification of the altitude alert system may be highly desirable in short-haul aircraft, it may not be desirable for long-haul aircraft in which cockpit workloads are much lower for long periods of time. In these cockpits, the aural alert approaching altitudes is perceived as useful and helpful. If the systems are to be modified, it appears that additional emphasis on altitude awareness during recurrent training will be necessary; it is also possible that flight crew operating procedures during climb and descent may need examination with respect to monitoring responsibilities. A selection of alert bulletins and responses to them is presented

NASA aviation safety reporting system

The study deals with 165 inadvertent operations on or into inappropriate portions of the aircraft areas at controlled airports. Pilot-initiated and controller-initiated incursions are described and discussed. It was found that a majority of the pilot-initiated occurrences involved operation without a clearance; controller-initiated occurrences usually involved failure to maintain assured separation. The factors associated with these occurrences are analyzed. It appears that a major problem in these occurrences is inadequate coordination among the various system participants. Reasons for this, and some possible solutions to various aspects of the problem, are discussed. A sample of reports from pilots and controllers is presented. These relate to undesired occurrences in air transport, general aviation, and air traffic control operations; to ATC coordination problems; and to a recurrent problem in ASRS reports, parachuting operations. A sample of alert bulletins and responses to them is presented

NASA aviation safety reporting system

Knowledge of limitations of the Air Traffic Control system in conflict avoidance capabilities is discussed. Assumptions and expectations held by by airmen regarding the capabilities of the system are presented. Limitations related to communication are described and problems associated with visual approaches, airspace configurations, and airport layouts are discussed. A number of pilot and controller reports illustrative of three typical problem types: occurrences involving pilots who have limited experience; reports describing inflight calls for assistance; and flights in which pilots have declined to use available radar services are presented. Examples of Alert Bulletins and the FAA responses to them are included

NASA aviation safety reporting system

The origins and development of the NASA Aviation Safety Reporting System (ASRS) are briefly reviewed. The results of the first quarter's activity are summarized and discussed. Examples are given of bulletins describing potential air safety hazards, and the disposition of these bulletins. During the first quarter of operation, the ASRS received 1464 reports; 1407 provided data relevant to air safety. All reports are being processed for entry into the ASRS data base. During the reporting period, 130 alert bulletins describing possible problems in the aviation system were generated and disseminated. Responses were received from FAA and others regarding 108 of the alert bulletins. Action was being taken with respect to 70 of the 108 responses received. Further studies are planned of a number of areas, including human factors problems related to automation of the ground and airborne portions of the national aviation system

NASA aviation safety reporting system

A sample of reports relating to operations during winter weather is presented. Several reports involving problems of judgment and decisionmaking have been selected from the numerous reports representative of this area. Problems related to aeronautical charts are discussed in a number of reports. An analytic study of reports involving potential conflicts in the immediate vicinity of uncontrolled airports was performed; the results are discussed in this report. It was found that in three-fourths of 127 such conflicts, neither pilot, or only one of the pilots, was communicating position and intentions on the appropriate frequency. The importance of providing aural transfer of information, as a backup to the visual see and avoid mode of information transfer is discussed. It was also found that a large fraction of pilots involved in potential conflicts on final approach had executed straight-in approaches, rather than the recommended traffic pattern entries, prior to the conflicts. A selection of alert bulletins and responses to them by various segments of the aviation community is presented

NASA aviation safety reporting system

During the second quarter of the Aviation Safety Reporting System (ASRS) operation, 1,497 reports were received from pilots, controllers, and others in the national aviation system. Details of the administration and results of the program to date are presented. Examples of alert bulletins disseminated to the aviation community are presented together with responses to those bulletins. Several reports received by ASRS are also presented to illustrate the diversity of topics covered by reports to the system

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary

Incident reporting as a key mechanism for organisational learning and the establishment of a stronger safety culture are pillars of the current patient safety movement. Studies have suggested that incident reporting in healthcare does not achieve its full potential due to serious barriers to reporting and that sometimes staff may feel alienated by the process. The aim of the work reported in this paper was to prototype a novel approach to organisational learning that allows an organisation to assess and to monitor the status of processes that often give rise to latent failure conditions in the work environment, and to assess whether and through which mechanisms participation in this approach affects local safety culture. The approach was prototyped in a hospital dispensary using Plan-Do-Study-Act (PDSA) cycles, and the effect on safety culture was described qualitatively through semi-structured interviews. The results suggest that the approach has had a positive effect on the safety culture within the dispensary, and that staff perceive the approach to be useful and usable

Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools

Background: The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety climate in healthcare organizations; however, the rigour with which safety climate tools were developed and psychometrically tested was shown to be variable. This paper aims to identify and review questionnaire studies designed to measure safety climate in acute hospital settings, in order to assess the adequacy of reported psychometric properties of identified tools. Methods: A systematic review of published empirical literature was undertaken to examine sample characteristics and instrument details including safety climate dimensions, origin and theoretical basis, and extent of psychometric evaluation (content validity, criterion validity, construct validity and internal reliability). Results: Five questionnaire tools, designed for general evaluation of safety climate in acute hospital settings, were included. Detailed inspection revealed ambiguity around concepts of safety culture and climate, safety climate dimensions and the methodological rigour associated with the design of these measures. Standard reporting of the psychometric properties of developed questionnaires was variable, although evidence of an improving trend in the quality of the reported psychometric properties of studies was noted. Evidence of the theoretical underpinnings of climate tools was limited, while a lack of clarity in the relationship between safety culture and patient outcome measures still exists. Conclusions: Evidence of the adequacy of the psychometric development of safety climate questionnaire tools is still limited. Research is necessary to resolve the controversies in the definitions and dimensions of safety culture and climate in healthcare and identify related inconsistencies. More importance should be given to the appropriate validation of safety climate questionnaires before extending their usage in healthcare contexts different from those in which they were originally developed. Mixed methods research to understand why psychometric assessment and measurement reporting practices can be inadequate and lacking in a theoretical basis is also necessary

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data.

BACKGROUND: The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems. METHODS: This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure. FINDINGS: 5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)]. CONCLUSION: The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure