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57-477: A notable feature of the ASRS is its confidentiality and immunity policy. Reporters may, but are not required to, submit their name and contact information. If the ASRS staff has questions regarding a report, it can perform a callback and request further information or clarification from the reporter. Once the staff is satisfied with the information received, the report is stripped of identifying information and assigned

114-492: A December 3, 1969, internal Airlines for America meeting, ARINC (Aeronautical Radio Incorporated) reported to the membership that a majority of the airlines surveyed, had chosen not to participate in the program. After receiving this news, Allen would share the results with NTSB leadership and although they thought there would soon be acceptance, implementation would be stalled for years. In December 1974, two years after Allen's death at age 50, TWA Flight 514 would crash into

171-497: A Virginia mountaintop. After investigators learned that similar circumstances had occurred on a United Airlines flight just six weeks earlier a scramble ensued to overcome the public's outcry and in May 1975, the FAA announced the inauguration of a confidential, non-punitive incident reporting scheme. In January 1978, final design review of the system would begin, and the system would be called

228-516: A charting error led to the collision between the dry bulk carrier Ocean Princess and the SP-83A oil and gas production platform in the Gulf of Mexico on January 7, 2021. The incident occurred because the platform was not visible on the vessel's electronic chart display, although it was present on the paper chart used by the mate on watch. The NTSB highlighted the importance of effective bridge management and

285-661: A critical role in the investigation of the Norfolk Southern Railway derailment in East Palestine, Ohio , in February 2023. The NTSB's report, unanimously adopted by its board, highlighted significant failures by Norfolk Southern , particularly in the decision to conduct a vent and burn of toxic chemicals, which was deemed unnecessary and based on misleading information provided by the railway. The report also criticized Norfolk Southern's obstruction during

342-463: A design study titled "Aircraft Design-Induced Pilot Error", both of which were broadly used by the aviation community. Allen was instrumental in establishing the "Go Team" for catastrophic accident investigations. This "Team Concept" is still used today by the NTSB as well as numerous other nations of the world. In 1967, Allen was a member of the task force which planned the organization and staffing of

399-465: A dozen, depending on the nature of the incident. The agency may then hold public hearings on the issue following the investigation. Ultimately, it will publish a final report which may include safety recommendations based on its findings. The NTSB has no legal authority to implement or impose its recommendations. Its recommendations are often implemented by regulators at the federal or state level or by individual transportation companies. The NTSB played

456-516: A mail delivery mix-up. After resolving the errant mail issue, the two began dating and within several months, decided to marry. As required by Naval regulation, Mrs. Allen resigned her commission and returned to her home in Akron Ohio where she would wait for Ensign Allen to complete fighter training. During their marriage, they raised five children. National Transportation Safety Board The National Transportation Safety Board ( NTSB )

513-462: A major accident, even if a violation occurs. If enforcement action is taken by the FAA against an accidental rule violation that did not result in an accident, a reporter can present their ASRS ID strip as proof that the incident was reported to NASA in the interest of aviation safety. Reporters do not have to share their report with the FAA and NASA will not share the report with the FAA. The FAA considers

570-419: A particular investigation. However, the use of the party system is not without controversy. The NTSB invited Boeing to participate as a party to the investigation of the crash of TWA Flight 800 , a Boeing 747 , in 1996. While the NTSB relied on Boeing's sharing of expertise, it was later determined that Boeing had withheld a study of military versions of the 747 that investigated flammable vapor combustion in

627-437: A report number. The part of the reporting form with contact information is detached and returned to the reporter. ASRS will issue alerts to relevant parties, such as airlines, air traffic controllers, manufacturers, and airport authorities if NASA considers the issue to be significant to improved aviation safety. The ASRS also publishes a monthly newsletter highlighting safety issues, and now has an online database of reports that

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684-419: Is accessible by the public. This database makes a large body of de-identified reports available to safety researchers world-wide. In addition, the ASRS occasionally conducts special studies on topics of interest to researchers and regulators. These special studies are also made available on the ASRS website. The first government official to advocate the use of an immunity policy was Bobbie R. Allen , Director of

741-468: Is an independent U.S. government investigative agency responsible for civil transportation accident investigation . In this role, the NTSB investigates and reports on aviation accidents and incidents , certain types of highway crashes , ship and marine accidents , pipeline incidents , bridge failures , and railroad accidents . The NTSB is also in charge of investigating cases of hazardous materials releases that occur during transportation. The agency

798-487: Is authorized to establish and manage separate sub-offices for highway, marine, aviation, railroad, pipeline, and hazardous materials investigations. Since its creation, the NTSB's primary mission has been "to determine the probable cause of transportation accidents and incidents and to formulate safety recommendations to improve transportation safety (in the USA) ". Based on the results of investigations within its jurisdiction,

855-687: Is based in Washington, D.C. It has four regional offices, located in Anchorage, Alaska ; Denver, Colorado ; Ashburn, Virginia ; and Seattle, Washington . The agency also operated a national training center at its Ashburn facility. The origin of the NTSB was in the Air Commerce Act of 1926, which assigned the United States Department of Commerce responsibility for investigating domestic aviation accidents. Before

912-469: Is it, then, that stands in the way of communicating this incident information to the appropriate governmental agency for processing? Repeatedly, when this question is asked, one hears the reply-FEAR: fear of litigation; fear of regulation; fear of punitive action." Often, reports are submitted because a rule was accidentally broken. The FAA's immunity policy encourages submission of all safety incidents and observations, especially information that could prevent

969-515: The Aviation Safety Reporting System . Allen's work in the mid– to late 1960s laid the groundwork for NASA's Aviation Safety Reporting System, yet due to his untimely death, most people in the aviation community know little about his contributions. The concepts he envisioned and promoted, which are in use today are the very basis and foundation of the Aviation Safety Reporting System . Allen served during WWII in

1026-642: The Pacific theater . He was assigned to Night Fighter Squadron VF-52(N) (Night Mares) flying the Grumman F6F Hellcat from the USS Roi (CVE-103) , USS Saratoga (CV-3) , USS Corregidor (CVE-58) , USS Tripoli (CVE-64) , USS Bon Homme Richard (CV-31) . The war was ending when Allen deployed, and little action was seen. In late 1952, Allen was recalled to Active Duty for the Korean War . He

1083-908: The federal court system by the losing party, whether it is the individual or company, on the one hand, or the FAA or the Coast Guard, on the other. However, from Ferguson v. NTSB , the NTSB's determinations are not overturned by the federal courts unless the NTSB abused its discretion or its determination is wholly unsupported by the evidence. The Safety Board maintains a training academy in Ashburn , Virginia , where it conducts courses for its employees and professionals in other government agencies, foreign governments or private companies, in areas such as general accident investigation, specific elements of investigations like survival factors or human performance, or related matters like family affairs or media relations . The facility houses for training purposes

1140-508: The "National Transportation Safety Board" refers to a five-manager investigative board whose five members are nominated by the President and confirmed by the Senate for five-year terms. Board members may continue to serve until a successor is confirmed and takes office. No more than three of the five members may be from the same political party. One of the five board members is nominated as

1197-621: The Civil Aeronautics Board. In 1966 - twelve years before ASRS was launched, Bobbie R. Allen, Director of the Bureau of Aviation Safety, was advocating the use of computers and the concept of non-punitive incident reporting. In a Nov 1966 speech at a Flight Safety Foundation seminar in Madrid, Allen stated: “We must find a way of moving this raw material for accident prevention to the processing machine.” He further stated: "What

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1254-494: The Department of Transportation. In 1966 – twelve years before the Aviation Safety Reporting System (ASRS) was launched – Allen, as Director of the Bureau of Aviation Safety, was advocating the use of computers and the concept of non-punitive incident reporting. In a November 1966 speech at a Flight Safety Foundation seminar in Madrid, Allen stated: We must find a way of moving this raw material for accident prevention to

1311-537: The NTSB investigative process" and that participant parties "are uniquely able to provide essential information about aircraft design and manufacture, airline operations, or functioning of [the National Airspace System] that simply cannot be obtained elsewhere". However, Rand also found conflicts of interest inherent in the party system, "may, in some instances, threaten the integrity of the NTSB investigative process". The Rand study recommended that

1368-479: The NTSB is that it serves as a court of appeals for airmen, aircraft mechanics , certificated aviation-related companies, and mariners who have their licenses suspended or revoked by the FAA or the Coast Guard . The NTSB employs administrative law judges who initially hear all appeals, and the administrative law judge's ruling may be appealed to the five-member Board. The Board's determinations may be appealed to

