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JAL incident at Haneda Airport

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JAL incident at Haneda Airport

Old 6th Jan 2024, 05:05
  #841 (permalink)  
 
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Originally Posted by glekichi
All of the initial actions were hindered by multiple system failures.
My understanding is the megaphone was used because both the primary and secondary systems used to initiate an evac in the first place had both failed so something else had to be done.

Even when deciding to evac after being unable to contact the flight deck you would normally communicate this with the other cabin crew that this is happening, but the channels for doing this had also all failed.
How is L4 supposed to know that L1 is evacuating if they cannot tell them, or vice-versa.
Almost nothing could be done according to the procedures in place. It seems literally every step needed to be done by alternate means. That's one hell of a scenario.
Yet some here, even those who have worked in Japan, sit and accuse them of inaction and/or a lack of initiative, based on race/culture.
I'm only a pilot so my understanding in this area may be deficient compared to a cabin crew member, but my wife is also a cabin manager at a Japanese airline (not JAL).

Using the megaphone is the right procedure when PA system fails and you need to give instructions, for control crowd and to communicate with aft station crew in this case.
From what we know so far, the crew displayed beautiful CRM skills and were quick to adapt to a very difficult situation (unplanned emergency) and make the right decisions. When SOPs are no longer applicable, you evaluate the situation and make decisions using available resources. And that's what they did and they did it fast believe it or not. People that said it took too long have no clue...
I used similar scenarios for cabin crew in the flight simulator to train and evaluate them. This includes putting fire on the door viewing windows, jamming doors, limited visibility on pax windows, change in ac attitude when plane comes to a complete stops and so on. From what I have seen so far, crew performed very well given the circumstances.
I know it is a public forum....but people should remember that "little knowledge is dangerous". I see a lot of posts from people with very little understand (or none) of such events.

The fact that pax walked away from this with no serious injuries is due to the crew's professionalism and courage. This was not luck, this was crew performing very well in the face of an unplanned emergency.
Meanwhile let's wait for more official info to come out.
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Old 6th Jan 2024, 05:07
  #842 (permalink)  
 
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Originally Posted by physicus
Your comment on the NACp = 10 indicating 95 percentile position accuracy of 10m or better is fair enough - however, in reality the accuracy is indeed often centimeter grade. This assertion has absolutely nothing to do with number of decimals available from the the ADS-B output, but is based on a large sample of GNSS positions in the runway environment. You did get the number of decimals somewhat jumbled up: 0.000001 degrees in latitude equals about 10cm, so it would indeed have been more appropriate for me to state "decimeters" instead of "centimeters".
Umm. No. If you take a feed of GNSS output and plot it, it jumps around all over the place. The number of digits in the output does not show the correctness of the output.

Sometimes consumer GNSS seems better than it really is because the data is augmented by context. When you are driving down the road, Apple/Google maps show you as being on the correct side of the road because that makes sense, NOT because that is the location of your GNSS fix.

Last edited by UnreliableSource; 6th Jan 2024 at 05:33. Reason: replaced 'plot' with 'feed'
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Old 6th Jan 2024, 05:11
  #843 (permalink)  
 
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As far as I am aware (having been retired now for many years), all alerts from A-SMGCS, and any other type of airport surface warning systems, go only to the Tower. Would there not be some safety benefit from also sending appropriate warning messages to appropriate aircraft? Had it been possible to display such a warning on the moving map display in the aircraft, I suspect the pilots on the JAL A350 would have been alerted to the presence of the Dash8 and would have gone around.

I would be grateful for any feedback from current ATCOs and active large transport aircraft pilots as I believe this is an aspect that should be investigated. As fdr rightly points out, however professional and well trained we may be, simple errors are always possible - we have all made them. Another safety layer might help.
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Old 6th Jan 2024, 05:22
  #844 (permalink)  
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Originally Posted by bud leon
Interesting.

