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94035-0189
Number 204 June 1996
ASRS Recently Issued Alerts On...
Autopilot rate gyroscope failure in a B747-100
Ambiguous taxiway signage at a Louisiana airport
Extraneous GPWS warnings near a California airport
Inconsistent Tower/ASOS indications at a Missouri airport
Loss of separation for two carriers in Venezuelan airspace
March 1996 Report Intake
Air Carrier Pilots 1815
General Aviation Pilots 637
Controllers 83
Cabin/Mechanics/Military/Other 33
TOTAL 2568
From There to Here, With Your Support
ASRS Celebrates Its 20th Birthday
An anonymous wit once observed that “a diplomat is a
person who remembers a lady’s birthday, but forgets her
age.”
advice, CALLBACK is proud to announce both the birthday
and age of the NASA Aviation Safety Reporting System: the
program’s birthday occurred on April 15, 1996, a date which
also marked the 20th anniversary of ASRS operations.
As ASRS enters its 21st year, the program has met the test
of time, fulfilled the early hopes of its founders, and achieved
many “firsts”:
★ Processed more than 338,000 total aviation incident
reports without violating a single reporter’s
confidentiality;
★ Issued more than 2,500 alert messages of all types;
★ Responded to more than 4,800 database search requests;
★ Performed more than 90 Quick Response research
efforts for the FAA, NTSB, and NASA;
★ Published 56 research reports and papers;
★ Returned information to the aviation community
through its two award-winning publications,
CALLBACK (in its 17th year of publication), and
Directline, an aviation safety journal.
In its 20 years of existence, ASRS has become the world’s
largest, and longest-operating, incident reporting program.
Without any doubt, it has also saved lives.
Yet as important as all these achievements are, it is not the
ASRS as an organization—but the aviation community it
serves—that is the real story.
not exist.
a national reporting system to take root in the aviation
community, and to gather its support and trust.
A Phoenix from the Ashes
The precipitating event for the ASRS was a tragedy that
occurred on December 1, 1974.
Trans World Airlines (TWA) Flight 514 was inbound to
Dulles Airport through cloudy and turbulent skies, when the
aircraft descended to 1,800 feet before reaching the approach
segment where that minimum altitude applied.
collided with a Virginia mountain top, with the loss of all
lives on board.
According to the accident report issued by the National
Transportation Safety Board (NTSB), the crew’s decision to
descend was the result of inadequate depiction of altitude
restrictions on the profile view of the approach plate, and
confusion in interpreting air traffic terminology.
investigation uncovered another disturbing, yet provocative,
detail.
crew had very narrowly escaped the same fate, during the
same approach, and at the same location.
Under this
The United pilots involved in the
Other United
Unfortunately, there did
In May 1975, the
The FAA assumed a sponsorship role for
Thus the
Here are some of the
A new alerting product, the
As you celebrate
Putting a more festive (if less discreet) spin on that
For at one time, the ASRS did
Many years of effort were required for the idea of
On that Sunday morning,
Flight 514
The NTSB
Six weeks prior to the TWA crash, a United Airlines
Bill Reynard A Lawyer for All Seasons
Editor’s Note: This tribute to Bill Reynard, NASA Director of the
ASRS from 1980-1996, is deeply indebted to the following
individuals, who also made major contributions to the ASRS
throughout this period: Edgar Cheaney, the Battelle ASRS Program
Manager from 1977-1987; Rex Hardy, CALLBACK’s Editor Emeritus;
and Dr. Charles Billings, Chief Scientist (retired) of NASA Ames.
On April 10, 1996, in one of the poignant ironies that life
sometimes offers, William (Bill) Douglas Reynard, the NASA
Director of the ASRS since 1980, died from long-term
complications related to an earlier heart transplant. Less than a
week shy of ASRS’s 20th anniversary, the man who was most
responsible for guiding the ASRS to its present status as a
worldwide model for aviation incident reporting systems—and who
we hoped would be here to celebrate his and the program’s
achievements—was taken from the helm.
Those who shared Bill’s sense of humor would agree: It was no way
to treat a lawyer. For Bill was a paradox of our contemporary
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