On the morning of December 1, 1974, TWA Flight 514 was descending toward Dulles International Airport, outside Washington, in cloud. Air traffic control cleared it for the approach. The crew took that to mean they could go straight down to 1,800 feet, the altitude printed for the last part of the approach. They were still miles short of that part. The plane hit the west slope of Mount Weather, Virginia, at about 1,670 feet. All 92 people on board, 85 passengers and 7 crew, were killed.
The National Transportation Safety Board found that pilots and controllers had been misreading “cleared for the approach” for years, and that the FAA had known about the confusion without fixing it.
Then the board found something it called ironic. About six weeks earlier, a United Air Lines crew had been cleared for the same approach to the same runway and made the same descent to 1,800 feet too early. They landed without incident. Only afterwards, going back over the approach, did they work out what they had done. The board’s report notes that a United plane had “narrowly missed the same mountain.”
The crew told their company. They could, because in January 1974 United had started a Flight Safety Awareness Program. Pilots could report anything with safety implications without naming themselves or their crewmates, and the airline promised it would take no punitive action over what it learned. United looked into the report and published a notice to all its flight crews: the words “cleared for approach” generally put the crew on their own, so don’t start down without checking the other minimum altitudes.
The notice went to United’s pilots. TWA’s crew never saw it. At the hearings, witnesses testified that reports of unsafe conditions often never reached the FAA or the airlines at all, “because the individuals were afraid of punitive action.” The board called it “most unfortunate” that the near miss had not been open to “uninhibited reporting,” which might have spread United’s warning widely and in time.
The FAA knew it was the wrong body to collect such reports, since it also enforced the rules. In August 1975 it agreed with NASA that the FAA would pay for a national reporting program and provide limited immunity, and NASA would run it. The Aviation Safety Reporting System began operating in April 1976. Reports are voluntary and confidential. By federal regulation, the FAA will not use them in any enforcement action, “except information concerning accidents or criminal offenses.” The protection has limits. For an unintentional violation that meets the program’s conditions, a report can spare a pilot a fine or a certificate suspension. The FAA can still find, through its own investigation, that a rule was broken.
By 2016, its 40th year, the system had received more than 1.3 million reports.