Summary of Aircraft Accidents and Serious Incidents, and Measures
A summary of past safety troubles and measures
FY2019
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).
Cabin attendant injured due to the turbulence on JC3763
Outline
On October 12, 2019, a cabin attendant on JC3763 (from Kagoshima Airport to Tanegashima Airport) fell and sustained a bone fracture when encountering turbulence during descent. This case was rated as an Aircraft Accident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT). None of passengers onboard was injured.
Investigation into the cause
Investigations were conducted by the Japan Transport Safety Board, and results were announced on July 29, 2021. According to their report, "In this accident, it is highly probable the cabin attendant, who was walking down the aisle, lost her balance and fell when the aircraft suddenly shook and injured. It is probable that the sudden shaking of the aircraft was caused by the encounter of local changes in wind direction and velocity and also the following factors; a change in the aircraft’s attitude when the pilots pulled up the nose to avoid an overspeed (VMO* exceedance) and the resulting increase in speed."
* VMO: maximum operating limit speed
Countermeasures
After the accident, JAC implemented the following measures.
- Issued a notice on aircraft operation when approaching or exceeding VMO.
- If the aircraft’s speed is expected to approach VMO due to sudden changes in wind or outside temperature, promptly select a speed with enough leeway from VMO.
- If the aircraft’s speed approaches or exceeds VMO, correct the speed with the autopilot system.
- As deceleration by manual control may cause a sudden change in pitch, it should be performed only when it is clearly evident that the aircraft’s speed has not been corrected by the autopilot system.
- Simultaneous manual control by PF(Pilot Flying) and PM(Pilot Monitoring) is prohibited. (It is highly probable that the PF and PM pulled the control column strongly almost simultaneously to avoid VMO.)
- Clearly call out change of control. (Be sure to call out "I have" and "You have” when changing control.)
- Perform takeover early.
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 by another aircraft before landing of JTA212
Outline
On July 21, 2019, while Japan Transocean Air (JTA) flight 212(Kumejima-Naha) was approaching Naha Airport, another aircraft enterd the runway, which was instructed by ATC(Air Traffic Control) to hold short of the runway. Then JTA212 was instructed to go-around by ATC and landed with a new landing permission. None of the passengers or crew was injured. This case was rated as a "Serious Incident" by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) because it corresponded to a "situation prescribed in Civil Aeronautics Law Enforcement Regulations Article 166 Paragraph 4 (Serious Incident)."
Investigation into the cause
Investigations were conducted by the Japan Transport Safety Board, and results were announced on January 21, 2021.
According to their report, it is probable that the serious incident occurred because the JTA aircraft, which had been cleared for landing by ATC, attempted to land on the same runway as the runway which the other carrier’s aircraft had entered despite instructions to hold short of Runway. It is probable that the reason why the other carrier’s aircraft entered the runway was that the captain of the other carrier’s aircraft, on receiving ATC instructions, mistook the instructions to hold short of the runway for instructions to enter the runway, and did not correct his misunderstanding. It is probable that the reason why the captain of the other carrier’s aircraft did not correct his misunderstanding was that the captain and co-pilot of the other carrier’s aircraft did not mutually confirm ATC instructions as prescribed in company regulations.
Runway incursion by another aircraft before landing of JL2163
Outline
On October 3, 2019, while JL2163(Itami-Misawa, operated by J-AIR) received landing clearance from ATC(Air Traffic Control) and was approaching Misawa Airport, another aircraft crossed the stop line and entered the runway. Then JL2163 was instructed to go-around by ATC and landed with a new landing permission. None of the passengers or crew was injured. This case was rated as a "Serious Incident" by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) because it corresponded to a "situation prescribed in Civil Aeronautics Law Enforcement Regulations Article 166 Paragraph 4 (Serious Incident)."
Investigation into the cause
Investigations were conducted by the Japan Transport Safety Board, and results were announced on January 21, 2021.
According to their report, it is probable that the Japan Air Self-Defense Force aircraft incorrectly entered the runway during final approach of the J-Air aircraft on receiving landing clearance because the captain of the SDF aircraft holding on the taxiway short of the runway mistook ATC instructions concerning departure delay information from ATC for takeoff clearance, made other communications immediately after reading back the mistunderstood instructions and therefore was unable to receive ATC instructions to correct the readback, and did not visually confirm the final approach course.
Runway Excursion of JC3830
Outline
On January 8, 2020 , after landing at Amami Airport, JC3830 (JAC-operated) ran off the side of the runway while decelerating and the aircraft came to a halt.
This case was rated as a Serious Incident by the Ministry of Land, Infrastructure, Transport and Tourism (MLIT), as it corresponded to ‘runway excursion’ (limited to when an aircraft is disabled to perform taxiing).
Investigation into the cause
nvestigations were conducted by the Japan Transport Safety Board, and results were announced on March 24, 2022.
According to their report, the probable cause of this serious incident was the delay in correcting the deviation to the left immediately after the touchdown at landing in a crosswind from the left, which resulted in the Aircraft running off the side of the runway, halting in the grass area and being disabled to move on its own.
Countermeasures
JAC and the Design and Manufacturer have taken the following measures to avoid recurrence of the serious incident:
（1)JAC
01.Revised Manuals
- Regarding landing performed when a gust is reported, it is stipulated in OM （Operations Manual）Supplement that judgment, whether to continue approach or halt for a go-around, is made based on the guide that crosswind component of the gust is 1.5 times the maximum crosswind in addition to that the crosswind component of the mean wind velocity satisfies the maximum crosswind stipulated in AOM（Airplane Operating Manual）.
- AOM is revised to incorporate the revisions of FCOM（Flight Crew Operating Manual) by the Design and Manufacturer in terms of normal procedures in landing roll.
- “OPERATIONS IN WIND CONDITIONS” is newly incorporated in AOM that reflects what is described in FCOM.
- Descriptions in FTG（Flight Technical Guide） regarding takeoff and landing in crosswind are revised.
02.Flight Crew Member Holding Type Rating for ATR Aircraft
- Conducting ground school training and simulator training to establish knowledge and technique of crosswind landing maneuver recommended by the Design and Manufacturer.
- Conducting ground school training for appropriate operations of Stabilized Approach.
(2) The Design and Manufacturer
Reviewed the procedures for normal operation in landing roll to revise FCOM.
01. Clarified that braking was a primary role in deceleration after touchdown.
02. Clarified to set power levers to ground idle at the time of touchdown of a nose wheel and use the reverse as required.
