I have previously introduced the Aviation Safety Reporting System (ASRS) in mainland China and Taiwan. Recently, Japan’s ASRS has also launched; its system is called 航空安全自発報告制度 (Voluntary Information Contributory to Enhancement of the Safety), or VOICES for short. Its registration system uses a different URL, which can be found here.

Currently, VOICES has released two information feedbacks, published quarterly on the website: No. 2014-001 from last December and No. 2014-002 from this March. After reading them, I found that the information here not only reflects problems but also includes many reflections and information sharing from aviation practitioners. This may be related to the national character, I suppose.

Here are a few selected items to take a look at:

1. A pilot reported that while approaching Sendai Airport at 1500 feet, many balloons suddenly appeared, estimated to be from a nearby wedding ceremony. Although this incident did not have a major impact on the flight, caution is needed in the future.

2. A pilot reported that during a parallel Runway approach, the instruction sent by Approach was late and verbose, affecting the timing of the turn onto the localizer (ILS course). As a result, when contacting the Tower, the pilot was told they had overshot.

3. When turning from Taxiway W into Spot 5 at Haneda Airport, since Spot 5 is located on the corner of Taxiways W and H, there was an aircraft on Taxiway H ahead. The space available to turn was extremely narrow, nearly causing a collision. It is hoped that ATC will pay attention to this in the future.

4. Upon entering the cockpit and adjusting the rudder pedal position, I discovered a plastic bottle that had been left inside!

5. During the Arrival into Narita, the plan made based on the ATIS changed completely—first the ILS, then the STAR Waypoints, and finally the Runway changed. As a result, the pilot was continuously operating the FMS, occupying time that should have been spent monitoring instruments and the external environment.

6. A small aircraft was flying above 10,000 feet. The pilot did not brief the passengers on the symptoms of hypoxia in advance. As a result, one passenger experienced toothache due to hypoxia.

7. Some foreign passengers brought their own seat belt extenders on board; this behavior needs to be prohibited.

8. 40 minutes after Takeoff, cabin crew discovered that in a row of 3 seats, two adults were holding an infant. It is estimated that the passenger on the aisle side had moved the child from its originally assigned seat. Since there are only 4 oxygen masks for a row of 3 seats, if an emergency occurred, it would not be possible to ensure everyone could use oxygen. Therefore, the child was moved back to the original position.

9. After Takeoff, encountering strong frontal Turbulence, I used VNAV PATH mode to Climb, but the speed became slower and slower. The Pitch reached a maximum of 15 degrees, and the vertical rate reached a maximum of 8000 ft/min. SPD was set to 280, but the speed dropped below 250. Later, I switched to VS mode and set it to 1000 ft/min, but the speed was still decreasing. Consequently, I disengaged the autopilot and manually pushed the Pitch to restore the speed to a normal value.

10. I received airport clearance quite late. After that, when closing the cabin door, the tug had not yet arrived. As a result, I was still waiting for the tug when requesting pushback. In the confusion, after taxiing out, I remembered I had forgotten to execute the PREFLIGHT Checklist.

11. I subconsciously entered the wrong direct-to Waypoint. Fortunately, the PM reminded me, and I did not deviate from the Airway.

12. During the Descent, I used FLCH mode with the speed set to 270 in the MCP IAS window. Later, I used VNAV intending to decelerate to 250 and pressed the MCP MACH Selector. However, without confirming the result, I pressed it while in FLCH; the light did not go out, but I subconsciously believed the speed value in VNAV had been set. Later, at an altitude of 8500 feet, I noticed the overspeed. I used V/S mode to reduce the Descent rate and extended the speed brakes to lower the speed to 240.

13. After Takeoff, encountering wake turbulence from the aircraft ahead, an Over Bank warning occurred, and the AFDS (Autopilot Flight Direction System) mode changed to CWS (Control Wheel Steering) Roll mode. Later, the Roll Rate recovered, so I turned off the autopilot and reset the Heading.

14. Due to weather and high traffic volume, I forgot to deactivate the Speed Intervention setting. As a result, I exceeded the speed limit from 10000 feet down to 8000 feet.

15. When docking at a Jet Bridge at Shanghai Pudong Airport, I used the VDGS. However, because the nose tire had passed the blue stop position box on the ground, I had to use a tug to push back 30 centimeters to get within the box so the Jet Bridge could connect. As a result, it took over ten minutes from stopping to connecting the PBB (Passenger Boarding System). When using the VDGS at Pudong Airport, if the speed exceeds 7.7 km/h, it displays a “Slow Down” message, so be sure to reduce speed.

There are too many things, so I will stop here for today. I have two main takeaways: First, even very experienced pilots can make mistakes due to cognitive bias. Although these did not have a major impact on the flight mission in the end, summarizing experience and actively sharing it is very important. Second, the division of duties between PF and PM is too important. Even during the extremely busy phase of an Arrival, the PM must not forget their primary responsibility of monitoring, nor should they excessively participate in the work for which the PF is responsible.

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