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JAL incident at Haneda Airport

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JAL incident at Haneda Airport

Old 13th Jan 2024, 20:27
  #1061 (permalink)  
 
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Originally Posted by Old Carthusian
The reported comment is a leak. This is standard in disaster situations in Japan. It might not seem ethical but is considered quite acceptable here.
You could not miss my point more completely, and what is even more ludicrous is the inference that disaster-related information leaks are somehow more standard in Japan than anywhere else. It’s the Orient you know… oh of course. If there is one country that knows how to deal with disasters better than any other country, that country might be Japan.
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Old 13th Jan 2024, 20:32
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Originally Posted by Bergerie1
I agree with ATC Watcher, any changes to rules and/or procedures need to be very carefully considered before implementation. Knee jerk reactions soon after an incident or accident are very rarely useful and somtimes downright dangerous.
Originally Posted by ATC Watcher
Sailplaneflier : No , would not help much and you use the wrong example in mentioning Tenerife, . . . .Just remember that all the recent runway incursions that hit the media would not have been prevented with what you propose. But sticking to standard phraseology would have most likely prevented them all , including here
Thank you for the humor and for keen additions to these discussions. I've added bold to your words as I plan to re-review them many times further and hope others will also. I submit that we're being too hasty in dismissing this possible solution.

I cited to Tenerife for reasons associated both with the determined cause of the incident, and with regard to the outcome of the investigation and changes made to call out rules because of it.

I submit that we're in that boat again, and that changes involving call outs might be made to fully secure that gate- i.e., assume "ownership" of a runway when taking a route which will cross it or if intending to take off. We learn from the losses and move forward, making it safer for all. Perhaps the solution lies somewhere in between - i.e., eliminating specific pleasantries in an effort to buy a bit more bandwidth to announce "Taking active 34R". All of the technology we have (and don't use) should not act as the final safeguard. Instead, the pilot announces his intention following the lead of ATC. "MY RUNWAY. ALL." Problem averted (or at least warned of to all involved.) One last fail-safe.

The subsequent investigation by Spanish authorities concluded that the primary cause of the accident was the KLM captain's decision to take off in the mistaken belief that a takeoff clearance from air traffic control (ATC) had been issued.[4] Dutch investigators placed a greater emphasis on a mutual misunderstanding in radio communications between the KLM crew and ATC,[5] but ultimately KLM admitted that their crew was responsible for the accident and the airline agreed to financially compensate the relatives of all of the victims.[6]
Changes:
As a consequence of the accident, sweeping changes were made to international airline regulations and to aircraft. Aviation authorities around the world introduced requirements for standard phrases and a greater emphasis on English as a common working language.[16]

Air traffic instruction must not be acknowledged solely with a colloquial phrase such as "OK" or even "Roger" (which simply means the last transmission was received),[64] but with a readback of the key parts of the instruction, to show mutual understanding. The word "takeoff" is now spoken only when the actual takeoff clearance is given, or when canceling that same clearance (i.e., "cleared for takeoff" or "cancel takeoff clearance"). Until that point, aircrew and controllers should use the word "departure" in its place (e.g., "ready for departure"). Additionally, an ATC clearance given to an aircraft already lined-up on the runway must be prefixed with the instruction "hold position".
Early on in this thread, someone suggested we should view this crash as two entire hull losses. I agree. 350+ souls lost was miraculously avoided (and buys us time to change things.) Agree, also, that runway incursions are occurring far too often, and that's the proof we must change. If we counted souls involved in all of the incursion events, we'd fill football stadiums. Lots at stake and I'd ask that we keep the discussions focused on prevention. We are men. We are pilots. Own it if you're using it (34R).
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Old 13th Jan 2024, 20:57
  #1063 (permalink)  
 