1425-421: The NTSB issues formal safety recommendations to agencies and institutions with the power to implement those recommendations. The NTSB considers safety recommendations to be its primary tool for preventing future civil transportation accidents. However, the NTSB does not have the authority to enforce its safety recommendations. The current board members as of September 24, 2024: President Biden has nominated

1482-528: The NTSB reduce its reliance on party representatives and make greater use of independent investigators, including from NASA , the Department of Defense , government research laboratories, and universities. As of 2014 , the NTSB has not adopted these recommendations and instead continues to rely on the party system. As of 2014 , the NTSB has issued about 14,000 safety recommendations in its history, 73 percent of which have been adopted in whole or in part by

1539-655: The NTSB reported to the DOT for administrative purposes, while conducting investigations into the Federal Aviation Administration, also a DOT agency. To avoid any conflict, Congress passed the Independent Safety Board Act , and on April 1, 1975, the NTSB became a fully independent agency . As of 2015 , the NTSB has investigated over 140,000 aviation incidents and several thousand surface transportation incidents. Formally,

1596-609: The NTSB, the Federal Aviation Administration 's (FAA; at the time the CAA / Civil Aviation Authority ) independence was questioned as it was investigating itself and would be biased to find external faults, coalescing with the 1931 crash killing Notre Dame coach Knute Rockne and the 1935 crash that killed Senator Bronson Cutting. The US's first "independent" Air Safety Board was established in 1938: it lasted only fourteen months. In 1940, this authority

1653-692: The Navy's V-5 program, and during training, his mother would die from cancer at the age of 40. Allen joined the Civil Aeronautics Board in May 1959 as an Air Safety Investigator. He was subsequently promoted to Chief of the Chicago office and later named Deputy Director in Washington, D.C. He was then named Director of the Bureau of Safety on October 1, 1964, and remained Director when the National Transportation Safety Board

1710-640: The aircraft. Within seconds, the carrier, cruising at 30 knots, cut the plane in half, just forward of the empennage . Allen climbed out and was hoisted aboard a rescue helicopter, surviving the incident. Several weeks later, the squadron boarded the USS Lake Champlain (CVA-39) and sailed to Korea where they joined Marine Squadron VMF-513 at K-6 Airbase in Pyeongtaek South Korea providing bomber escort and night combat air patrol over North Korea until late 1953. After returning to

1767-605: The airlines of the world had the best safety record in their history and United States scheduled carriers had their best safety record since 1954. Charles S. Murphy , adviser to three U.S. Presidents and Chairman of the Civil Aeronautics Board , nominated Allen for the Rockefeller Public Service Award and wrote the following: "His outstanding work has contributed significantly to the constantly improving safety record throughout

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1824-469: The center fuel tank. Boeing had told the NTSB that it had no studies proving or disproving the vapor combustion theory. In response to political pressure after the Boeing incident, the NTSB commissioned the nonprofit Rand Corporation to conduct an independent study of the NTSB's aircraft investigation process. In 2000, Rand published its report, which concluded that the party system is "a key component of

1881-546: The chair by the President and then approved by the Senate for a fixed three-year term; another is designated as vice-chair for a fixed three-year term and who becomes acting chair when there is no formal chair. This board is authorized by Congress under Chapter 11, Title 49 of the United States Code to investigate civil aviation, highway, marine, pipeline, and railroad accidents and incidents. This five-member board

1938-417: The dangers of over-reliance on electronic navigation tools. To conduct its investigations, the NTSB operates under the "party system", which utilizes the support and participation of industry and labor representatives with expertise or technical knowledge specifically useful to its investigation. The NTSB may invite these individuals or organizations to become parties to the investigation and participate under

1995-470: The dissemination of this information, rendering it valueless to those who might use it to combat hazards in the aviation system, Mr. Allen commented: In the event that the fear of exposure cannot be overcome by other means, it might be profitable if we explored a system of incident reporting which would assure a substantial flow of vital information to the computer for processing, and at the same time, would provide some method designed to effectively eliminate

