Subject: AVIATION SAFETY
ACTION PROGRAM (ASAP) Date: 11/15/02 Initiated By: AFS-230
AC No: 120-66B Change:
1. PURPOSE. This Advisory Circular (AC) provides guidance for establishing an air transportation Aviation Safety Action Program (ASAP). The objective of the ASAP is to encourage air carrier and repair station employees to voluntarily report safety information that may be critical to identifying potential precursors to accidents. The Federal Aviation Administration (FAA) has determined that identifying these precursors is essential to further reducing the already low accident rate. Under an ASAP, safety issues are resolved through corrective action rather than through punishment or discipline. The ASAP provides for the collection, analysis, and retention of the safety data that is obtained. ASAP safety data, much of which would otherwise be unobtainable, is used to develop corrective actions for identified safety concerns, and to educate the appropriate parties to prevent a reoccurrence of the same type of safety event. An ASAP is based on a safety partnership that will include the FAA and the certificate holder, and may include a third party, such as the employee’s labor organization. To encourage an employee to voluntarily report safety issues, even though they may involve the employee’s possible noncompliance with Title 14 of the Code of Federal Regulations (14 CFR), enforcement-related incentives have been designed into the program.
a. Information obtained from these programs will permit ASAP participants to identify actual or potential risks throughout their operations. Once identified, the parties to an ASAP can implement corrective actions in order to reduce the potential for reoccurrence of accidents, incidents, and other safety-related events. In order to gain the greatest possible positive benefit from ASAP, it may be necessary for certificate holders to develop programs with compatible data collection, analysis, storage, and retrieval systems. The information and data, which are collected and analyzed, can be used as a measure of aviation system safety.
b. An ASAP provides a vehicle whereby employees of participating air carriers and repair station certificate holders can identify and report safety issues to management and to the FAA for resolution, without fear that the FAA will use reports accepted under the program to take legal enforcement action against them, or that companies will use such information to take disciplinary action. These programs are designed to encourage participation from various employee groups, such as flight crewmembers, mechanics, flight attendants, and dispatchers.
c. The elements of ASAP are set forth in a Memorandum of Understanding (MOU) between the FAA, certificate holder management, and an appropriate third party, such as an employee’s labor organization or their representatives.
2. CANCELLATION. This AC cancels AC 120-66A, Aviation Safety Action Programs (ASAP), dated March 17, 2000.
3. BACKGROUND. The FAA’s safety mission requires it to take action to reduce or eliminate the possibility or recurrence of accidents in air transportation. Over the past several years, the FAA and the air transportation industry have sought innovative means for addressing safety problems and identifying potential safety hazards. To this end, the FAA, in cooperation with industry, established several demonstration ASAPs in an effort to increase the flow of safety information to both the air carrier and FAA, and issued an ASAP AC in January 1997. Among these programs were the USAir Altitude Awareness Program, the American Airlines Safety Action Partnership, and the Alaska Airlines Altitude Awareness Program. These programs included incentives to encourage employees of air carriers participating in the programs to disclose information which may include possible violations of 14 CFR without fear of punitive enforcement sanctions or company disciplinary action. Events reported under a program that involved an apparent violation by the air carriers of the regulations were handled under the Voluntary Disclosure Policy, provided that the elements of the policy were satisfied. In view of the positive safety results from those programs, the FAA issued a revised ASAP AC in March 2000, which established industry-wide guidelines for participation. Based on the lessons learned from over two dozen programs established since that date, the present AC contains revised guidance to facilitate achievement of ASAP’s safety goals, as well as to encourage wider participation in the program. This revised guidance is based upon the recommendations of an ASAP Aviation Rulemaking Committee, comprised of representatives from airlines, labor associations, and FAA management.
