SAFETY Safety-related information

A summary of past safety troubles and measures

FY2015

Aircraft Accident

  • JL3512 Evacuation Case

Serious Incident

  • Go Around by Japan Airlines Flight 455
  • Japan Transocean Air flight 610 lands on runway after another airline's aircraft rejected takeoff
  • Abnormal Decompression of Cabin Pressure on Japan Transocean Air Flight 002
  • JAL038 commenced take-off procedure on a Taxiway
  • Go Around by Japan Airlines Flight 651

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).

JL3512 Evacuation Case

Outline

On February 23, 2016 2:34 p.m. (JST), Japan Airlines flight JL3512 (operating from New Chitose airport to Fukuoka airport) during taxiing for departure, the flight was decided to return to the parking spot due to heavy snow. Later during the return at the taxiway the right engine experienced trouble, smoke entered into the cabin of the aircraft and an emergency evacuation was initiated. As a result of the evacuation, three passengers have been reported with injuries and one of the injured had bone fracture.

Investigation into the cause

Japan Transport Safety Board, MLIT is investigating the cause of the incident. JAL is providing full cooperation with the investigations.

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 by Japan Airlines Flight 455

Outline

On April 5, 2015 (Sun.) at Tokushima Airport, a JAL aircraft was cleared for landing by air traffic control even though a car was working on the runway. The pilot noticed the car right before the wheels touched down and executed go-around.

This incident was rated a Serious Incident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) as it corresponded to an incident under Civil Aeronautics Law Enforcement Regulations Article 166-4 (Serous Incident). None of the passengers or crew was injured.

Investigation into the cause

Investigations were conducted by Japan Transport Safety Board of MLIT, and the results were disclosed on August 25, 2016. According to the report, it is highly probable that the serious incident occurred as JL455 attempted to land because local control at Tokushima Aerodrome control tower had issued a landing clearance to JL455 on the runway occupied by the Work Vehicle. It is probable that the Tower had issued a landing clearance to JL455 to land because the Supervisor, who had the combined duties of the Tower and the Ground, had forgotten about the presence of the Work Vehicle.

Japan Transocean Air flight 610 lands on runway after another airline's aircraft rejected takeoff

Outline

On June 3, 2015, All Nippon Airways (ANA) flight 1694, rejected takeoff at Naha Airport as an Air Self-Defense Force helicopter took off without ATC clearance and crossed airspace in front of ANA1694. ATC instructed Japan Transocean Air (JTA) flight 610, which was approaching the same runway, to Go Around. But JTA610 landed on the runway before ANA1694 was off the runway. None of the passengers or crew was injured.

This incident was rated as a Serious Incident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT), as it corresponded to a case of "landing on a runway occupied by another aircraft."

Investigation into the cause

Investigations were conducted by the Japan Transport Safety Board, and results were announced on April 27, 2017. According to their report, it is probable that the JTA Aircraft on the runway was because the PIC, recognizing the existence of the ANA Aircraft on the runway when it started flare, as it has been issued the landing clearance by the ATC, although he could not confirm the trend of the ANA Aircraft, based on his experience at the airport and on the same type of aircraft and the landing performance, it was judged by the PIC that it could land safely. It is also somewhat likely that the judgement is related to the fact the PIC could not confirm the trend of the SDF Aircraft which had crossed over the runway. Regarding the JTA Aircraft landed on the runway although the ATC instructed it excute a go-around, it is probable that it had already landed on the runway and reverse thrust operation was started when PIC and the FO were recognizing the instruction. In addition, it is probable that it was involved that the instruction of executing go-around had missed the timing.

Countermeasures

Japan Transocean Air took the following preventive measures against recurrence.

  • To the relevant crew members, education, training and examination were conducted.
  • Measures to prevent recurrence for all flight crew members
    - Attract attention on the necessity of monitoring including the ATC at take-off and landing.
    - Crew members at managerial position cautioned attention on this serious incident during the summer safety campaign of 2015. The case was confirmed at the 2015 second half Safety Review meeting.
    - It is planned to execute practice training of go-around just before touch-down in the periodic training (ADVT) for 2016.

Abnormal Decompression of Cabin Pressure on Japan Transocean Air Flight 002

Outline

On June 30, 2015, Japan Transocean Air (JTA) flight 002 experienced abnormal decompression of cabin pressure during flight in the vicinity of Tanegashima. JTA002 requested priority to ATC and descended to an altitude of 3,000m. None of the passengers or crewmembers was injured, and the aircraft arrived at the destination, Kansai International Airport.

