JAL incident at Haneda Airport
Based on the transcript, my mental picture as JAL516 is that JA722A who was cleared to taxi to C5 and hold would be taking off behind us, and before JAL166.
There is absolutely nothing in that transcript that would hint at any missed opportunity by JAL516 to pick up a hint of something going wrong.
The Swiss cheese tragedy is the late switch of JA722A to the TWR frequency *after* the landing clearance was given to JAL516.
Perhaps there's an opportunity to reconsider how far out a landing clearance should be given to lower the window duration during which someone is approaching with clearance to land expecting a clear runway.
There is absolutely nothing in that transcript that would hint at any missed opportunity by JAL516 to pick up a hint of something going wrong.
The Swiss cheese tragedy is the late switch of JA722A to the TWR frequency *after* the landing clearance was given to JAL516.
Perhaps there's an opportunity to reconsider how far out a landing clearance should be given to lower the window duration during which someone is approaching with clearance to land expecting a clear runway.
I am not suggesting that the JAL 516 crew were in error. Just that the ATC transmissions were confusing, if not wrong. And certainly not ICAO standard.
Last edited by MissChief; 3rd Jan 2024 at 18:59. Reason: typo
But maybe it's: yes, you would, in the sequence of Tx that happened here:
JAL516 continue....we have departure
JAL516 cleared to land
JAL166 (= the next guy in line behind you) continue....reduce...we have departure
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Seems like the High Reach Extendable Turrets with piercing nozzles would have helped to fight/contain the fire inside the A350. Not sure if Haneda is equipped with them though.
Based on the transcript, my mental picture as JAL516 is that JA722A who was cleared to taxi to C5 and hold would be taking off behind us, and before JAL166.
There is absolutely nothing in that transcript that would hint at any missed opportunity by JAL516 to pick up a hint of something going wrong.
The Swiss cheese tragedy is the late switch of JA722A to the TWR frequency *after* the landing clearance was given to JAL516.
Perhaps there's an opportunity to reconsider how far out a landing clearance should be given to lower the window duration during which someone is approaching with clearance to land expecting a clear runway.
There is absolutely nothing in that transcript that would hint at any missed opportunity by JAL516 to pick up a hint of something going wrong.
The Swiss cheese tragedy is the late switch of JA722A to the TWR frequency *after* the landing clearance was given to JAL516.
Perhaps there's an opportunity to reconsider how far out a landing clearance should be given to lower the window duration during which someone is approaching with clearance to land expecting a clear runway.
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Feasibility of a GA
Simplistic question (from an old non-ATP commercial pilot)
During short finals, up until what point could a go around still be initiated in a 350, had the Dash been sighted by the JAL crew?
During short finals, up until what point could a go around still be initiated in a 350, had the Dash been sighted by the JAL crew?
OK on IATA code for a Dash 8 (even though the IATA website does not recognise them and I can't find a authoritive reference) but there is no such thing as a Dash 8 Q300 The "Q" (quiet) series started with the DHC-8-400 with revised propellers and active noise reduction in the cabin. Yes, I'm pedantic ;-)
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Could be the "number one" [for departure] the "killer", triggering in pilots' minds the idea that they were entitled to go first, thus line-up once they arrived at the runway? Especially if they previously used to take-off in the same manner? I would be curious...
How many special-ops flights did this crew in that day and the previous? How did they develop?
How many special-ops flights did this crew in that day and the previous? How did they develop?
All that’s needed is ABC123 taxi to C5 via C, report ready.
The clearance limit is C5, and the route specified.
ICAO compliant.
Unambiguous.
Sequence information isn’t required, though it can be useful at times for overall awareness.
If only the RGBs at C5 were u/s, why didn’t the airport authority withdraw it from use? However, if there was a total failure of RGBs why on earth were they conducting mixed mode operations at a large airport with multiple runways?
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45 seconds on the runway. What distractions in the tower? Even without an SMR or maybe modern electronic wizardry to prevent runway incursions, a precautionary glance out of the window prior to giving landing or take off clearance was drummed into me during training. Granted, at night it is more difficult to spot. Add into the equation, stop bars inoperative. Even more reason to look out of the window. I'd not be surprised if a Swiss Cheese hole relates to what was happening in the tower at the time? A350 was cleared to land on a blocked runway.
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A flight attendant is allowed to open an emergency exit without the permission of cockpit in case of: (or)
- fire
- smoke
- structural damage
All three factors being present in the actual case.