4. KEY TERMS. The following key terms and phrases are defined for the purposes of ASAP to ensure a standard interpretation of the guidance.
a. Administrative Action. Under paragraph 205 of FAA Order 2150.3A, Compliance and Enforcement Program, administrative action is a means for disposing of violations or alleged violations that do not warrant the use of enforcement sanctions. The two types of administrative action are a warning notice and a letter of correction.
b. Air Carrier. A person who undertakes directly, by lease, or other arrangement, to engage in air transportation.
c. Certificate Holder. Refers to a person authorized to operate under 14 CFR Part 121, or who holds a certificate issued under 14 CFR Part 145.
d. Certificate Holding District Office (CHDO). The Flight Standards District Office (FSDO) or Certificate Management Office (CMO) having overall responsibility for all FAA reporting requirements, technical administration requirements, and regulatory oversight of a certificate holder.
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e. Consensus of the Event Review Committee (ERC). Under ASAP, consensus of the ERC means the voluntary agreement of all representatives of the ERC to each decision required by the MOU.
f. Corrective Action. For the purposes of ASAP, corrective action refers to any safety-related action determined necessary by the ERC based upon a review and analysis of the reports submitted under an ASAP. Corrective action may involve joint or individual action by the parties to the ASAP MOU.
g. Covered Under the Program/Qualified for Inclusion/Included in ASAP. For the purposes of ASAP, these terms all have the same meaning. They mean that the enforcementrelated incentives and other provisions of the ASAP apply to the employee who submitted the report.
h. Enforcement-Related Incentive. Refers to an assurance that lesser enforcement action will be used to address certain alleged violations of the regulations to encourage participation by certificate holder employees.
i. Event Review Committee (ERC). A group comprised of a representative from each party to an ASAP MOU. The group reviews and analyzes reports submitted under an ASAP.
The ERC may share and exchange information and identify actual or potential safety problems from the information contained in the reports. The ERC is usually comprised of a management representative from the certificate holder, a representative from the employee labor association (if applicable), and a specifically qualified FAA inspector from the CHDO.
j. Intentional Falsification. For the purposes of ASAP, intentional falsification means a false statement in reference to a material fact made with knowledge of its falsity. It does not include mistakes or inadvertent omissions or errors.
k. Major Domestic Repair Station. Refers to a Part 145 certificated repair station located in the United States that is certificated to perform airframe and/or engine maintenance for certificate holders operating under Part 121.
l. Memorandum of Understanding (MOU). Refers to the written agreement between two or more parties setting forth the purposes for, and terms of, an ASAP.
m. Party/Parties. Refers to the certificate holder, the FAA, and any other person or entity
(e.g., labor union or other industry or Government entity) that is a signatory to the MOU.
n. Person. A person refers to an individual, firm, partnership, corporation, company, association, joint stock association, or government entity. It includes a trustee, receiver, assignee, or similar representative of any of them.
o. Safety-Related Report. Refers to a written account of an event that involves an operational or maintenance issue related to aviation safety reported through an ASAP.
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p. Sole-Source Report. For the purposes of ASAP, the ERC shall consider a report to be sole-source when all evidence of the event available to the FAA outside of ASAP is discovered by or otherwise predicated on the ASAP report. It is possible to have more than one sole-source report for the same event.
(Similarly, for the purpose of any additional action taken by the company outside of ASAP, an airline considers a report to be sole-source when all evidence of the event known to the airline is discovered by or otherwise predicated on the ASAP disclosure. The company does not use any information obtained through ASAP to initiate or support disciplinary action outside of ASAP, with the exception of those events excluded from ASAP due to the appearance of possible criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification.)
q. Sufficient Evidence. Sufficient evidence means evidence gathered by an investigation not caused by, or otherwise predicated on, the individual’s safety-related report. There must be sufficient evidence to prove the violation, other than the individual’s safety-related report. In order to be considered sufficient evidence under ASAP, the ERC must determine through consensus that the evidence (other than the individual’s safety-related report) would likely have resulted in the processing of a FAA enforcement action had the individual’s safety-related report not been accepted under ASAP. Accepted ASAP reports for which there is sufficient evidence will be closed with administrative action.
r. Voluntary Disclosure Policy. A policy under which regulated entities may voluntarily report apparent violations of the regulations and develop corrective action satisfactory to the FAA to preclude their recurrence. Certificate holders that satisfy the elements of the Voluntary Disclosure Policy receive a letter of correction in lieu of civil penalty action. Voluntary disclosure reporting procedures are outlined in the current version of AC 00-58, Voluntary Disclosure Reporting Program.