This incident was rated a Serious Incident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) as it corresponded to "Abnormal decompression of cabin pressure".

Investigation into the cause

Japan Airlines Group will cooperating with the Japan Transport Safety Board, MLIT for further investigation and will make a full effort to conduct a thorough examination into the cause and take preventive measures against recurrence.

JAL038 commenced take-off procedure on a Taxiway

Outline

On July12 2015 (Local Time), JAL flight 38 commenced take-off procedure on Taxiway at Singapore Changi Airport. Just after the acceleration, pilot noticed that they misidentified runway and aborted at once. At the same time ATC also instructed to abort and the aircraft stopped on the taxiway. None of passengers and crew onboard was injured.

This case was certified as "Serious Incident "from AAIB(*) of Singapore and MLIT of Japan on July31 2015. (* Air Accident Investigation Bureau)

Investigation into the cause

The Singapore Authority (AAIB : Air Accident Investigation Bureau) disclosed on August 2016, its Serious Incident Investigation Report* concerning "Commencing Take-off procedure on a Taxiway" which occurred on July 12, 2015.

Discussion:
The ground movement controller (GMC) instructed the flight crew to 'taxi on the greens' to the holding point of Runway 20C. But FO appeared to have fixated on this mental picture of taxi route (i.e. one single and gradual right turn to enter R20C). FO didn't also confirm the position of the aircraft by checking the signboard & marking etc. There may be merit in ATC verbalising the specific taxi route.
Also When the GMC asked the flight crew what the latest time would be that they had to depart to meet the time restriction, the PIC misunderstood the question. He thought the ATC was asking what the earliest time would be that they needed to depart to meet the time restriction. Therefore when the runway controller (RWC) asked the flight crew to expedite taxiing, the PIC was puzzled. However, he did not query the ATC. When PIC told the time, ATC had a chance to realize that flight crew is misunderstanding to the question.
There were red stop-bar lights on taxiway before the intersection to prevent an aircraft on taxiway from taxiing beyond the intersection. However, this line of defense was breached by the flight crew. The RWC gave the clearance for the flight crew to line up and take off from Runway 20C. Had the flight crew not been issued with a take-off clearance, the error of mistaking taxiway as the departure runway 20C could have been contained.

Countermeasures

During the course of the investigation and through discussions with the investigation team, the following safety actions were initiated by Japan Airlines and the ATC.

By Japan Airlines

  1. Highlighted the following, among others, to its flight crew members in a circular.
    • The importance of reporting unsafe events to the operator.
    • When in doubt, always check before proceeding.
    • The importance of adhering to aircraft manuals and SOP in assuring flight safety.
  2. Introduced a new taxi procedure with a view to preventing its flight crews from losing situation awareness during taxiing.
  3. Developed training material to be used for discussion on safety issues in flight crews' group meetings, e.g. concerning procedures that could be wrongly performed or neglected.
  4. Introduced a mandatory requirement, in the form of a web test, for flight crew members to review their knowledge on non-technical skills *1, especially on multi-crew co-operation *2.

*1 It doesn't directly rely to aircraft operation, system and procedures but skill of necessary recognition to aircraft operations, judgement and interpersonal.
*2 With the cooperation within the flight crew members, corporate as a team under the Captain.

By the ATC

  • To be aware of the possibility of pilots mistaking a parallel taxiway as a runway, especially in situations when pilots need to taxi through a number of turns to reach the runway entry point.
  • To consider separating line up clearance from take-off clearance.
  • Classified the area where the incident took place as a hot spot and made this known in the Singapore AIP Changi Aerodrome Advisory Chart

Go Around by Japan Airlines Flight 651

Outline

On October 10, 2015 (Sat.) JAL crew confirmed another airline's small aircraft cut into its final approach course during descent to Kagoshima Airport after receiving landing clearance and performed Go Around.

The JAL Captain submitted a Captain's Report (report of near midair collision) according to Civil Aeronautics Law Article 76-2, and the incident was rated a serious incident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT).

Investigation into the cause

Japan Transport Safety Board, MLIT is investigating the cause of the incident. JAL is providing full cooperation with the investigations.