Absolutely! Fire does not evolve in a linear fashion, and the main cause of death from fire is smoke inhalation..
Video of the lone fire fighter trying to suppress the fire in the fuselage behind the LH engine is concerning WRT non linearity with the CFRP hull. There is a rapid development of fire within the fuselage that gets out of control rapidly that suggests that there are volatile being generated in this case which are either from the structure, the furnishing or from the fuel system. The development of the fire was pretty standard thereafter, the crown of the aircraft is compromised, the L4 door opening is acting as a chimney and there is rapid development of the intensity and area of the fire. These are not good things to have. Had they occurred any earlier, this would have been a catastrophe, so the reports analysis of the progression and fuel source of the fuselage fire will be interesting reading. This seems to be an open question. There are other examples of fire in aluminium hulls as well, a comparison will indicate whether CFRP is a better material or not compared to aluminium. I hope it is better, it resolves other issues, but flammability wise, this event is a unique study of where we are heading with the modern airliner designs.

Dealing with the hazmat side of this aircraft is going to be another thing entirely [1-5]. CFRP has generally been handled as a hazmat material in military aircraft accidents, will be interesting how the local CAA's handle this one. I suspect it will be insignificant as a factor to the pax and RFF crews, investigators or cleanup crews, or those that live downwind of the site, but it is going to need to be addressed at some point. Would seem that the studies on toxicity would raise concerns on the smoke particulate level more than the debris that remains as composite slag, but we will find out soon enough.




[1] Martin TR, Meyer SW, Luchtel DR. An evaluation of the toxicity of carbon fiber composites for lung cells in vitro and in vivo. Environ Res. 1989 Aug;49(2):246-61.
[2] Friesen A, Fritsch-Decker S, Mülhopt S, Quarz C, Mahl J, Baumann W, Hauser M, Wexler M, Schlager C, Gutmann B, Krebs T, Goßmann AK, Weis F, Hufnagel M, Stapf D, Hartwig A, Weiss C. Comparing the Toxicological Responses of Pulmonary Air-Liquid Interface Models upon Exposure to Differentially Treated Carbon Fibers. Int J Mol Sci. 2023 Jan 18;24(3):1927.
[3] Wang J, Schlagenhauf L, Setyan A. Transformation of the released asbestos, carbon fibers and carbon nanotubes from composite materials and the changes of their potential health impacts. J Nanobiotechnology. 2017 Feb 20;15(1):15.
[4] Luchtel DL, Martin TR, Boatman ES. Response of the rat lung to respirable fractions of composite fiber-epoxy dusts. Environ Res. 1989 Feb;48(1):57-69.
[5] Saber AT, Mortensen A, Szarek J, Koponen IK, Levin M, Jacobsen NR, Pozzebon ME, Mucelli SP, Rickerby DG, Kling K, Atluri R, Madsen AM, Jackson P, Kyjovska ZO, Vogel U, Jensen KA, Wallin H. Epoxy composite dusts with and without carbon nanotubes cause similar pulmonary responses, but differences in liver histology in mice following pulmonary deposition. Part Fibre Toxicol. 2016 Jun 29;13(1):37.






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Old 6th Jan 2024, 05:26
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Originally Posted by fdr
I'd wager that it is an error of omission or comprehension, not what you are suggesting which is... [arrogance/contempt/deliberate rule violation] ?

Hanlon's razor: "Never attribute to malice that which is adequately explained by stupidity". That is also not likely to be the case, no one was being stupid on this night, they were being human. Humans err, it is our weakness and also that knowledge is often our strength. Computers also err, and give the BSOD.
No the suggestion is that the pilots heard what they wanted to hear. It was a dissonance reduction mode which had fatal consequences in both examples. I very much liked your previous post on human error but I will caution one thing. Your comments on runway transgressions relates to the US. This is Japan and it would not attract much attention in Japan except perhaps for the comment 'we're stricter, it couldn't happen here'.
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Old 6th Jan 2024, 05:31
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Camera solution ?

There are millions of cameras in the streets, so these airports should have at least cameras at the start positions of their runways, controllers would be able to clearly see the zone instead of arguing about bad long range visibility with all of these lights at night , still mid 60s scenarios...
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Old 6th Jan 2024, 05:47
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Originally Posted by fdr
I'd wager that it is an error of omission or comprehension, not what you are suggesting which is... [arrogance/contempt/deliberate rule violation] ?

Hanlon's razor: "Never attribute to malice that which is adequately explained by stupidity". That is also not likely to be the case, no one was being stupid on this night, they were being human. Humans err, it is our weakness and also that knowledge is often our strength. Computers also err, and give the BSOD.
Been trying to stay out of this, unable as yet to marshal my thoughts and express them logically.