5. APPLICABILITY. ASAPs are intended for air carriers that operate under Part 121. They are also intended for major domestic repair stations certificated under Part 145. ASAPs are entered into voluntarily by the FAA, a certificate holder, and if appropriate, other parties.
6. DEVELOPMENT. Certificate holders may develop programs and submit them to the FAA for review and acceptance in accordance with the guidance provided. Ordinarily, programs are developed for specific employee groups, such as flight crewmembers, flight attendants, mechanics, or dispatchers. The FAA will determine whether a program is accepted. The FAA may suggest but may not require that a certificate holder develop an ASAP to resolve an identified safety problem.
a. Development Considerations. The development and implementation of an ASAP is a multifaceted task:
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(1) The certificate holder, employee group, and the FAA must first develop a relationship that will promote the ASAP concept. The reluctance of one or more parties to commit to the program is detrimental to the process.
(2) The process for report review must be outlined in detail.
(3) Safety data collection, analysis, and retention processes must be developed and agreed upon.
(4) Event investigation tasks must be assigned.
(5) Prior to the implementation of the ASAP, a comprehensive company employee and management education program must be undertaken.
(6) The ASAP process may require cultural change for all parties involved.
(7) Continuity of ERC representation personnel during the early stages of program implementation will promote the desired partnership relationship between program members.
b. Demonstration Programs. Certificate holders initially must develop a separate demonstration program for each employee group sought to be covered by an ASAP. The objective of a demonstration program is to measure its effectiveness and ensure that it meets the safety objectives of the specific ASAP.
(1) The initial demonstration program, which shall be limited to the period of time needed to achieve the desired goals and benefits articulated in the program, should have a duration of no longer than 18 months.
(2) At the conclusion of the initial demonstration program, all parties will review the program. Demonstration programs that require modification may be extended for an additional time, not to exceed 12 months, to effectively measure any change(s) made to the original program to address a deficiency identified by any of the parties to the MOU.
c. Continuing Programs. After a demonstration program is reviewed and determined to be successful by the parties to the agreement, it may be accepted as a continuing program, subject to review and renewal every 2 years by the FAA.
d. Withdrawal. Regardless of the duration of a program, any party to the ASAP MOU may withdraw from the program at any time.
7. RESOURCES. An ASAP can result in a significant commitment of both human and fiscal resources by the parties to the program. During the development of a program, it is important that each party be willing to commit the necessary personnel, time, and monetary resources to support the program.
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8. PROCESSING OF REPORTS.
a. Event Review Committee (ERC) Process. The determination of whether reports qualify for inclusion in the ASAP will be made by a consensus of the ERC.
(1) The ERC is composed of one designated representative and an alternate each from the FAA, the certificate holder, and any third party, e.g., the employee’s union or representative organization.
(2) The ERC will:
/g183/g32 review and analyze reports submitted under the ASAP
/g183/g32 determine whether such reports qualify for inclusion
/g183/g32 identify actual or potential problems from the information contained in the reports, and
/g183/g32 propose solutions for those problems
(3) For official meeting purposes, a quorum exists when all designated ERC representatives, or their alternates, are present. Some reported events may involve matters that are complex or sensitive, or that require the expertise of other FAA or industry persons. The ERC representatives are encouraged to consult with such persons as needed during the ASAP process.
b. Consensus of the ERC. The success of ASAP is built on the ability of the ERC to achieve consensus on each event that is reported. Consensus of the ERC means the voluntary agreement of all representatives of the ERC.
(1) The ERC must reach a consensus when deciding whether a report is accepted into the program and when deciding on corrective action recommendations arising from the event, including any FAA administrative action. It does not require that all members believe that a particular decision or recommendation is the most desirable solution, but that the result falls within each member’s range of acceptable solutions for that event in the best interest of safety.
