http://www.wsj.com/articles/on-asias-flights-potentially-dangerous-mistakes-go-unreported-1436836841
On Asia's Flights, Potentially Dangerous Mistakes Go Unreported
Daniel Stacey
14 July 2015
[Many incidents aren't logged, increasing risk as the Asian aviation market booms]
Last year, an Indian Jet Airways Boeing 777 accidentally dropped 2,500 feet while its captain was asleep and its co-pilot was absorbed in her tablet device.
It was a serious mishap known as an "altitude bust" that put the plane in the wrong part of the sky where it could have collided with another jet.
The pilots and airline never reported the incident to authorities. Word only reached India's Director General of Civil Aviation a few days later when an anonymous tipster alerted officials.
Jet Airways suspended the captain and co-pilot after regulators opened an investigation. An airline spokesman said "appropriate corrective training" was provided. The pilots' names weren't released.
A Wall Street Journal analysis of flight data and interviews with pilots, air-traffic controllers and aviation experts reveals patterns that indicate many other similar incidents are going unreported across the fast-accelerating Asian aviation market.
In terms of annual passenger numbers, India and Indonesia both grew more than 200% during the last decade and China over 300%.
According to the United Nations' International Civil Aviation Organization, Asia had 39.2 million departures in 2013, compared with 35.66 million in Europe and 51.49 million in North America.
Though North America still has more departures, Asia is now the world's largest market by annual passenger counts, according to the International Air Transport Association.
Such volume raises fears across the aviation industry that Asia's booming markets may be blind to certain risks—both in the air and on the ground.
Safety is becoming a bigger concern in the region after several disasters.
They include Malaysia Airlines Flight 370, which disappeared in March 2014 with all 239 passengers and crew presumed dead.
AirAsia Flight 8501 crashed in December after leaving Surabaya, Indonesia, killing all 162 on board.
TransAsia Airways Flight 235 went down soon after takeoff in Taipei in February, killing 43
Without proper accounting, experts say, airlines can't learn from mistakes and regulators can't properly assess safety risks.
Even smaller incidents—like component failures and near misses on the runway—are key bellwethers for major crashes. Left undocumented, botched procedures are left to grow endemic.
Lack of transparency
The United Nations' International Civil Aviation Organization, which sets global standards for national regulators, compiles the industry's most-trusted database of accidents and other major incidents.
But it says it doubts its results for Asia fully reflect reality—except when it comes to fatal accidents which are hard to hide.
That is all the more important considering the special nature of the aviation industry, which relies on information-sharing and transparency to ensure public safety.
Careful attention to even minor details has helped boost safety considerably in recent years, though concerns remain in areas where rapid growth is putting strains on infrastructure.
Consider Indonesia. About three million commercial-jet flights took off in the country over the last five years, roughly the same as Australia, according to ICAO data.
During that period Indonesia had 28 major accidents—a category that includes deadly crashes or severely-damaged planes—compared with five in Australia. The tallies suggest higher risks in Indonesian airspace.
Yet when it comes to incidents that don't involve fatalities, the statistics tell a different story.
Indonesia reported only 13 serious incidents over the half-decade for big passenger aircraft, versus Australia's 58, ICAO data showed.
Serious incidents include events that come close to causing death or injury, which are mandatory to report under ICAO rules.
For less serious incidents, which the ICAO recommends countries report, but aren't mandatory, Indonesia logged five compared with Australia's 74.
Such incidents include flying too low or too fast, drifting into the wrong airspace, engine failure or smoke in the cockpit.
A report prepared by carrier Garuda Indonesia for a safety conference in 2012 found several near misses across the country that weren't reported to the ICAO.
They include an incident on the ground in which a Lion Air plane missed a Garuda Indonesia jet by three meters.
In another case, stairs were blown off a Garuda plane by blasts from a passing jet engine as passengers were about to disembark.
A Garuda spokesman said these events were investigated internally, and reported to the country's airworthiness directorate.
A Garuda internal report found neither "violation nor negligence" and no staff were suspended or punished, or safety procedures changed, the spokesman said.
Lion Air didn't respond to requests for comment.
The head of safety for Indonesia's air traffic control authority, Wisnu Darjono, told The Wall Street Journal the country doesn't report ground incidents to the ICAO unless planes crash into each other.
It only reports near misses in air when they trigger collision avoidance warnings in aircraft, which happens when planes are 40 seconds away from colliding.
In more advanced ICAO member states like Europe, the protocols are different.
Any incident between two planes that requires an avoidance maneuver, or where the plane's separation is less than half of what it should be, is treated as a serious incident and reported to the ICAO.
The ICAO has "recognized (under reporting) as an issue" and is seeking ways to improve data collection, including tracking media reports of incidents that may not have been officially reported, said Anthony Philbin, a spokesman for the U.N. agency. The agency uses its incident reports to help set safety guidelines for the industry.
Using ICAO data, The Wall Street Journal found that China, compared with the U.S., reported only 6% as many nonfatal accidents and incidents to the ICAO for the last five years of complete data, ending in 2013.
But during that time, China operated 26% as many flights as the U.S.—indicating a much lower reporting rate in some categories.