A series of ifs here, a theory only, ...but many Japanese experience a kind of inferiority complex brain freeze in the presence of the English language. Perhaps he asked his crew to wear headphones and monitor the airwaves to make sure in his mind that at least someone among them would be able to understand ATC's English directions, i.e. to spread the responsibility. I can even visualize the captain (partly through fatigue) unable, unwilling to formulate a follow-up clarification question back to the tower, and just hope they had got it right. Perhaps the 30+ seconds on the runway were a debate among themselves as to what to do?

The first time I experienced it was visiting my new workplace, a universty in Kyoto. A professor of English came out of his room and seeing me at the beginning of the corridor went back in and shut the door. Puzzled, I asked my professor friend who said, "He can read and write and translate, but cannot speak a word, which is a matter of shame for him."

On a personal note as a native speaker, having listened to the tower/Dash8 recordings posted earlier in this thread, I was neither able to understand them clearly nor match them to more than about 50% of the various (official) transcripts (interpretations?) which have subsequently appeared.

Naturally this will probably not come up officially anywhere, but I am posting this in process of trying to understand at least part of the possible psychological frame of mind behind actions which have not yet been otherwise adequately explained. (Neither malice nor overt stupidity?)
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Old 6th Jan 2024, 05:47
  #848 (permalink)  
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Originally Posted by Bergerie1
As far as I am aware (having been retired now for many years), all alerts from A-SMGCS, and any other type of airport surface warning systems, go only to the Tower. Would there not be some safety benefit from also sending appropriate warning messages to appropriate aircraft? Had it been possible to display such a warning on the moving map display in the aircraft, I suspect the pilots on the JAL A350 would have been alerted to the presence of the Dash8 and would have gone around.

I would be grateful for any feedback from current ATCOs and active large transport aircraft pilots as I believe this is an aspect that should be investigated. As fdr rightly points out, however professional and well trained we may be, simple errors are always possible - we have all made them. Another safety layer might help.
Bergy, I operate routinely my own jet into HND, and due to dual runways, the general procedure is to use TA Only. However, I always have ADSB-IN on FOREFLIGHT and it will give traffic alerting for the aircraft on final as a target, alert message and aural alert. I don't get out of bed without my iPad. It also alerts to entering a runway, identifies the runway and the intersection, and now it also provides the distance that remains on the runway, based on the runway that was loaded for the procedures. It is dispiriting that a $300/yr software program, a $500 tablet, and a $599 ADSB-IN receiver can provide greater protection than the best of the best of the best offerings we have within our existing systems. That at the same time we have to fight intransigence and inertia of the CAA's that we deal with who are averse to change (admittedly with some reasonable justification on occasions) is tedious.

This function has been generally available for some time, but FOREFLIGHT have enhanced the capability earlier last year in response to the number of transgressions that had occurred. Why we would start up an engine without it being displayed to the crew I cannot fathom. Previously the traffic would display and alert as proximate and then conflicting traffic, now it adds some additional guidance for those that cannot determine what the TAWS I display is already giving, such as "Traffic on RWY XX (NNNN)", "Traffic on short finals RWY XX (NNNN)", definitely a nice touch, instead of the previous "Traffic Traffic". This is however, an improvement, and would have helped the A350 crew, the JCG crew and even in the tower would apparently be better than they had on the night. $1,400 USD... per setup, ~300/Yr per user.

Now watch the consultants crawl out of the woodwork to give solutions to the JCAB and HND ATC for their problem, like PWC and the rest billing AUS some 20M AUD for not sorting out a good location for a runway in Antarctica.


https://ipadpilotnews.com/2023/06/fo...fety-features/







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Old 6th Jan 2024, 06:16
  #849 (permalink)  
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Originally Posted by DIBO
I won't post it here (as per mod's request) but I made some transcripts well before the official one, including GND, and GND instructed 722A freq.switch 8 seconds before 516's 'Cleared to land' reply. Subtracting 722A's acknowledgement (which was not recorded on LiveATC) from these 8 seconds, subtracting time to switch on the comm box, .... my guess is 722A might never have heard 516.


GND instructed 722A to 'continu to Charlie holding point' (and yes Charlie without further suffix, is what I heard) and then TWR seems to have revised this to C5. That might explain your question.

So everybody might have been doing their utmost to keep things moving as swiftly as possible...until.....