2052-542: The entities to which they were directed. Starting in 1990, the NTSB annually published a "Most Wanted List", which highlights safety recommendations that the NTSB believes would provide the most significant — and sometimes immediate — benefit to the traveling public. The list was discontinued in 2023 such that "the NTSB can more nimbly advocate for [their] recommendations and emerging safety issues". Among transportation safety improvements brought about or inspired by NTSB recommendations: A less well-known responsibility of

2109-533: The following to fill a seat on the board. They await Senate confirmation. The NTSB is the lead agency in investigating a civil transportation accident or incident within its sphere. An investigation of a major accident within the United States typically starts with the creation of a "go team", composed of specialists in fields relating to the incident who are rapidly deployed to the incident location. The "go team" can have as few as three people or as many as

2166-501: The foundation for accident investigations throughout the world. The U.S. formally adopted the proposals at the White House on Dec 1, 1965. Allen traveled extensively throughout South America, Asia, and Europe emphasizing the importance of accident investigation and stressing the need for professionally trained investigators. His organization provided investigative assistance and on-the-scene expertise to numerous countries around

2223-539: The happening!“ Several years later, speaking before a Flight Safety Foundation International Air Safety Seminar in Madrid in November 1966, Bobbie R. Allen , the Director of the Bureau of Safety of the U.S. Civil Aeronautics Board, referred to the vast body of accumulated aviation safety incident information as a "sleeping giant." Noting that fear of legal liability and of regulatory or disciplinary action had prevented

2280-400: The investigation, noting delays in providing critical information and attempts to influence the investigation's outcome. The NTSB's findings have led to new safety recommendations aimed at preventing similar incidents in the future, including better communication protocols and more stringent oversight of emergency response procedures. The NTSB concluded that poor bridge resource management and

2337-485: The maximum extent possible, not only in after-the-fact learning from past history but in safety projections for the future.... We in the Board are endeavoring to define and apply the lessons learned from accident investigations and special safety studies using to the extent possible electronic computers to identify those subtle and elusive common denominators in accident causation. In this increasingly important task, we welcome

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2394-443: The on-going cooperative efforts of all concerned in the aviation community." By mid 1968, due to declining health, Allen had stepped down as Director, but continued efforts to overcome the industry’s reluctance to participate. In his role as Special Assistant to the Director, he dedicated much of his time promoting the project. He traveled extensively, wrote documents, gave speeches, and often communicated with industry leaders. On

2451-504: The personal aspect of the individual occurrences so that the information derived would be helpful to all and harmful to none. See Aviation Safety Reporting System, Early History to view early letters, speeches and memos. According to the National Transportation Safety Board , ASRS was first incepted in 1976 by Charles Billings . Bobbie R. Allen St. Mary's College Naval War College University of Southern California Bobbie R. Allen (July 26, 1922 – November 17, 1972)

2508-532: The processing machine.... What is it, then, that stands in the way of communicating this incident information to the appropriate governmental agency for processing? Repeatedly, when this question is asked, one hears the reply-FEAR: fear of litigation; fear of regulation; fear of punitive action." At a 1968 SMU speech in Dallas Texas, Allen again spoke of using computers for accident prevention: We intend to exploit its memory and data retrieval capabilities to

2565-650: The reconstruction of more than 90 feet of the TWA Flight 800 Boeing 747 , which was recovered from the Atlantic Ocean after it crashed on July 17, 1996, following a fuel tank explosion. On February 22, 2021, the NTSB announced that the TWA Flight 800 recreation would be decommissioned on July 7, 2021. This decision comes as the lease for the Ashburn training center expires shortly. The NTSB indicated it

2622-575: The reliability of the reports submitted: The need for a system of recording and cataloging aviation safety's institutional knowledge and shared history was apparent long before ASRS came to fruition. In testimony before the U.S. Senate on legislation proposing the Federal Aviation Act of 1958 , United Airlines president William A. Patterson touched the concept: "On the positive side," said Mr. Patterson, "you take your statistics - and your records - and your exposures - and you act before

2679-678: The states, Allen would remain on active duty until 1959, when he accepted an Aircraft Accident Investigation position with the Civil Aeronautics Board. During the Berlin Crisis of 1961 , Allen was recalled to active duty, and served as Commanding Officer of VS-721 (Eagle Scouts) . Based at NAS Whidbey Island Washington, the squadron operated S2F Trackers patrolling waters off the Pacific Northwest coast, searching for Soviet submarines using airborne Anti-Submarine Warfare techniques until August 1962. From 1963 to 1966, Allen