(This rule is made exactly for this moment: If broken aircraft does not allow for proper communication anymore).
- fire
- smoke
- structural damage
All three factors being present in the actual case.
(This rule is made exactly for this moment: If broken aircraft does not allow for proper communication anymore).
Much more credit to Airbus than JAL that the fuse remained survivable for the extra 8 minutes the crew was conferring which exits were safe to use. This is definitely a necessary task, but 8 minutes when the evacuation standard is 90 seconds ???
While everybody got out, smoke inhalation injuries could have been reduced.
While everybody got out, smoke inhalation injuries could have been reduced.
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What were they thinking?
It's now clear that there are many inter-relating contributory causes of this accident, but one over-riding question occurs to me: what were the crew of JA722A waiting for?
Regardless of the transcript of who said what to whom when, JA722A's crew obviously thought that they had been cleared to line up and hold because that is exactly what they did. They entered the runway from a 90º intersection at a time when the approaching A350 was clearly visible to them on finals, lined up, and then waited for over 40 seconds for departure instructions.
Had they even seen the approaching A350? If so, what did they think it was going to do in that time? Had they forgotten about it? If not, and knowing it was approaching, why did they not remind ATC that they were lined up and awaiting departure?
They knew they were departing from a busy airport operating in mixed mode; it had taken them 50 minutes to taxi (at an average of walking pace) from their apron to the holding point. Why did they feel no sense of urgency when on the runway and lined up?
Regardless of the transcript of who said what to whom when, JA722A's crew obviously thought that they had been cleared to line up and hold because that is exactly what they did. They entered the runway from a 90º intersection at a time when the approaching A350 was clearly visible to them on finals, lined up, and then waited for over 40 seconds for departure instructions.
Had they even seen the approaching A350? If so, what did they think it was going to do in that time? Had they forgotten about it? If not, and knowing it was approaching, why did they not remind ATC that they were lined up and awaiting departure?
They knew they were departing from a busy airport operating in mixed mode; it had taken them 50 minutes to taxi (at an average of walking pace) from their apron to the holding point. Why did they feel no sense of urgency when on the runway and lined up?
Last edited by Iron Duck; 3rd Jan 2024 at 21:30.
No it wasn’t.
JAL incident at Haneda Airport
It was cleared to land before the coastguard made first contact with the tower controller.
JAL incident at Haneda Airport
It was cleared to land before the coastguard made first contact with the tower controller.
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Let me see if I am understanding this tragedy of errors...
1) Confusing radio calls. (at least to the CG pilots obviously).
2) Seemingly half the airport equipment is inop especially the stop bars at C5.
3) CG pilots park on an active runway for 45 seconds after missing an A350 on approach ~3 miles out as they turned onto the runway.
4) Even from the perfect vantage of the tower, no one noticed an aircraft parked on an active runway for 45 seconds.
5) It took 8 minutes to open the first door on the A350.
6 It took 18 minutes to evacuate the A350.
7) It took fire services 6 minutes to arrive.
8) Neither of the other two airliners holding at C1 noticed the CG aircraft on the active runway for 45 seconds.
9) Neither pilot in the A350 saw the CG aircraft for 45 seconds.
That is a lot of holes in a lot of cheese.
1) Confusing radio calls. (at least to the CG pilots obviously).
2) Seemingly half the airport equipment is inop especially the stop bars at C5.
3) CG pilots park on an active runway for 45 seconds after missing an A350 on approach ~3 miles out as they turned onto the runway.
4) Even from the perfect vantage of the tower, no one noticed an aircraft parked on an active runway for 45 seconds.
5) It took 8 minutes to open the first door on the A350.
6 It took 18 minutes to evacuate the A350.
7) It took fire services 6 minutes to arrive.
8) Neither of the other two airliners holding at C1 noticed the CG aircraft on the active runway for 45 seconds.
9) Neither pilot in the A350 saw the CG aircraft for 45 seconds.
That is a lot of holes in a lot of cheese.
Let me see if I am understanding this tragedy of errors...
1) Confusing radio calls. (at least to the CG pilots obviously).
2) Seemingly half the airport equipment is inop especially the stop bars at C5.
3) CG pilots park on an active runway for 45 seconds after missing an A350 on approach ~3 miles out as they turned onto the runway.
4) Even from the perfect vantage of the tower, no one noticed an aircraft parked on an active runway for 45 seconds.
