SAFETY Safety-related information

A summary of past safety troubles and measures

FY2009

Aircraft Accident

  • Damage to the aircraft of Japan Air Commuter Flight 2356

Serious Incident

  • Runway incursion with no permission of JAL Express Flight 2200

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).

Damage to the aircraft of Japan Air Commuter Flight 2356

Outline

On November 29, 2009, Japan Air Commuter 2356 (from Izumo Airport to Osaka International Airport) confirmed some birds near 300ft altitude after take-off, and encountered a bird strike with one bird immediately afterwards.
As instructions of flight instruments, etc. were normal, the flight crew continued the flight, and landed at Osaka International Airport in normal conditions.
During inspection after arrival, damage suspected to be caused by the bird strike was found on the left front Nose panel.
As the damage corresponded to major repair under the Civil Aeronautics Law, MLIT classified this case as an Aircraft Accident on December 2.

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 Izumo 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).

Runway incursion with no permission of JAL Express Flight 2200

Outline

On July 23, 2009, JAL Express 2200 (from Sendai Airport to Itami Airport) crossed Runway A without permission from Air Traffic Control (ATC) after landing on Runway B of Itami Airport. As a result, Japan Air Commuter 2400(from Kagoshima Airport to Itami Airport), which was approaching Runway A, performed Go Around under ATC instructions. None of the passengers and crew were injured. This case was classified as a Serious Incident by MLIT.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board, and the results were announced on July 30, 2010. According to their report, the assumed cause is human error by the flight crew and ATC. In other words, the flight crew of JAL Express misheard ATC instructions "standby short of the runway" and read back as "cross the runway." As ATC, who heard this read back, did not notice the mistake, the aircraft entered the runway.

Countermeasures

As it was necessary to intensify coordination between ATC and pilots, and develop the environment of both software and hardware to prevent human error of both sides, MLIT and JAL Express implemented the measures below.

MLIT, JCAB

  1. Improve warnings to pilots

    Always keep runway warning lights illuminated
    Develop runway signage on the taxiway

  2. Prevent mishearing and hearing slip

    Review ATC terms
    Prevent hearing slips by simplifying ATC instructions
    Reinforce check of read back

JAL Express

  1. Disseminate this case and caution flight crew
  2. Train flight crew using past cases of mis-communication with ATC
  3. Check implementation of measures through observation by managerial Captain
  4. Hold meetings with Itami Airport ATC to consider measures

JAL Group will continuously reinforce communications with ATC and implement safety activities in coordination with ATC.