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Sailplainflyer, I hesitate to ask but what exactly is your knowledge of commercial aviation? The complexity of the interactions between flight operations, air traffic management and running a busy airport are best left to those who are closely involved. I my past life, I was a flight manager and ATC Watcher was in a senior position in ATM. Unless you have had responsibilty in these fields you are unlikely to understand that, in trying to resolve one issue, you are very likely to create another problem. That is why any changes have to be very carefully evaluated before taking action.
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Old 13th Jan 2024, 21:04
  #1064 (permalink)  
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Originally Posted by Sailplaneflier
I submit that we're in that boat again, and that changes involving call outs might be made to fully secure that gate- i.e., assume "ownership" of a runway when taking a route which will cross it or if intending to take off. We learn from the losses and move forward, making it safer for all. Perhaps the solution lies somewhere in between - i.e., eliminating specific pleasantries in an effort to buy a bit more bandwidth to announce "Taking active 34R". All of the technology we have (and don't use) should not act as the final safeguard. Instead, the pilot announces his intention following the lead of ATC. "MY RUNWAY. ALL." Problem averted (or at least warned of to all involved.) One last fail-safe.

Changes:

As a consequence of the accident, sweeping changes were made to international airline regulations and to aircraft. Aviation authorities around the world introduced requirements for standard phrases and a greater emphasis on English as a common working language.[16]

Air traffic instruction must not be acknowledged solely with a colloquial phrase such as "OK" or even "Roger" (which simply means the last transmission was received),[64] but with a readback of the key parts of the instruction, to show mutual understanding. The word "takeoff" is now spoken only when the actual takeoff clearance is given, or when canceling that same clearance (i.e., "cleared for takeoff" or "cancel takeoff clearance"). Until that point, aircrew and controllers should use the word "departure" in its place (e.g., "ready for departure"). Additionally, an ATC clearance given to an aircraft already lined-up on the runway must be prefixed with the instruction "hold position".
You're almost misconstruing your own point. Yes, radio procedure was reviewed and redesigned, so as to reduce the chance of someone wrongly thinking they had runway clearance.

But adding some new required phrase now isn't really the solution to non-compliance with what is already there.

A clearance to a specific holding point is exactly that, and not a clearance to the runway and takeoff via that point on the way.

It is implied, without actually asking, that the pilot will hold and report at the holding point (even the name directly implies it: hold), and then be given the next instruction.

The elements of this event are failure to report at the holding point, the wrong assumption the clearance lasted beyond there, and the failure or inability of anyone else to detect it on the runway.

Your wish for a new call of entering the runway would in theory ameliorate only the last part, but not the first two; if someone is going to get those wrong in the existing routine, why would they suddenly remember an additional new required call after they've just made the two mistakes of omission and wrong assumption?

Last edited by aox; 13th Jan 2024 at 21:14.
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Old 13th Jan 2024, 21:16
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Originally Posted by Bergerie1
Sailplainflyer, I hesitate to ask but what exactly is your knowledge of commercial aviation?.
I'd be willing to wager that I love aviation more than you do. I'd be willing to wager I've loved life as much as you, and I'd be willing to place my neck on the line if I felt that it might make a positive difference for one of my (or hundreds of my) fellow humans. That said, I have spent 40 years acting as a final fail safe. When trains crashed, I was there. When planes crashed, I was involved. When semi trucks crashed, I was involved. Autos too. Hundreds and hundreds of instances of playing 'clean up' using courtrooms following often common-sense mistakes. Keeping this short, I've developed a knack for pointing out the obvious, even when it's patently not obvious to those involved. Sometimes the detached distance a courtroom provides is a litmus test for common sense actions which make a difference in commercial transportation, where only the safest companies survive.

I've also spent thousands of hours listening to ATC and am proud of my grasp of the lingo, in addition to reading Pprune, Av Herald, incessantly (and sometimes posting trying to solve crashes AF447.) Loving airplanes more than you, perhaps.

I will beg for the clarity of logic as to what's been said, rather than for badge comparisons, if possible. I win my cases. I call it like I see it and hope for the best on people making appropriate changes. In advance when possible as I feel that's much better than waiting for people like me to clean up the aftermaths and weed out the bad apples in the long run. I'll stop posting for awhile and hope for the best.
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Old 13th Jan 2024, 21:19
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Originally Posted by aox
You're almost misconstruing your own point. Yes, radio procedure was reviewed and redesigned, so as to reduce the chance of someone wrongly thinking they had runway clearance. * * *