In order for this concept to work effectively, the ERC representative must be empowered to make decisions within the context of the ERC discussions on a given report. Senior management and supervisors should not preempt their respective ERC representative’s decision-making discretion for an event reported under ASAP. If the parties to an ASAP MOU do not permit their respective ERC representative to exercise this discretion, the capacity of the ERC to achieve consensus will be undermined, and the program will ultimately fail.
(2) Recognizing that the FAA holds statutory authority to enforce the necessary rules and regulations, it is understood that the FAA retains all legal rights and responsibilities contained in Title 49 of the United States Code (49 U.S.C.), and FAA Order 2150.3A. In the event there is not a consensus of the ERC on decisions concerning a report involving an apparent violation(s), a qualification issue, or medical certification or qualification issue, the FAA ERC representative Page 6 Par 8
will decide how the report should be handled. The FAA will not use the content of an ASAP report in any subsequent enforcement action except as described in paragraph 11c(2).
c. Reports Involving Medical Certification or Medical Qualification Issues. When the ERC becomes aware of an issue involving the medical qualification or medical certification of an airman, the ERC must immediately advise the appropriate Regional Flight Surgeon about the issue. The ERC will work with the Regional Flight Surgeon and the certificate holder’s medical department or medical consultants to resolve any medical certification or medical qualification issues or concerns revealed in an ASAP report or through the processing of that report. The FAA ERC member must follow the direction(s) of the Regional Flight Surgeon with respect to any medical certification or qualification issue(s) revealed in an ASAP report.
9. GUIDELINES FOR ACCEPTANCE OF REPORTS UNDER ASAP.
a. General. Participation in ASAP is limited to certificate holder employees and to events occurring while acting in that capacity. Each employee participating in ASAP must individually submit a report in order to receive the enforcement-related incentives and benefits of the ASAP policy. However, in cases where an event may be reported by more than one person, each individual who seeks coverage under ASAP may either sign the same report or submit separate signed reports.
b. Criteria for Acceptance. The following criteria must be met in order for a report involving a possible violation to be covered under ASAP:
(1) The employee must submit a report in a timely manner. In order to be considered timely, a report must be submitted in accordance with either of the following two criteria:
(a) Within a time period following the event that is defined in the MOU, such as within 24 hours of the end of the duty day in which the event occurred. If this criterion has been met, a report would not be rejected for timeliness, even if the FAA was already aware of the possible noncompliance with the regulations, and may have brought it to the attention of the employee;
(b) Within 24 hours of having become aware of possible noncompliance with 14 CFR in accordance with the following criteria: If a report is submitted later than the time period after the occurrence of an event stated in the MOU, the ERC will review all available information to determine whether the employee knew or should have known about the possible noncompliance with 14 CFR within that time period. If the employee did not know or could not have known about the apparent noncompliance with 14 CFR within that time period, then the report would be included in ASAP, provided the report is submitted within 24 hours of having become aware of possible noncompliance with 14 CFR, and provided all other ASAP acceptance criteria have been met. If the employee knew or should have known about the apparent noncompliance with 14 CFR, then the report will not be included in ASAP.
(2) The alleged regulatory violation must be inadvertent, and must not appear to involve an intentional disregard for safety.
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(3) The reported event must not appear to involve criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification.
(4) Sole-source reports that meet all of the above acceptance criteria except timely submission will be accepted under ASAP.
c. Repeated Violations. Reports involving the same or similar possible noncompliance with 14 CFR that were previously addressed with administrative action under ASAP will be accepted into the program, provided they otherwise satisfy the acceptance criteria under paragraphs 9a and 9b above. The ERC will consider on a case-by-case basis the corrective action that is appropriate for such reports.
d. Non-Reporting Employees Covered Under an ASAP MOU. If an ASAP report identifies another covered employee of the certificate holder in a possible violation, and that employee has neither signed that report nor submitted a separate report, the ERC will determine on a case-by-case basis whether that employee knew or reasonably should have known about the possible violation. If the ERC determines that the employee did not know or could not have known about the apparent violation(s), and the original report otherwise qualifies for inclusion under ASAP, the ERC will offer the non-reporting employee the opportunity to submit an ASAP report. If the non-reporting employee submits a report within 24 hours of notification from the ERC, that report will be afforded the same consideration under ASAP as that accorded the report from the original reporting employee, provided all other ASAP acceptance criteria are met.
