SAFETY Safety-related information

A summary of past safety troubles and measures

FY2007

Aircraft Accident

  • Passenger injured by rocking on Flight 636
  • Damage to the aircraft on Flight 3228

Serious Incident

  • Go Around on Flight 2576
  • Running out of runway during landing on Japan Air Commuter Flight 2345
  • Breach of the ATC instruction on Flight 502

Others

  • Stowing meal cart in the lavatory at landing of Flight 958
  • Runway incursion on Flight 1280

Aircraft Accident

Fatal or serious injury of an person as a result of the operation of an aircraft, or an aircraft crash, collision or fire, as classified by the Japanese Ministry of Land, Infrastructure, Transport and Tourism (MLIT).

Passenger injured by rocking on Flight 636

Outline

On October 27, 2007, Japan Airlines flight 636 (from Hangzhou to Narita) encountered turbulence during approach to Narita International Airport, causing injury to one passenger. After landing, the passenger informed the staff, and received a medical checkup at the airport clinic and a nearby hospital. Nothing abnormal was found, but as a result of a checkup at another hospital 2 days later, it was found that the passenger suffered thoracic vertebral fracture. As a result, this case was classified as an Aircraft Accident by MLIT on October. 30.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board, and the results were announced on December 19, 2008. According to their report, the aircraft passed a frontal zone that had developed north of a typhoon during descent, when the seatbelt sign was turned on. The aircraft rocked violently when it encountered strong air current disturbance. It is assumed that the carryon baggage, which the passenger was carrying on his/her lap, contacted and unfastened the seatbelt lock. The passenger was thrown from passenger's seat and struck passenger's lower back against the seatback in front.

Countermeasures

We are carrying out the following activities to prevent injury caused by turbulence.

  1. Review the information communication system;
  2. Improve precision of analysis of airspace where turbulence is predicted (develop new atmospheric analysis charts and promote their use, etc.);
  3. Improve training on meteorology for flight crew, cabin attendants and operation controllers.

We have revised the manual of the in-flight announcement to request passengers to stow their personal belongings in the overhead compartment, under the seat, or in the seat pocket when turbulence is expected or has struck, as well as at take-off and landing.

Damage to the aircraft on Flight 3228

Outline

On March 11, 2008, on JAL3228 (from Fukuoka to Chubu) strange sound and quake occurred from the front lower part of the cockpit during take-off. The pilot confirmed that the engine indication reading, cabin pressure etc. were correct and continued the flight, and it arrived at Chubu International Airport. In the after-flight inspection, the dent which seemed to be made by the bird strike was found on the forward right side of the aircraft. At the same time, the deformation and crack were also found in the inner structure of nose landing gear storage space. As the damage corresponded to major repair under the Civil Aeronautics Law, MLIT classified this case as an Aircraft Accident on March 13.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board, MLIT, and the results were announced on May 28, 2010. According to their report, the assumed cause of the damage is the bird strike after take-off from Fukuoka Airport.

Serious Incident

An incident involving circumstances indicating that there was a high probability of an accident, such as overrunning, emergency evacuation, fire or smoke inside the cabin and abnormal depressurization, encountering abnormal weather conditions, etc, as classified by the Japanese Ministry of Land, Infrastructure, Transport and Tourism (MLIT).

Go Around on Flight 2576

Outline

On October 20, 2007, Japan Airlines flight 2576 (from Naha to Kansai) received permission for landing from ATC and was approaching Runway A of Kansai International Airport when Air Canada flight 036, which was scheduled to take-off from the same runway, entered the runway against ATC instructions to standby short of the runway. The JAL aircraft performed Go Around under ATC instructions. None of the passengers and crews were injured. This case was classified as a Serious Incident by MLIT, but the JAL aircraft is handled as a related aircraft, and is not involved in the cause of the incident.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board (JTSB), and the results were announced on August 27, 2010. According to their report, it is assumed that the Air Canada flight crew, who were instructed to standby short of the runway , mistook it and read back as "enter the runway." The air traffic controllers misunderstood the read back and did not confirm it. As the Air Canada aircraft entered the runway, the JAL aircraft which had already received ATC clearance for landing had to perform Go Around.

Running out of runway during landing on Japan Air Commuter Flight 2345

Outline

On February 18, 2007, Japan Air Commuter flight 2345(from Itami to Izumo)veered to the right after landing at Izumo Airport, crossed the lawn and taxiway from the runway center, and stopped on entering the Spot. On checking after the aircraft stopped, it was found that the front left tire had gone flat, and the right tire was loose. None of the passengers and crews were injured. MLIT classified this case as a Serious Incident.

Investigation into the cause

Investigations were conducted by JTSB, and the results were announced on August 28, 2009. According to their report, the left propeller experienced Coarsen Pitch when making touchdown. When the Nose veered to the right during run, the flight crew did not implement the necessary operation to stop and correct this. The aircraft ran out of the runway, damaged the front gear, and was unable to self-propel on the ground. As for the cause of the Coarsen Pitch of the left propeller, it is assumed that the Auto Coarsening System*1 was activated when operating the power lever before making touch down.

*1 Auto Coarsening System
When either the Engine of either side malfunctions at take-off or , the system sets the propeller of the troubled side in feather positions (propeller angle is set parallel to the direction of movement) to reduce the pilot's workload.

