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Safety Operations

Safety Incidents and Countermeasures in 2005
Emergency Landing by Flight 047
Damage to Landing Gear on Flight 778
Damage to Nose-Gear Wheels on Flight 1002
Engine Trouble on JALways Flight 58
Problems with Emergency Escape Chutes on JAA Flight 209
Failure of Thrust Reversers on Flight 3913
Time Limit Exceeded for Mandatory Tests on an MD-87
Emergency Landing by Flight 047

On May 8, 2005, JAL flight 047 from São Paulo to Narita via New York had to make an emergency landing at New Chitose Airport. This resulted after its rapid descent owing to a drop in cabin pressure at approximately 11,000 meters at a point about 370 kilometers southeast of New Chitose Airport. This descent and landing were achieved without injuries to passengers.

Temporary Measures: JAL carried out functional tests on the pressurization systems on all 747-400 aircraft in its fleet. We removed all cabin-pressure controllers that had been in use for extended periods and tested them at our component-maintenance facility. In addition, we implemented detailed inspections of internal circuit boards for these controllers. The Ministry of Land, Infrastructure and Transport classified the flight-047 event as a serious incident, and an investigation into the causes is being carried out by the Aircraft and Railway Accidents Investigation Commission. JAL is fully prepared to implement any necessary additional measures upon receipt of the accident-investigation report.

Damage to Landing Gear on Flight 778
On May 30, 2005, JAL flight 778, scheduled to fly from Sydney to Kansai International Airport, suffered damage to part of the left-wing landing gear while being towed from the parking apron. The Australian Transport Safety Bureau classified this event as a serious incident, and an investigation is ongoing. According to the interim report, it is assumed that the damaged forward trunnion suffered reduced fatigue strength as a result of skipping shot peening and inadequate wall thickness owing to inappropriate mechanical processing during manufacture, and that long usage led to fatigue failure.

Temporary Measures: JAL implemented an emergency inspection of the forward trunnions on all 747-400 aircraft in its fleet and confirmed that there were no similar defects. The company also measured the wall thickness of the forward trunnions and performed non-destructive inspections on them. JAL has also fully established a maintenance program for periodic inspection. We are prepared to implement any necessary additional measures upon receipt of the official investigation report.
Flight-Crew Member on Restricted Medicines
A flight-crew member was diagnosed with a benign tumor of the parotid gland. He had an operation to remove the tumor in May 2006 while on leave and did not inform the company doctor of the situation. After the operation, he was taking four types of medication and was on duty on seven flights from June to July — a total of 9 hours, 50 minutes. These medicines did not make him drowsy, but possible side effects included hypersensitivity, stomach and bowel irritation and headaches. Flight crew are prohibited from serving onboard within 24 hours after taking such medication.

Countermeasures: We made a public announcement of this event and confirmed that there were no other cases. We will establish simple health guidelines, publish these in brochures and distribute them to flight crews. We will review the company regulations, based on these guidelines, and educate flight crews about health control.
Damage to Nose-Gear Wheels on Flight 1002
On June 15, 2005, two tires from the nose-gear wheels on JAL flight 1002 from New Chitose Airport became separated as the plane landed at Haneda Airport. There was also damage to part of the wheels, and the aircraft became stranded on the runway. Three passengers complained of neck pain and of feeling sick, with one receiving treatment at the airport clinic.

Temporary Measures: JAL implemented visual checks of the tires and wheels on all aircraft in its fleet, confirming that there were no similar defects. The Ministry of Land, Infrastructure and Transport classified this event as a serious incident, and an investigation into the causes is being carried out by the Aircraft and Railway Accidents Investigation Commission. The company is prepared to implement any necessary additional measures upon receipt of the accident-investigation report.
Engine Trouble on JALways Flight 58
On August 12, 2005, JALways flight 58 (DC-10) from Fukuoka to Honolulu encountered left-wing engine trouble shortly after takeoff and immediately returned to Fukuoka Airport. In the process, some engine parts fell on the Sharyo district of Fukuoka. As a result, several people were slightly injured and windscreens of automobiles parked around Sharyo were damaged. Investigation revealed that the probable cause was erosion of the turbine blade inside the engine. The erosion produced holes in the blade, through which the cooling air escaped, and the blade overheated, leading to failure.

Countermeasures: The company shortened the borescope-inspection interval from 2,500 to 1,000 hours for 747 aircraft using the same type of turbine blade. By October 2005, all DC-10 aircraft had been decommissioned.
Problems with Emergency Escape Chutes on JAA Flight 209
On December 26, 2005, a flight engineer on Japan Asia Airways (JAA) flight 209 from Narita to Taipei discovered that the slide packs storing the emergency escape chutes, positioned by the emergency exits on the upper deck of the aircraft, were not in their correct position in front of the emergency doors, but were to the rear. The attendant responsible for the upper-deck cabin had made a preflight check and mistakenly given the OK.

Measures to Prevent Recurrence: The reason why the slide packs were not in their correct position could not be identified. The crew had failed to discover the problem with the slide packs prior to the flight, and JAL put the cabin crew through retraining. To prevent recurrence of the problem, JAL modified the slide packs so that they could be fixed in position.
Failure of Thrust Reversers on Flight 3913
On January 7, 2006, the left-engine thrust reversers on JAL flight 3913 from Itami to Kagoshima failed to operate upon landing at Kagoshima Airport. The pilot performed a normal landing, and there were no injuries to passengers or crew. Checks revealed that the safety lock pin, which is used during maintenance to prevent activation of the thrust reversers, had been left in place on the left engine.

Upon investigation, it was found that when repair work was carried out on the left engine at Itami Airport, the mechanic had disabled the thrust reversers by inserting the safety lock pin without a streamer, attached to the hydraulic-control unit of the aircraft as a safety precaution. However, the mechanic failed to remove the safety lock pin when the work was completed.

Countermeasures: The company has enforced the use of safety lock pins with streamers, which are stored in the tool room, when disabling the thrust reversers.
Time Limit Exceeded for Mandatory Tests on an MD-87
On March 20, 2006, it was discovered that the time limit for carrying out inspection of the main-gear section of an MD-87, mandated by the Ministry of Land, Infrastructure and Transport as being 450 flights, had been exceeded by 41 flights (10 days). JAL rushed an inspector to New Chitose Airport to perform the necessary inspection. On March 22, reconfirmation of the contents of the inspection revealed that it had not been carried out in accordance with the manual.

Countermeasures: The aircraft underwent further inspection at New Chitose Airport. Inspection of the main gear of all MD-87 aircraft was completed by March 26. On March 22, JAL was issued with a written reprimand by the Ministry of Land, Infrastructure and Transport. On April 5, the company submitted a reply to the ministry, detailing the results of investigations into the causes and measures to prevent a recurrence of the incident.
We are promoting safety awareness by following the advice of the Safety Advisory Group: improving communication between management and staff, continuing regular education of managers in charge of safety and making effective use of the Safety Promotion Center.
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