However, if the non-reporting employee fails to submit a report within 24 hours of notification, the possible violation by that employee will be referred to an appropriate office within the FAA for additional investigation and reexamination and/or enforcement action, as appropriate, and for referral to law enforcement authorities, if warranted.
e. Non-Reporting Employees Not Covered Under the MOU. If an ASAP report identifies another employee of the certificate holder who is not covered under the MOU, and the report indicates that employee may have been involved in a possible violation, the ERC will determine on a case-by-case basis whether it would be appropriate to offer that employee the opportunity to submit an ASAP report. If the ERC determines that it is appropriate, the ERC will provide that employee with information about ASAP and invite the employee to submit an ASAP report. If the employee submits an ASAP report within 24 hours of notification, that report will be covered under ASAP, provided all other ASAP acceptance criteria are met. If the employee fails to submit an ASAP report within 24 hours of notification, the possible violation by that employee will be referred to an appropriate office within the FAA for additional investigation and reexamination and/or enforcement action, as appropriate, and for referral to law enforcement agencies, if warranted.
10. GUIDELINES FOR EXCLUDING REPORTS FROM ASAP.
a. Exclusion. The following types of reports are excluded under an ASAP:
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(1) Reports involving an apparent violation that is not inadvertent or that appears to involve an intentional disregard for safety.
(2) Reports that appear to involve possible criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification.
(3) Untimely reports excluded under paragraph 9b(1) or reports where a consensus on acceptance under paragraph 9 is not reached by the ERC.
(4) Reports of events that occurred when NOT acting as an employee of the certificate holder.
b. Failure to Complete Corrective Action. Reports initially included in an ASAP will be excluded from the program if the employee fails to complete the recommended corrective action in a manner satisfactory to all members of the ERC. In those cases, failure of any individual to complete corrective action for an apparent violation, a qualification issue, or medical certification or qualification issue in a manner acceptable to all members of the ERC, may result in the reopening of the case and referral of the matter for appropriate action.
11. ENFORCEMENT POLICY.
a. FAA Investigation of Events Involving Possible Noncompliance with 14 CFR. By public law and FAA orders, the FAA is responsible for the proper investigation and disposition of all suspected cases of noncompliance with 14 CFR. The FAA establishes investigative and enforcement jurisdiction and responsibility regarding events reported to the ASAP ERC.
(1) The FAA CHDO ERC representative is empowered to complete ASAP investigations and is responsible for coordinating all corrective and administrative actions in accordance with the current versions of the following FAA orders, as applicable:
(a) Order 2150.3, Compliance and Enforcement Program;
(b) Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting;
(c) Order 8400.10, Air Transportation Operations Inspector’s Handbook; and/or
(d) Order 8300.10, Airworthiness Inspector’s Handbook.
(2) The determination of whether or not a reported event meets the criteria for inclusion into ASAP will be made in accordance with the applicable orders and through the ERC process.
If an event meets the criteria for participation and is accepted into ASAP by the ERC, the FAA shall transfer all jurisdiction and responsibility for compliance and enforcement investigations related to the event to the CHDO, even if an enforcement investigation has been previously opened outside of ASAP.
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b. Reports Covered Under ASAP.
(1) Those non-sole-source reports included in ASAP with sufficient evidence (see paragraph 4q for the definition of sufficient evidence) to support a violation of 14 CFR will be closed with administrative action. Those non-sole-source reports without sufficient evidence to support a violation of 14 CFR will be closed with a FAA Letter of No Action.