Countermeasures

Japan Air Commuter and Hokkaido Air System, which operates the same aircraft type, instructed their flight crew to recheck related manuals about the features of the Auto Coarsening System, including precautions of the system, and conducted training.

Breach of the ATC instruction on Flight 502

Outline

On February 16, 2008, Japan Airlines flight 502 (from Shin-chitose to Haneda) did not read back ATC instructions correctly "anticipate immediate take-off," conceived that clearance for take-off was issued, and started take-off run. ATC immediately instructed the aircraft to suspend take-off, which it did. After returning to the Spot, the aircraft was told that it had started take-off run without receiving permission and an aircraft that had landed was still on the runway. None of the passengers and crews were injured. MLIT classified this case as a Serious Incident.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board (JTSB), and the results were announced on January 23, 2009. According to their report, as for the reason why the aircraft started take-off run without receiving permission, it is assumed that ATC conveyed air traffic information which included the rarely used term "IMMEDIATE TAKE-OFF," which the Captain mistook as instructions to "immediately take-off." Also the other flight crew members did not offer any advice.
The report contained the following Comment*2 to the Minister of LIT.

*2 Comment
When deemed necessary, JTSB provides comments to the Minister of LIT or related administrative organizations on measures to reduce damage.

Comment:In conformance to the Act for Establishment of the Japan Transport Safety Board, we would like to provide the following comment to the Minister of LIT based on results of the Serious Incident investigation in order to secure safety in air transportation.

  1. Review CRM training

    Provide guidance to the airline to review content and timing, etc. of CRM training in order to create an environment to enable flight crewmembers including pilot trainees to quickly and proactively offer advice to the Captain at times they question the Captain's judgment, operation, etc. in line training.

  2. Consider language of ATC

    Implement the following items to prevent runway incursion, or misdeparture, etc. When implementing these items, make the necessary adjustments with the Minister of Defense, as ATC duties of commercial aircraft taking off and landing at Shin-chitose Airport, etc. are entrusted to the Minister of Defense under the control of the Minister of LIT, according to the Civil Aeronautics Law.

    1. Establish rules for usage limitations of the term "TAKE-OFF", which could cause misunderstanding by flight crew, and consider the need for similar rules for other terms. Conduct adequate training of air traffic controllers and reduce the risk of misunderstanding of communications with air traffic controllers.
    2. Consider reduction of workload of air traffic controllers, in terms of manpower and facilities, at airports with heavy air traffic where aircraft operation requirements are strict and weather conditions make visual confirmation of aircraft difficult.
    3. Air traffic controllers should perform their duties with a good understanding of the conditions faced by flight crew and their needs, and consider measures.

Countermeasures

The following measures were implemented immediately after this incident.

  1. We disseminated this case to all flight crew and reminded them to securely follow procedures (read back ATC instructions with the specified language, recheck when you are in doubt, unify understanding among all flight crew) in any situation, and improved training methodology.
  2. We instructed organization management staff to swiftly remind all flight crew through direct communication to "reinforce the importance of verbal confirmation and the basics" and "observe manuals and code of conduct, etc."
    (Refer to "Others" :Runway incursion of Flight 1280)

Others

The following 2 cases don't correspond to an Aircraft Accident, Serious Incident or Safety Trouble.

Stowing meal cart in the lavatory at landing of Flight 958

Outline

On February 6,2008, Japan Airlines flight 958 (from Busan to Narita) took-off and landed with one meal cart in the lavatory as it could not be stowed in the specified location.

Countermeasures

The following measures were implemented to prevent recurrence.

  1. We disseminated the case immediately at crew briefing of departure and arrival flights and cautioned crew.
  2. We reminded crew of the importance of making reports on safety (report immediately to the Captain in case of a situation that affects safety).
  3. We interviewed and checked the knowledge and perception of all Cabin Supervisors concerning the handling of carts and communication of safety-related information.
  4. The executive director in charge of cabin attendants and management staff held Urgent Safety Meetings and discussed problems on the frontline in depth.

Runway incursion on Flight 1280

Outline

On March 4, 2008, Japan Airlines flight 1280 (from Komatsu to Haneda) read back ATC instructions to stop short of the runway, but overran the runway as the area near the taxiway was dark at night and it was difficult to confirm the stop line. The aircraft immediately reported conditions to ATC and visually confirmed the lights of an approaching aircraft, therefore, requested ATC that the approaching aircraft perform Go Around. After it performed Go Around, the aircraft took-off under ATC instructions.

Countermeasures

Immediately after this incident, we disseminated it to all flight crew and cautioned them.
Taking into account that this case and the JAL 502 case occurred during training, we suspended all line training on/after March 6, 2008. As a result of investigation problems in the present situation through interviews with many flight crew, etc., we found that human error occurring during training were not appropriately managed. We determined that safety could be adequately secured through training by implementing the following corrective measures. Therefore, we immediately implemented these measures and gradually resumed line training from April 5, 2008.

(Major remedy)
We reminded both instructors and trainees that in line operations, even during training, the greatest precondition is to improve performance as a team by pointing out or advising matters that are necessary for safety.
We will gather and disseminate information on threats (factors that could trigger errors).
We will consider corrective measures to rebuild a system to reduce threats through adjustments with related organizations.
We will review requirements for a candidate co-pilot to sit in the cockpit seat and receive training and requirements of qualified co-pilots (environmental limitations, experience limitations) in co-pilot line training.