The elements of this event are failure to report at the holding point, the wrong assumption the clearance lasted beyond there, and the failure or inability of anyone else to detect it on the runway.
Your wish for a new call of entering the runway would in theory ameliorate only the last part, but not the first two; if someone is going to get those wrong in the existing routine, why would they suddenly remember an additional new required call after they've just made the two mistakes of omission and wrong assumption?
I appreciate your views, more than you know and respect that I'm way out of my element. I am proposing something safer, as a last-ditch effort to stop these types of incursion events (whatever their cause) and increase clarity of comms. Like Tenerife. Radio call outs being changed are the gate that can keep us safe when the rest of the fences go down...
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Old 13th Jan 2024, 23:41
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Originally Posted by bud leon
You could not miss my point more completely, and what is even more ludicrous is the inference that disaster-related information leaks are somehow more standard in Japan than anywhere else. It’s the Orient you know… oh of course. If there is one country that knows how to deal with disasters better than any other country, that country might be Japan.
Not at all - the comment can be taken as reliable. Leaking can pretty much be regarded as a national sport in Japan. There are also numerous complex reasons at to why the Japanese response to disasters is in fact pretty poor. Certainly I could elaborate but at the danger of going very much off topic. If you wish me to do so please do drop me a PM.
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Old 14th Jan 2024, 00:33
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Originally Posted by Old Carthusian
Not at all - the comment can be taken as reliable. Leaking can pretty much be regarded as a national sport in Japan. There are also numerous complex reasons at to why the Japanese response to disasters is in fact pretty poor. Certainly I could elaborate but at the danger of going very much off topic. If you wish me to do so please do drop me a PM.

My point was it was never reported that the captain sought confirmation from the crew.

Thank you, but I’m very familiar with Japan and Japanese culture, I work in a Japanese led organization. There are two things I find fascinating and annoying on this forum. Whenever an aircraft incident occurs in Asia there are always comments that attribute actions to Asian culture. That is just ludicrous in the 21st century. JAL flight crew are as cosmopolitan as anyone. I find many Asians more western than westerners. I find it fascinating that many cultural factors which are solely attributed to Asia are equally manifest in the west. One example is the idea that losing face is unique to Asian culture. I’ve never met anyone regardless of cultural background who was happy to lose face and I’ve worked with many western people who would rather ruin another person’s career than lose face.

Japanese are so outrageously polite they will bow each other to the floor, and indeed business decisions are made outside the meeting room to avoid conflict, but to think that extends to making decisions which could put people’s lives in danger is simply wrong. It’s wrong to generalize behaviour that way.

I wonder how many people posting on this forum would accept being characterized as anything other than being an individual.

Last edited by bud leon; 14th Jan 2024 at 01:00.
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Old 14th Jan 2024, 01:12
  #1069 (permalink)  
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Originally Posted by Sailplaneflier
I appreciate your views, more than you know and respect that I'm way out of my element. I am proposing something safer, as a last-ditch effort to stop these types of incursion events (whatever their cause) and increase clarity of comms. Like Tenerife. Radio call outs being changed are the gate that can keep us safe when the rest of the fences go down...
What you are suggesting has some redundant duplication if people are doing the current system correctly, and you can't guarantee it will definitely be done by someone missing a couple of other calls as well

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Old 14th Jan 2024, 01:42
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Originally Posted by Sailplaneflier
I am proposing something safer, as a last-ditch effort to stop these types of incursion events (whatever their cause) and increase clarity of comms. Like Tenerife. Radio call outs being changed are the gate that can keep us safe when the rest of the fences go down...
I think a few posters are suggesting you are putting the cart before the horse. Once the investigation has determined exactly what happened, the investigators will likely make recommendations. It seems premature to make proposals without know the exact circumstances surrounding the cause(s) of the accident. Proposing a further safety barrier to prevent another safety barrier from failing to catch a potential incident because someone didn't do what the safety barrier called for isn't making things safer, just more complex. I fail to see what Tenerife has to do with it unless you are suggesting the captain of the JCG aircraft had a similar attitude and personality to the captain of the KLM 747.
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Old 14th Jan 2024, 02:31
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Originally Posted by bud leon
My point was it was never reported that the captain sought confirmation from the crew.