(2) Those sole-source reports that are included in ASAP will be closed with no action.
(3) Those reports included in ASAP that demonstrate a lack of qualification or raise a question of a lack of qualification will be addressed with appropriate corrective action recommended by the ERC.
c. Reports Excluded From ASAP.
(1) Reported events that are excluded from ASAP will be referred to the FAA for possible enforcement action and/or re-examination under 49 U.S.C., Subtitle VII, and as prescribed in FAA Order 2150.3A.
(2) Reports of events that appear to involve possible criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification will be referred to an appropriate FAA office for further handling. The FAA may use such reports for any enforcement purposes, and will refer such reports to law enforcement agencies, if appropriate. If upon completion of subsequent investigation it is determined that the event did not involve any of the aforementioned activities, then the report will be referred back to the ERC for a determination of acceptability under ASAP. Such reports will be accepted under ASAP provided they otherwise meet the acceptance criteria contained in paragraph 9 of this advisory circular.
(3) Neither the written ASAP report nor the content of the written ASAP report will be used to initiate or support company discipline or as evidence for any purpose in a FAA enforcement action except as provided for in 11c(2). The FAA may conduct an independent investigation of an event disclosed in a report.
12. REOPENING REPORTS BASED ON NEW EVIDENCE. All safety-related reports should be fully evaluated and, to the extent appropriate, investigated by the FAA. A closed ASAP case, including any related enforcement investigative report (EIR), involving a violation addressed with administrative action or for which no action has been taken, may be reopened and appropriate enforcement action taken if evidence later is discovered that establishes that the violation should have been excluded from the program.
13. VIOLATIONS OF CERTIFICATE HOLDERS. Apparent violations of certificate holders disclosed through a safety-related report under an ASAP may be handled under the Voluntary Disclosure Policy, provided the certificate holder voluntarily reports the apparent violations to the FAA and the other elements of that policy are met. (See the current version of AC 00-58 and FAA Order 2150.3A, Appendix 1: Compliance/Enforcement Bulletins, Bulletin No. 90-6.)
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14. EXAMPLES. The following are examples of the disposition of events involving possible noncompliance with 14 CFR reported under ASAP:
a. Accepted Reports.
(1) Non-Sole-Source Report with Sufficient Evidence (Pilot). A pilot reports an altitude deviation where the aircraft was assigned by air traffic control (ATC) to climb to an altitude of 10,000 feet MSL, but actually levels off at 11,000 feet MSL. The report is submitted within 24 hours of the end of the flight sequence for the day in accordance with the airline’s ASAP MOU. Following review of the report, the FAA ERC member determines that ATC has filed a pilot deviation report for this event, and obtains a copy of the ATC tapes, radar data, and a statement from the air traffic controller concerning this event. A review by the ERC determines that the pilot deviation was inadvertent. The ERC further determines through consensus that since this event was disclosed in a non-sole-source report for which there was sufficient evidence
(i.e., evidence gathered by an investigation not caused by, or otherwise predicated on, the filing of the safety-related report), the event should be closed with administrative action. The ERC determines that the appropriate administrative action is a FAA Letter of Correction. Following verification by the ERC that the employee has satisfactorily completed the recommended corrective action to the satisfaction of all members of the ERC, the ERC closes the report.
(2) Sole-Source Report (Mechanic). A repair station discovered that the check sheet for a required inspection item (RII) accomplished seven days prior had not been signed. The company immediately informed the responsible mechanic that the required signature on the check sheet was missing. The mechanic filed an ASAP report within 24 hours of having been informed by the company of the omission. Prior to signing the check sheet, the mechanic had become distracted by an aircraft that had unexpectedly returned to the maintenance facility. The ERC determined that the mechanic did not know or could not have known about the possible noncompliance with 14 CFR within 24 hours of its occurrence. An investigation by the ERC determined that the inspection was in fact properly accomplished by the reporting employee, although the check sheet had not been signed. The ERC determined through consensus that the omission by the mechanic was inadvertent, and that the report met all ASAP acceptance criteria. As there was no evidence of the event available to the FAA, other than the employee’s ASAP report, the ERC determined that the report should be considered sole-source. The report was closed with an ERC response.
