Summary of Aircraft Accidents and Serious Incidents, and Measures
A summary of past safety troubles and measures
FY2015
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
Investigations were conducted by the Japan Transport Safety Board, and the investigation report was disclosed on October 26, 2017. It suggests that, the passenger suffered major injuries by landing on her hip when sliding down the evacuation slide during the emergency evacuation, which was performed because small flames were observed in the rear part of the second engine when there was foul smell and smoke in the cabin while the aircraft was waiting on the taxiway due to heavy snow. The foul smell, smoke, and the flames in the rear part of the second engine were caused by heavy snow with the sudden change in weather. The engine oil leaked (*1) inside the engine because snow stayed on the fan blade and low-pressure compressor. The oil nebulized and entered into the cabin (*2), and the leaked engine oil accumulated in the exhaust causing flames in the rear part of the engine.
In addition, it is pointed out that it is desirable that the Civil Aviation Bureau of MLIT and the air carriers should inform the general users of the safety information at the emergency evacuation with its reason for the settings and study how to promote the more sound understanding and awareness, considering possibilities for other companies to have similar accident.
*1 Part of the air inlet was clogged with the snow, reducing the amount of air flowing into the engine. This reduced the pressure in the bearing compartments within the engine and as a result the engine oil leaked from the said compartments.
*2 Since part of the air is used for the air conditioning in the cabin, the leaked oil mixed with the air, nebulized, and flowed into the cabin causing foul smell having a smoke - like appearance.
Countermeasures
JAL implemented the following measures after the accident.
- Measures to prevent snow from sticking on the engine , foul smell and smoke.
- Notified the flight crews that engine oil can leak when ice and snow accumulate inside the engine. Furthermore JAL clarified the procedures of heavy snow for 737-800 and changed the procedures to prevent snow from sticking on the engine when the weather is identified as heavy snow.
- Notified the ground personnel operations to proactively contact the flight crews when detecting sudden unexpected weather changes such as heavy snowfall.
- Measures for emergency evacuation.
- Revised the in-flight safety video to emphasize to passengers not to carry their baggage during emergency evacuation and to help support other passengers at the bottom of the evacuation slide.
- Enforced training sessions for cabin attendants for a faster and safer evacuation under a setting where a number of passengers evacuate with their baggage.
- Enforced education for all JAL Group staff to cooperate with cabin attendants during emergency landing. Furthermore, JAL Group emergency evacuation training sessions are conducted to understand appropriate assistance for passengers.
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
- 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
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
Investigations were conducted by the Japan Transport Safety Board, and results were disclosed on October 26, 2017. According to the report, it is assumed that left-engine bleed air(*1) temperatures rose due to trouble with the precooler control valve(*2) that reduces left-engine bleed air temperature. However, as the thermostat to detect rising temperatures (450℉ thermostat) was broken(*3), left-engine bleed air flow was not regulated and bleed air temperatures continued to rise, causing the switch to detect abnormal high temperatures and shut down bleed air (490℉ switch) to activate and stop left-engine bleed air flow. As left-engine bleed air flow stopped, it is thought that burden increased on the right-engine bleed air system. As with the left-engine, it is assumed that right-engine bleed air temperatures rose due to trouble with the precooler control valve, and as the thermostat to detect rising temperatures (450℉ thermostat) was broken, right-engine bleed air temperatures continued rising, causing right-engine bleed air flow to stop.
(*1)Compressed air that is taken from the engine compressor. Used to pressurize the cabin.
(*2)Trouble was found, in which the volume of precooled air flow was inadequate compared to input from the temperature sensor due to valve deterioration.
(*3)It is assumed that the thermostat was broken before this incident, but the trouble was not found at regular inspections because the thermostat does not function when bleed air is cooled normally.
Countermeasures
After this incident, JTA implemented the following measures on all aircraft of the same type.
- Conducted an emergency inspection to verify airworthiness of precooler control valves, and newly initiated regular inspection every 4,000 flight hours.
- Conducted modification to an improved-type bleed air temperature detecting thermostat (450℉ thermostat), and newly initiated regular replacement and inspection every 16,000 flight hours.
❊Japan Airline have implemented preventive measures on JAL-owned 737-800 aircrafts to avoid similar trouble.
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
- 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.
- Introduced a new taxi procedure with a view to preventing its flight crews from losing situation awareness during taxiing.
- 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.
- 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
Investigations were conducted by the Japan Transport Safety Board, and the Serious incident investigation report was disclosed on December 15, 2016.
According to the report, the small aircraft's captain mistook another company's DHC-8 aircraft, which was flying in front of the Japan Airlines aircraft, for the related preceding aircraft, and the small aircraft followed the DHC-8 aircraft into the final approach path and approached the following Japan Airlines aircraft.