Thank you, but I’m very familiar with Japan and Japanese culture, I work in a Japanese led organization. There are two things I find fascinating and annoying on this forum. Whenever an aircraft incident occurs in Asia there are always comments that attribute actions to Asian culture. That is just ludicrous in the 21st century. JAL flight crew are as cosmopolitan as anyone. I find many Asians more western than westerners. I find it fascinating that many cultural factors which are solely attributed to Asia are equally manifest in the west. One example is the idea that losing face is unique to Asian culture. I’ve never met anyone regardless of cultural background who was happy to lose face and I’ve worked with many western people who would rather ruin another person’s career than lose face.

Japanese are so outrageously polite they will bow each other to the floor, and indeed business decisions are made outside the meeting room to avoid conflict, but to think that extends to making decisions which could put people’s lives in danger is simply wrong. It’s wrong to generalize behaviour that way.

I wonder how many people posting on this forum would accept being characterized as anything other than being an individual.
The important thing to note about Japan is that it is a group culture. Belonging to the group is drummed in to Japanese people from childhood and is vital to their self-image especially for official organisations like the Coastguard and ATC. The group culture has an entirely different ethos and approach to the more individualistic cultures. You're right that there are individualistic Japanese but they are exceptions and as the examples of Horie and Murakami show Japanese society frowns upon these. Generally, the police and crime reporters form a group and police officers are quite willing to help out crime reporters in their reports with driblets of useful or interesting information. As the comment by the coastguard captain was reported in the early stages after the accident one can be sure it was a leak to one of these and it was mentioned on Japanese TV.

As for making decisions that put peoples lives in danger I could provide a depressingly long list of the sort of decision made, but I will highlight one where the emergency generators at the Fukushima Daiichi power station were located on the lower floors to save costs but rendering them susceptible to flooding.
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Old 14th Jan 2024, 05:05
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Sailplaneflyer, I humbly apologise for what was a fairly terse post. Clearly, you have a lot of experience in investigating (litigating?) the aftermath of many different types of transport accidents. And I am the first to say that the outside view sometimes spots the obvious when those of us more closely involved fail to see the wood for the trees.

Chronic Snoozer is right when he suggests that you may be putting the cart before the horse, because it is essential to wait for what the investigation unearths and also hope that the investigaters do their jobs thoroughly without fear or favour.

Having been involved in aviation all my working life, first as a pilot, then as an instructor and airline flight manager, followed by a long period working with ATM managers across Europe, I can only counsel caution when changing procedures of any type because of the possibility of introducing unintended consequences. The main problem with the controller/pilot interface is the reliance on the human voice for most of the vital instructions in a very complicated and fast moving environment. However, gradually, through trial and error, the current procedures have evolved. Of course there are improvements that may be made, but all I ask is that they are very carefully evaluated, based on known facts before anything is changed.

And I wager I have loved aviation in all its many aspects every bit as much as you. And also have done my utmost to protect human life.
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Old 14th Jan 2024, 07:00
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Originally Posted by Old Carthusian
The important thing to note about Japan is that it is a group culture. Belonging to the group is drummed in to Japanese people from childhood and is vital to their self-image especially for official organisations like the Coastguard and ATC. The group culture has an entirely different ethos and approach to the more individualistic cultures. You're right that there are individualistic Japanese but they are exceptions and as the examples of Horie and Murakami show Japanese society frowns upon these. Generally, the police and crime reporters form a group and police officers are quite willing to help out crime reporters in their reports with driblets of useful or interesting information. As the comment by the coastguard captain was reported in the early stages after the accident one can be sure it was a leak to one of these and it was mentioned on Japanese TV.

As for making decisions that put peoples lives in danger I could provide a depressingly long list of the sort of decision made, but I will highlight one where the emergency generators at the Fukushima Daiichi power station were located on the lower floors to save costs but rendering them susceptible to flooding.
;Again, the comment reported to be from the Captain did not in any way indicate the Captain sought agreement from the crew to decide to enter the runway.