DIBO, your timeline may become a point of interest in JTSBs investigation. If they did not hear JAL516 at all, then the "one departure" call could have resulted in a bias, the crew would be pre-primed to having a clearance. We fill in the gaps within our awareness as a natural matter of course, (this being the basic problem with eyewitness statements).
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Old 6th Jan 2024, 06:57
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small piece of info...
it was reported that the CG pilot had returned just 24 hours before this flight from a 7-hout mission chasing around some Chinese vessel.
No further details about his rank, experience, training etc.
(sorry, but I do not remember the name of the Japanese media that reported that).
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Old 6th Jan 2024, 07:17
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fdr, I will send you a PM later today about ADS-B-In and how it should have been adopted by the ANSPs and airlines years ago for warnings of the type you desceribe.
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Old 6th Jan 2024, 07:19
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Originally Posted by fdr
DIBO, your timeline may become a point of interest in JTSBs investigation. If they did not hear JAL516 at all, then the "one departure" call could have resulted in a bias, the crew would be pre-primed to having a clearance. We fill in the gaps within our awareness as a natural matter of course, (this being the basic problem with eyewitness statements).
It is noticeable in the published transcript that two landing aircraft are advised of one departure, but the shortly to depart aircraft is not advised about a relevant landing that was approved just before it joined the frequency.

Something like you will be number one departure after one landing could have been useful in this circumstance.

I'll ask possibly naive questions here. The inclusion of advice as well as instruction is presumably discretionary to some extent. What are the recommendations for such extra info? Are there precedents for something like I suggest in the previous paragraph?
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Old 6th Jan 2024, 07:47
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Originally Posted by physicus
Your comment on the NACp = 10 indicating 95 percentile position accuracy of 10m or better is fair enough - however, in reality the accuracy is indeed often centimeter grade. This assertion has absolutely nothing to do with number of decimals available from the the ADS-B output, but is based on a large sample of GNSS positions in the runway environment. You did get the number of decimals somewhat jumbled up: 0.000001 degrees in latitude equals about 10cm, so it would indeed have been more appropriate for me to state "decimeters" instead of "centimeters".
I'd be very interested to know how you derive "centimeter grade" accuracy given an encoding algorithm which can't resolve to better than a meter.
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Old 6th Jan 2024, 07:58
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- Are there different requirements vs. the type of Operations (commercial vs military vs SAR) for example regarding crew rest and duty hours? If yes, I wonder if this is consistent with mixed operations at a busy airport?
- As has been noted, I understand that tools exist which are capable of alerting incoming a/c that a runway is occupied. So technically it is possible. There have been too many incidents and accidents of this type (even if the primary causes may differ). In my opinion, a standard "TCAS-like" system, to alert incoming a/c of this exact type of conflict, should become the rule. And in case of Emergencies requiring operation of a/c not equipped with an up-to-date system, then commercial traffic should stop for as long as needed ... again in my opinion.
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Old 6th Jan 2024, 08:00
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Originally Posted by jolihokistix
Been trying to stay out of this, unable as yet to marshal my thoughts and express them logically.
One of the best recent posts on the thread, speaking the wisdom of one who knows. The "R" word was mentioned several times, but it is impossible to understand the events here without a knowledge of Japanese culture (which, I must add, I greatly admire) and their implications. This applies to both the pre- and post- collision events.
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Old 6th Jan 2024, 08:10
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Originally Posted by fdr
In this case, it appears a pretty normal evening went bad, and few of the anomalies were particularly surprising. Given the near routine state of runway transgressions in the USA of late, it is hardly reasonable to state that an SA error by the JCG crew was that exceptional that it was unable to be envisaged. What is unfortunate is that all of the other safeguards to having 2 cockpits at the same point in space and time were not functioning in a manner that could recover the SA error.
Excellent summary, very well phrased. The key to understanding this accident is not so much the direct cause, but the contributing causes, with many lessons to be learned.
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Old 6th Jan 2024, 08:24
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Originally Posted by Claybird
Question: Maybe it's been asked and aswered. But here goes:

The transcript (if it's accurate) indicates the Dash-8 read back in the affirmative to stop at holding point C5.

So... which of the two pilots was communicating with the tower and what was the other pilot doingat that moment? Did he listen to his fellow airman confirm the command to hold short of the runway?

