Aviation Safety Reporting: VOICES Feedback Analysis

Previously, I introduced the Aviation Safety Reporting System (ASRS) in mainland China and Taiwan. Recently, Japan’s ASRS has also launched, known as the Aviation Safety Voluntary Reporting System (Voluntary Information Contributory to Enhancement of the Safety), or VOICES for short. Its registration system uses a different URL, available here.

VOICES has now released two information feedback reports, published quarterly on their website: No. 2014-001 from last December and No. 2014-002 from this March. After reviewing them, I found that beyond simply reporting problems, many entries reflect self-reflection and information sharing by aviation professionals - perhaps related to national culture.

Here are several selected cases for analysis:

1. Pilot reported: During approach to Sendai Airport at 1500 feet, numerous balloons suddenly appeared, likely released from a nearby wedding ceremony. Although this flight was not significantly affected, future vigilance is required.

2. Pilot reported: During parallel runway approach, approach control issued instructions late with lengthy communications, affecting the ILS localizer turn timing. Consequently, when contacting Tower, the pilot was advised they had overshot.

3. Reported: When turning from Taxiway W into Spot 5 at Haneda Airport, since Spot 5 is positioned at the corner of W and H taxiways with an aircraft on H, turning space was extremely limited. A near-collision occurred - hope ATC will pay more attention in the future.

4. Reported: Upon entering the cockpit and adjusting rudder pedals, discovered a plastic beverage bottle had been left inside!

5. Reported: During Narita approach, all plans based on ATIS changed - first ILS, then STAR waypoints, and finally runway changes. The pilot continuously operated the FMS, occupying time needed for instrument and external monitoring.

6. Reported: Small aircraft conducting flight above 10,000 feet; pilot didn’t brief passengers on hypoxia symptoms. One passenger experienced toothache from hypoxia.

7. Reported: Some foreign passengers brought their own seatbelt extenders - this behavior must be prohibited.

8. Reported: After takeoff, cabin crew discovered three-abreast seating with two adults holding an infant - apparently the aisle passenger moved a child from another seat. With only four oxygen masks for three seats, this couldn’t ensure oxygen access for everyone during emergencies, so the child was returned to the original position.

9. Reported: After takeoff encountered strong frontal turbulence while climbing in VNAV PATH mode. Speed progressively decreased with Pitch reaching 15 degrees maximum and vertical rate 8000ft/min. SPD was set to 280 but speed dropped below 250. Switching to VS mode at 1000ft/min still resulted in deceleration. Disengaged autopilot and manually pushed Pitch to restore normal speed.

10. Reported: Received airport clearance late; subsequently when closing doors, tug wasn’t in position yet. Requested pushback but had to wait for tug. In the rush after pushback, realized PREFLIGHT Checklist wasn’t executed.

11. Reported: Subconsciously entered wrong direct-to waypoint - PM’s timely reminder prevented route deviation.

12. Reported: During descent using FLCH mode with speed set to 270 in MCP IAS window. Later engaged VNAV intending to slow to 250 and pressed MCP MACH Selector, but without verifying result. In FLCH mode the light remained illuminated, but pilot subconsciously believed speed was set to VNAV value. Only noticed overspeed at 8500 feet - reduced descent rate using V/S mode and deployed speedbrakes to decrease speed to 240.

13. Reported: After takeoff encountered wake turbulence from preceding aircraft triggering Over Bank warning. AFDS (Autopilot Flight Direction System) mode changed to CWS (Control Wheel Steering) Roll mode. After Roll Rate recovered, disengaged autopilot and reset HDG.

14. Reported: Due to weather and high traffic, forgot to disable Speed Intervention - exceeded speed restrictions from 10000 to 8000 feet.

15. Reported: Docking at Shanghai Pudong Airport using VDGS, nose wheel had passed the blue stop position box. Had to push back 30cm with tug to properly position. This delayed Passenger Boarding Bridge (PBB) connection by over ten minutes. When using Pudong’s VDGS, speeds exceeding 7.7km/h trigger “Slow Down” message - speed reduction is critical.

That’s all for today - too many cases to cover. Two key observations: First, even highly experienced pilots can make errors due to cognitive bias - while these didn’t significantly affect flights, summarizing and actively sharing experiences remains crucial. Second, PF/PM role division is vital - even during extremely busy approach phases, PM must maintain primary monitoring responsibilities rather than excessively assisting PF tasks.

Appendix http://jihatsu.jp/news/feedback/FEEDBACK%202014-001.pdf http://jihatsu.jp/news/feedback/FEEDBACK%202014-002.pdf http://www.abc-narita.ac.jp/25_news/Abbreviation121016.pdf