As for Fukushima, I just point to the design failures of Three Mile Island, the operational failures of Chernobyl, and the outright negligence of Sellafield, to counter the idea that Fukushima was some kind of cultural failure.
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Old 14th Jan 2024, 08:31
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There are two things I find fascinating and annoying on this forum. Whenever an aircraft incident occurs in Asia there are always comments that attribute actions to Asian culture. That is just ludicrous in the 21st century. JAL flight crew are as cosmopolitan as anyone.
Hmm, not an expert at all in Japanese or asian culture (which I think are 2 different things anyhuw) but I have a friend who instructed Japanese pilots from scratch to first jet typerating for about 10 years until about a year ago. From what he says, there is a distinct difference. He actually said: you can´t compare them one bit to europeans (which he instructed as well). I value this dudes opinion a lot

Again: I´m not an expert, but think that generalizations are quite often an issue (the annoying in you post) and OTOH I fall for them sometimes as well. (see this post)

As for Fukushima - the basic issues were laid down in the seventies and IMHO ALL of the mentioned disasters have had root causes that one can call human errors. Each in the context of their own culture.

TMI and Fukushima one (at least) share something that I have found in aircraft: there were lights that showed the command to a valve, but NOT the actual condition. The block valve in TMI was commanded shut and stayed open. The F1 emer cooling system was closed down by operators and then they wanted it to start again and no indication was then available to tell em it is still shut down (or working). I flew aircraft were you would switch on anti ice and a light showed up indicating the leading edge is cold, that would extuingish when the temperature is fine, leaving one with no indication that the system is still on. It had a limitation of no usage above +10° and there are aircraft of the type that suffered a lot of internal wing damage from folks leaving A/I on. Thats all the same issue to me. F1 shared something else with Chernobyl, a lack of training was reported after the fact in both cases. F1 crews reportedly never tried to start their emergency cooling system manually, which was possible and would have saved that bacon.
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Old 14th Jan 2024, 09:54
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Originally Posted by Sailplaneflier
Thank you for the humor and for keen additions to these discussions. I've added bold to your words as I plan to re-review them many times further and hope others will also. I submit that we're being too hasty in dismissing this possible solution.

I cited to Tenerife for reasons associated both with the determined cause of the incident, and with regard to the outcome of the investigation and changes made to call out rules because of it.

I submit that we're in that boat again, and that changes involving call outs might be made to fully secure that gate- i.e., assume "ownership" of a runway when taking a route which will cross it or if intending to take off. We learn from the losses and move forward, making it safer for all. Perhaps the solution lies somewhere in between - i.e., eliminating specific pleasantries in an effort to buy a bit more bandwidth to announce "Taking active 34R". All of the technology we have (and don't use) should not act as the final safeguard. Instead, the pilot announces his intention following the lead of ATC. "MY RUNWAY. ALL." Problem averted (or at least warned of to all involved.) One last fail-safe.

Early on in this thread, someone suggested we should view this crash as two entire hull losses. I agree. 350+ souls lost was miraculously avoided (and buys us time to change things.) Agree, also, that runway incursions are occurring far too often, and that's the proof we must change. If we counted souls involved in all of the incursion events, we'd fill football stadiums. Lots at stake and I'd ask that we keep the discussions focused on prevention. We are men. We are pilots. Own it if you're using it (34R).
I'm not sure that I follow your logic nor the merit of such a proposal. Intersection departures, line up and wait, backtracking, aircraft taxiing via a runway.

As an air traffic controller, prior to issuing a take-off clearance I ensure that I have departure instructions, assessed other traffic, scanned the runway. Then and only then would I issue the take-off clearance e.g. "ABC123, RWY 34R, CLEARED FOR TAKE-OFF", pilot response "CLEARED FOR TAKE-OFF RWY 34R, ABC123", at which point its their runway.
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Old 14th Jan 2024, 10:31
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Originally Posted by bud leon
;Again, the comment reported to be from the Captain did not in any way indicate the Captain sought agreement from the crew to decide to enter the runway.