2736-423: The submission of the report as evidence of a "constructive attitude" and will not impose a penalty. However, this immunity can only be exercised once every five years, though an unlimited number of reports can be filed. Due to the self-selected, or voluntary nature of the reports to the ASRS, NASA cautions against statistical use of the data they contain. On the other hand, they do express considerable confidence in

2793-474: The supervision of the NTSB. The NTSB has discretion over which organizations it allows to participate. Only individuals with relevant technical expertise can represent an organization in an investigation, and attorneys and insurance investigators are prohibited by law from participating. The NTSB considers the party system crucial to the investigative process, as it provides the NTSB with access to individuals with specialized expertise or knowledge relevant to

2850-776: The world. In 1966, he traveled to the Soviet Union , for bilateral discussions between the U.S. and the U.S.S.R. to initiate air service between the two countries. As the first Chairman of the Board of Trustees of the National Aircraft Accident Investigation School at Oklahoma City, Allen was instrumental in organizing the school where students and investigators from around the world would attend. Allen and his teams authored "The Potential Role of Flight Recorders in Aircraft Accident Investigation" and

2907-641: The world."..."Devoted to duty, able to inspire, …Mr. Allen is a credit to the Bureau, the Board, the Federal Service, and the Nation." Bobbie Ray Allen was born on July 26, 1922 in Winnsboro, Texas . His father, Buddy Bura Allen (August 15, 1900 – November 7, 1978) was a deaf-mute and was one of twelve children born to Joe and Dollie Allen, who farmed cotton near the town of Winnsboro, Texas. Allen's mother, Edna Lorena Brown (March 6, 1903 - June 27, 1943),

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2964-537: Was Aviation Safety Officer of AWS-66 at Andrews Air Force Base , Maryland. In 1963, he participated in "Global Strategy Discussions" at the U.S. Naval War College in Newport, Rhode Island, and on March 4, 1966, he was promoted to Captain. Bobbie Ray Allen and his wife Arlene, a Nurse in the U.S. Navy Nurse Corps from Akron, Ohio, were married on November 18, 1944 at Vero Beach, Florida . They were each stationed at NAS Pensacola when they happened to meet because of

3021-628: Was Executive Officer of Night Fighter Squadron VC-4 DET44(N) (the Nightcappers) flying the Douglas F3D Skyknight . On March 4, 1953, 100 miles off the coast of Virginia, the "Nightcappers" were training on the USS Franklin D. Roosevelt (CV-42) . On Allen's last of five launches for the day, the ships catapult bridle failed, and his plane rolled forward, too fast to stop, and too slow to fly. He had no choice but to ditch

3078-400: Was a U.S. Government Official, Air Safety Investigator and Naval Aviator. As Director of the Bureau of Aviation Safety at the Civil Aeronautics Board – later the National Transportation Safety Board – Allen spearheaded the use of flight data recorders and laid the groundwork for what would become the Aviation Safety Reporting System . At the time of Allen's retirement from the NTSB in 1968,

3135-527: Was formed in 1967. He continued until health-related retirement on June 15, 1968, when he stepped down to become Special Assistant to the Director focusing on accident prevention until July 31, 1970, when he would fully retire. As chairman of the U.S. delegation at the ICAO third accident investigation division meeting at Montreal in January 1965, Allen was responsible for developing the U.S. proposals which laid

3192-662: Was one of five children, born to Walter Shook Brown and Hattie Belle Henderson, both of East Texas communities near Winnsboro. Allen's father was an oil field laborer and shoe cobbler, and his mother was a waitress at a small restaurant near their home in Marshall, Texas . His parents divorced; he and his mother remained in Marshall. In June 1942, Allen was working part time at the Logan and Whaley Hardware Store when he graduated from Marshall High School. In October of that year, he entered

3249-441: Was transferred to the Civil Aeronautics Board 's newly formed Bureau of Aviation Safety. In 1967, Congress created a separate cabinet-level Department of Transportation , which among other things, established the Federal Aviation Administration as an agency under the DOT. At the same time, the NTSB was established as an independent agency which absorbed the Bureau of Aviation Safety's responsibilities. However, from 1967 to 1975,

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