However, results during the period were different for Chinese airlines flying abroad, where they are under the jurisdiction of foreign regulators.
Those flights were 9.3 times more likely to be reported to the ICAO for accidents and incidents than when flying at home.
As a whole, Asia had 84 minor incidents for scheduled commercial flights over the last five full years of ICAO data, compared with 356 in Europe and 145 in North America.
Yet there were 31 fatal crashes involving large passenger jets in Asia during that period, compared with 12 in Europe and 6 in North America. Again, such figures suggest underreporting.
Africa and Latin America also have a major problem with underreporting, experts say.
Africa tends to have a higher accident rate per capita than Asia, as well.
Fatality rates per 1 million departures for large commercial passenger aircraft from 2009 through 2013 were 123.7 for Africa, 29.9 for Asia, 5.1 for Europe 18.5 for Latin America and the Caribbean, and 1.2 for North America, according to the ICAO.
But Asia's aviation industry is far bigger and is expected to grow more quickly.
In the next 20 years, Asia is expected to spend more on new planes than the U.S. and Europe combined, according to Boeing and Airbus, while potentially introducing millions of people to air travel for the first time.
Part of the problem is that reporting methods vary widely around the world.
Most countries are signatories to a 1944 Chicago Convention on Civil Aviation that requires national regulators to conduct investigations into accidents reported by airlines and others and provide their findings to the ICAO's head office in Montreal.
But there are variations from country to country. The ICAO has limited enforcement powers if some carriers or regulators decide not to report everything. Sometimes national regulators may be aware of problematic incidents but don't bother alerting the ICAO, experts say.
Harsh penalties
Another concern is that Asian nations have a history of stiff punishments for people involved in safety incidents—a disincentive for employees to speak up when mistakes occur.
After a Henan Airlines crash in 2010 that killed 44, the captain, who survived, was jailed.
Harsh penalties are less common in the U.S., which uses a confidential national reporting system that guarantees aviation employees won't be punished by the Federal Aviation Administration if they report air-safety incidents within 10 days—unless the violators were deliberately negligent or inebriated. U.S. carriers have similar systems in-house that keep reporters' names confidential from airline managers.
Since 1979, the U.S.'s national confidential reporting program has processed over a million anonymous tips. It published 4,565 incident reports last year.
By contrast, Mike O'Neill, president of the Hong Kong Air Traffic Controllers Association, said that he has never heard of a controller voluntarily reporting an error or accident.
With the threat of punishment, Asia air-traffic controllers "have no idea what their future holds if they have an accident," he said.
With guidance from U.S. regulators, Japan, Taiwan, Korea, China and Singapore set up confidential reporting systems between 1999 and 2004.
But safety officials say those attempts largely failed because aviation workers weren't guaranteed immunity from fines or jail time. The systems, they say, also weren't properly promoted.
Since it was established in 2004, the Sino Confidential Aviation Safety reporting System in China has averaged only around 22 published reports a year.
Hung-Sying Jing, an aviation expert at the National Cheng Kung University in Taiwan, said he believes Western-style safety systems haven't been adapted to the realities of a Chinese workplace, where a culture of saving face makes it hard to report mistakes.
A spokeswoman for China's Research Institute of Civil Aviation, which is affiliated with the aviation regulator, said the aviation administration doesn't offer immunity from punishment for those who report problems.
But it does collate the reports, protects the personal information of those who report problems and encourages aviation workers to share information.
An official at the Korea Transportation Safety Authority said they promote their confidential reporting system through newsletters which are distributed to airlines, aviation organizations and individuals. The system published 49 reports in 2014, its website shows.
The Taiwan Confidential Aviation Safety Reporting system received only 17 voluntary reports last year, according to a spokesperson. Taiwanese officials said a new law strengthening immunity for those reporting safety breaches was finally passed in November last year.
In Japan, officials said their system has fared better, receiving around 100 reports from pilots last year.
However, until recently the system only accepted reports from pilots.
After an ICAO request, the system was upgraded to allow reports from air-traffic controllers and other aviation workers in July 2014, they said.
The importance of careful reporting has been evident for years.
In 1974, TWA Flight 514 collided with a mountaintop en route to Washington, D.C., after the pilots became confused about landing instructions, killing all 92 on board.
Six weeks earlier a United Airlines flight had made a similar mistake, narrowly avoiding a crash.
But the pilots had only reported the incident internally to their airline, which had warned only its own staff—but not alerted the FAA.
That spurred development of the U.S.'s confidential reporting system, which also offered reporting persons immunity from fines and suspensions.
Shawn Pruchniki, a former commercial pilot with now-defunct Delta Air Lines subsidiary Comair, said reports from pilots jumped around 65% once confidentiality protections were put in place at his carrier.
He recalled a case in which two pilots from Comair reported accidental descents due to new lighting around a mural of horses and farmland under the approach path to Lexington's Blue Grass Airport. The new lights, the pilots said, looked similar to navigation aids.
A warning was immediately issued and emergency radio contact was made with flights en route to the airport.
A spokesman for the airport said the lights weren't the problem and that the mural had been included in the FAA's airports directory, at the airport's request. The lights were replaced a few days after the incident
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