However, the company had evidence of the event from information outside of ASAP and elected to counsel the individual concerning the possible impact of distractions.
(3) Sole-Source Report (Mechanic). An airline mechanic reported that he had inadvertently employed an improper lubricant on a rudder component during a heavy maintenance check. The report was submitted three days following the event. An investigation by the ERC determined that in fact the wrong lubricant had been used, but that the only evidence of the event is obtained from the investigation that was predicated upon the employee’s report.
Upon interviewing the mechanic, the ERC determined that the employee only became aware of the possible mistake while working on a similar aircraft three days after the event, and that he had submitted the report in a timely manner thereafter. While working on the subsequent aircraft he learned that the maintenance manual had been updated to remove a previously authorized substitute lubricant, and that he had used that lubricant because he was not employing the most Par 14 Page 11
recently updated revision of the manual at the time of the event. The ERC determined through consensus that the mistake was in fact inadvertent, that the employee submitted the report within 24 hours of having become aware of the event, and that the event should be accepted under ASAP as a sole-source report. The ERC recommended that changes be made to the maintenance department’s procedures for timely distribution of the most recent manual revisions, in order to preclude repetition of this event by others, and the report was closed with no action other than an ERC response to the reporting employee. The ERC followed-up with the maintenance department to verify that the recommended procedural change for timely distribution of documentation revisions had been accomplished.
(4) Untimely Sole-Source Report (Pilot). A pilot reported an altitude deviation where the aircraft was assigned by ATC to climb to an altitude of 10,000 feet MSL, but actually leveled off at 11,000 feet MSL. The report was not submitted within the timeframe following the event that was specified in the MOU. The ERC investigation of this event revealed that the deviation was due to an incorrect entry into the FMS that was not noticed by either flight crewmember.
The ERC also determined that the only evidence of the deviation was the pilot’s safety-related report filed under the ASAP. The ERC therefore concluded that the report should be considered sole-source. Although the report was not submitted on a timely basis, the ERC determined that it otherwise met ASAP acceptance criteria. Since the pilot’s safety-related report was determined to be sole-source, it was accepted under ASAP, and the ERC closed the event with no action, other than a recommendation that the pilot complete training on compliance with altitude clearances. The ERC monitored the completion by the pilot of the recommended corrective action. The ERC also solicited and received a sole-source report from the co-pilot concerning this event. That pilot’s report was closed in the same fashion, including corrective action.
b. Excluded Events. Examples of events involving possible noncompliance with 14 CFR that would be excluded from the ASAP:
(1) Intentional Disregard for Safety (Pilot). An aircraft being ferried in winter from a maintenance repair facility to another station for a revenue flight experienced a compressor stall in one of its engines shortly after lift-off, followed by a compressor stall in a second engine. The flightcrew declared an emergency and returned without further mishap to the departure airport.
Post flight examination of the aircraft revealed that ice was still attached to the upper wing surface near the wing root area. The captain and the first officer filed individual ASAP reports on this event. An investigation by the ERC determined that the flightcrew had been dispatched from operations via a company vehicle to the maintenance hanger at the departure airport, and had been dropped off at the forward aircraft door, from which position they could observe most, but not all, of the aircraft. The captain instructed the first officer to conduct the exterior pre-flight inspection, and proceeded to the cockpit to prepare the aircraft for departure.
Thereafter the first officer entered the cockpit and reported that the exterior of the aircraft was ready for flight. The ERC investigation determined that the first officer had not performed a complete walk-around inspection of the aircraft, including inspection of the top surface of the wing. The ERC concluded that this behavior constituted intentional disregard for safety on the part of the first officer, and the event as disclosed in the first officer’s report was excluded from ASAP. The ERC determined that the Captain did not violate the regulations.
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