5) It took 8 minutes to open the first door on the A350.
6 It took 18 minutes to evacuate the A350.
7) It took fire services 6 minutes to arrive.
8) Neither of the other two airliners holding at C1 noticed the CG aircraft on the active runway for 45 seconds.
9) Neither pilot in the A350 saw the CG aircraft for 45 seconds.
That is a lot of holes in a lot of cheese.
1) Confusing radio calls. (at least to the CG pilots obviously).
2) Seemingly half the airport equipment is inop especially the stop bars at C5.
3) CG pilots park on an active runway for 45 seconds after missing an A350 on approach ~3 miles out as they turned onto the runway.
4) Even from the perfect vantage of the tower, no one noticed an aircraft parked on an active runway for 45 seconds.
5) It took 8 minutes to open the first door on the A350.
6 It took 18 minutes to evacuate the A350.
7) It took fire services 6 minutes to arrive.
8) Neither of the other two airliners holding at C1 noticed the CG aircraft on the active runway for 45 seconds.
9) Neither pilot in the A350 saw the CG aircraft for 45 seconds.
That is a lot of holes in a lot of cheese.
There's another starter of a "contributing factors" in this thread I like better. I will seach and bump up. I'd like to discuss that one.
It was me wiping some of the quote's content on purpose:
That list of andrasz is only 1 day old. Few things don't really apply anymore ("different TWR frequencies", term "abeam") and the Delta Air non-report is not a contribution in his and my eyes.
What's new and missing? Maybe these:
Certainly the Dash-8 crew's missing of checking the approach path, where they clearly should have seen the A350.
The discrepancy of the Dash-8 crew in reading back a hold short command but still intruding on a runway. Now we could argue they were disoriented and not aware of having entered an runway - active Runway - Rwy 34R. But then sitting 45 seconds on that runway and not finding out what it is and that they entered it despite a hold short instruction was another big glitch. Let's see.
The situation of degraded airport lights versus Tower operating a complicated scenario and not extra checking? What Radar tech was available?
How about transponder replies from Dash-8?
From what we know so far, a classic case of Swiss cheese that will likely make it into future textbooks. Investigation will take months to years, but I doubt any significant new information will be added other than a more elaborate analysis of the individual holes:
- 34R was T/O only runway previously, JL516 was the first to use it for landing. The MA722 crew may have had a mental picture not to expect any landings on this runway. For same reason, they may not have expected the need to hold short.
- Usage of "Number one" by ATC may have further reinforced the MA722 crew,
missing the "abeam C5" or misunderstanding it as hold ON RWY abeam of C5 (which is exactly what they did).While usage of English in all ATC comms in Japan is commendable, in this case it probably just added to the confusion. - Stop bar and taxiway lighting INOP.
JL516 and MA722 on different frequencies- MA722 was sitting aligned on the runway for 45+ seconds. Probably Japanese culture at play, it is impolite to challenge authority or appear impatient, they were likely patiently waiting for ATC to clear them for T/O.
DL taxied past MA722 a good 20-25 seconds before the collision, it was already out of their view and expectantly on its t/o roll as the A350 was approaching, so no extra set of eyeballs to wave off JL, as it was done in SFO.- The combination of HUD and LED lighting probably prevented the JL crew from seeing MA722 even at close range, I'd wager they never saw what they hit.
- Visibility of a DH3 from the rear in the dark is practically nil. The only visible tail light is white, probably flooded out by runway lights, and the flashing orange upper ACL is obscured by the high tail from the approach angle. The otherwise fully warranted SOP of not using strobes until the beginning of T/O roll did not help in this case.
What's new and missing? Maybe these:
Certainly the Dash-8 crew's missing of checking the approach path, where they clearly should have seen the A350.
The discrepancy of the Dash-8 crew in reading back a hold short command but still intruding on a runway. Now we could argue they were disoriented and not aware of having entered an runway - active Runway - Rwy 34R. But then sitting 45 seconds on that runway and not finding out what it is and that they entered it despite a hold short instruction was another big glitch. Let's see.
The situation of degraded airport lights versus Tower operating a complicated scenario and not extra checking? What Radar tech was available?
How about transponder replies from Dash-8?
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The CC did a great job. All PAX and crew out before the aircraft was consumed by fire was exemplary. I am sad about the crew of the JCG -8.
Misty.
(Who has been into HND twice in the last year.)
Misty.
(Who has been into HND twice in the last year.)