Just a thought...
Goes a bit back to my initial thoughts that i posted earlier. Pilot Monitoring was handling comms and did the correct readback. Hold C5. Pilot Flying overran the holding and the the stopped on the runway and for 40 secs the kept discussing of what the understood and what they should do now. I am pretty convinced the the CVR will reveal that PM disagreed with PF of what was heard. And probably, thats a lot of speculation, once again, PF being higher ranked, overruled the PM and decided to wait for t/o clearance as they were considering themselfs anyway no1 for takeoff.
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Old 6th Jan 2024, 08:30
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Such a call will increase the potential for operational comms to be missed from the additional use of a limited bandwidth
That was in reference to a suggestion to add another radio call as an aircraft enters a runway. The above quote about limited bandwidth is correct in my mind. The extra call would undoubtedly result in other calls being missed at some airports. As an example, a report I recently read on a minor ground collision between two aircraft stated that in the two minutes leading up to the collision, the frequency was in use 92% of the time.
Adding another transmission on top of the current line- up instructions and read backs is not the answer. It’s like reinforcing the gate when part of the fence is down.
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Old 6th Jan 2024, 08:39
  #859 (permalink)  
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Originally Posted by Bergerie1
As far as I am aware (having been retired now for many years), all alerts from A-SMGCS, and any other type of airport surface warning systems, go only to the Tower. Would there not be some safety benefit from also sending appropriate warning messages to appropriate aircraft? Had it been possible to display such a warning on the moving map display in the aircraft, I suspect the pilots on the JAL A350 would have been alerted to the presence of the Dash8 and would have gone around.

I would be grateful for any feedback from current ATCOs and active large transport aircraft pilots as I believe this is an aspect that should be investigated. As fdr rightly points out, however professional and well trained we may be, simple errors are always possible - we have all made them. Another safety layer might help.
I have in my files a copy of a commercially produced video of a trial at Syracuse airport involving FAA where a composite Honeywell/Sensis system took the ASMGS (ASDX in US speak) alerts involving aircraft on a runway threatening or being threatened and transmitted them to an approaching or taxiing aircraft involved in the scenario,

Over many years (at least 15) I showed this video to pilots of all persuasions at trade shows internationally and without exception they wanted this system implemented. I have no idea why it was not vigorously perused by those who were able to progress the concept, which used (then) unused elements in the TCAS system to broadcast the alerts into cockpits at the same time they were annunciated in the ATC Tower.

Gne

.
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Old 6th Jan 2024, 08:47
  #860 (permalink)  
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Originally Posted by Jasonbay
Also, I believe it is SOP (at least it is for the FAA) for TWR to advise pilots performing intersection T/Os what the available rwy TORA is, and for the pilot to confirm that it is adequate for the the available T/O performance of the departing aircraft. In all likelihood, this would have been in the form of a call "722A, line up and wait/cleared for takeoff, runway 34R at C5. xxxx feet available." Or "722A, verify able to accept intersection departure [note: not "takeoff" since this is an interrogatory not imperative/clearance] from runway 34R at C5. xxxx feet available."
That might have been done in the GND frequency . we do not have yet seen a transcript of that frequency .

@ Bergerie1 :
all alerts from A-SMGCS, and any other type of airport surface warning systems, go only to the Tower. Would there not be some safety benefit from also sending appropriate warning messages to appropriate aircraft? I would be grateful for any feedback from current ATCOs and active large transport aircraft pilots as I believe this is an aspect that should be investigated
Has been discussed in ICAO, always the same answer : adding another alert on an already full Christmas tree on board an aircraft is always fiercely refused. Too many of those already it seems . To add to the problem there is no standard system ,each manufacturer has its own way of doing things. But from an ATCO point of view,, no problem., Anything that can prevent a collision is a good thing for us.

@ fdr : Foreflight , A fantastic tool , I also use it on my own GA aircraft. Problem: not certified. Cannot be included into ICAO discussions. Too cheap probably ( my pun) but integrating that into a HUD will be so easy , but hopefully maybe this accident will re-open the discussion . Foreflight is now part of Boeing that might help . But on our case here the Dash should have had is Mode S transponder ON to be seen ( still waiting to hear about that ) .

In a separate note Foreflight is also reducing drastically the airspace infringements of GA aircraft, which were a plague , some leading to major collisions before , until tools like Foreflight came along .

Last edited by ATC Watcher; 6th Jan 2024 at 09:12. Reason: typos
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