As for Fukushima, I just point to the design failures of Three Mile Island, the operational failures of Chernobyl, and the outright negligence of Sellafield, to counter the idea that Fukushima was some kind of cultural failure.
I rather think you're trying to shift the terms of the discussion. What was stated originally was that the captain said that there was a consensus among all members of the crew that they had take off clearance. This is also a significantly important cultural statement as consensus is a vital principle in Japanese culture. One can safely conclude that there must have been some discussion but at the moment we outsiders have no way of knowing what it was and who initiated it.
The Fukushima example was in response to your incorrect statement that Japanese wouldn't take decisions which put others in danger, nothing else. Always think honne and tatemae.
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Old 14th Jan 2024, 10:52
  #1077 (permalink)  
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Originally Posted by Sailplaneflier
I appreciate your views, more than you know and respect that I'm way out of my element. I am proposing something safer, as a last-ditch effort to stop these types of incursion events (whatever their cause) and increase clarity of comms. Like Tenerife. Radio call outs being changed are the gate that can keep us safe when the rest of the fences go down...
People (who are professionals) are being kind with you here. This idea is a non starter. As has been explained to you numerous times, there are enough radio calls and read backs for all involved to build up a mental picture. The frequencies are congested already, how do you think waiting 30 or 60 seconds or even longer to get a word in about your impending lineup or takeoff is going to impact the number of flights a very busy airport needs to depart every hour?
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Old 14th Jan 2024, 13:21
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So true. I first flew into Haneda in the early 1960's, sitting in the jump seat behind my father in a DC6B. I last flew operationally into Haneda in a B744 in 2016. In that time period it went from a 50 movement a day airport to a 50 movement an hour airport. And yet the basic system had not changed. The JCG was there in the early 60's and amazingly is still there today. This was a Swiss Cheese event in the planning for 60 years. Having the JCG still on the aerodrome is equivalent to having a flying school running out of Heathrow. Allowing mid-runway line-ups and take-offs is a serious no-no. Sadly the survivor from the JCG a/c will wear the blame but it really is the fault of the JCAB and the ATC system. Many friends who still fly in Japan say this was an accident waiting to happen.
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Old 14th Jan 2024, 13:29
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Originally Posted by Sailplaneflier
I am proposing something safer, as a last-ditch effort to stop these types of incursion events (whatever their cause) and increase clarity of comms.
I think most people can see the good intent in your “my runway” call, but aren’t convinced of its practicality or that it will prevent a similar accident.
As an example.
Lets imagine in 2020 ICAO had decided to introduce your suggestion as an improvement to runway occupancy awareness. So for the past two years everyone had got used to “my runway” calls. There is nothing to prevent a crew forgetting/omitting to make that call when entering a runway. So from what we currently understand of this accident, if the CG crew omitted to make the “my runway” call, the CG aircraft would still have been undetected, and the accident occurred. So whilst your “my runway” suggestion has good intent, it’s not IMO adding to any existing system or procedures that should have prevented this event occurring.
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Old 14th Jan 2024, 18:02
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Sailplane flyer , I think you got the answers om your proposal by now, which are : thank you but No, so no need to continue this debate .
just a point for your info or education :
when you use this quote :
The subsequent investigation by Spanish authorities concluded that the primary cause of the accident was the KLM captain's decision to take off in the mistaken belief that a takeoff clearance from air traffic control (ATC) had been issued.[4] Dutch investigators placed a greater emphasis on a mutual misunderstanding in radio communications between the KLM crew and ATC,[5] but ultimately KLM admitted that their crew was responsible for the accident and the airline agreed to financially compensate the relatives of all of the victims.[6]
This is just copy and paste from Wikipedia. If you really want to understand, quote and use Tenerife , at least spend the time and read one of the 3 reports, preferably the Spanish one , and the second version , which contains the Dutch RLD objections.
As I already said , I was part of the post investigation fallout, and it was nasty as the Dutch insurance companies wanted to put the blame on ATC to avoid paying , and used dirty tactics including disinformation . KLM was of course supporting them , claiming among other that Capt van Zanten, one of their top training Captains , could not have made that mistake. KLM also had , very unfortunately , used a photo of him in big billboard adverts in The Netherlands just a few weeks before mentioning " our best people " and that played a role in trying to deflect responsibilities. at last for the Dutch public. .Unfortunately some of that disinformation stuck., But all that is not on the reports.

The Wikipedia sentence you used is not the text used in the conclusions of the investigation . It is more what the Dutch RLD objections were, but they were just that , objections .Nobody knows what went in the head of Cap Van Zanten , also why only his FE understood the Pan Am was still on the runway and not him , and why he rejected this information coming from his FE. Maybe if he had been Japanese , he would have been more inclined to listen to the rest of his crew and asked confirmation on the R/T.?

You see Japanese culture has also its good sides..
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