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JAL incident at Haneda Airport

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JAL incident at Haneda Airport

Old 14th Jan 2024, 19:47
  #1081 (permalink)  
 
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Originally Posted by Old Carthusian
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.
No, the term consensus was not used in the original post on this matter. You can search for the original post if you like. In fact we simply donít know what the Captain actually said. We only have third hand translations of what the Captain was reported to have said. The original post was that the crew ďagreedĒ which could mean anything. It might mean no one said stop when the Captain maneuvered onto the runway.

And my other point was that it makes no sense that cultural behaviours underlie dangerous practices which is a trope on this forum when it comes to incidents which occur in Asia. No one ever says an incident occurred in the US because the pilots were American. Iím not pretending that there is no such thing as unique cultural dimensions. I know very well what the broad characteristics of Japanese culture are. I work with them daily. I also know that every Japanese person Iíve met is an individual and you canít say that the pilot made the fateful error of entering the runway because the crew is Japanese. Thatís all Iím saying.
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Old 14th Jan 2024, 20:52
  #1082 (permalink)  
 
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Originally Posted by bud leon
In fact we simply don’t know what the Captain actually said. ...The original post was that the crew “agreed” which could mean anything.
I think this underlines the essential for now, we don't know what exactly and precisely, was said by the captain.

Do we even know what exactly was meant by "crew"? Flight-deck crew, mission crew, both combined?
I doubt if Flight-deck crew decisions, as in agreeing and acting upon ATC instructions, would include the whole crew. It would include of course the whole flight-deck crew.
And how is a flight-deck crew composed on a 'Dash8 MPA' configuration? Both pilots, of course. But would that also include an additional 'radio operator'. I doubt it, but I have zero knowledge on MPA operations (only been on 2 short Seaking SAR flights and observed a little bit the total crew working together, but even that gives me zero operational knowledge)
Next to the captain, this was the crew with their qualifications (caution: based on newpaper-only info):
  • copilot (XO)
  • radio operator
  • search radar operator / assistant naval radio operator
  • mechanic
  • mechanic
Would the 'radio operator' have any (civil) ATC-RT license/qualification? I doubt it, and even then, would this 3rd person be actively involved in Flight-deck crew decisions (agreeing and acting upon ATC instructions)? Doubtful.

Would the PIC, just before departure, verify with the whole crew "OK guys, are we ready and set to go?". Of course, but that has nothing to do with "agreeing and acting upon ATC instructions"
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Old 14th Jan 2024, 22:34
  #1083 (permalink)  
 
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Originally Posted by bud leon
No, the term consensus was not used in the original post on this matter. You can search for the original post if you like. In fact we simply donít know what the Captain actually said. We only have third hand translations of what the Captain was reported to have said. The original post was that the crew ďagreedĒ which could mean anything. It might mean no one said stop when the Captain maneuvered onto the runway.

And my other point was that it makes no sense that cultural behaviours underlie dangerous practices which is a trope on this forum when it comes to incidents which occur in Asia. No one ever says an incident occurred in the US because the pilots were American. Iím not pretending that there is no such thing as unique cultural dimensions. I know very well what the broad characteristics of Japanese culture are. I work with them daily. I also know that every Japanese person Iíve met is an individual and you canít say that the pilot made the fateful error of entering the runway because the crew is Japanese. Thatís all Iím saying.
Honne and tatemae. The Captain's reported comment was for Japanese consumption thus would have meant consensus. He was sending a message - 'I'm not to blame it was the group'. Japanese culture very much operates on a blame basis - it is not a praise culture and an exposed individual in a disaster situation will catch an enormous amount of flak. People will go to the lengths of locating their parents and attacking them. I agree that we don't know what was actually said and that the pilot might not be recalling events correctly. However, to ignore the cultural aspects is dangerous. Japanese culture can be very complacent with regard to safety, chiefly on the basis that the particular group doesn't see an aspect of a safety procedure as necessary and so skips it.
I would certainly like to see more mentions of American culture in regard to accidents as this is also a big factor which is frequently un-addressed. If you're familiar with the 'Clipper Skipper' syndrome you'll know what I mean. However, that doesn't mean we ignore the cultural aspects of accidents in other nations. They are a legitimate subject for discussion and one must be aware is that there are many different routes to an accident.
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Old 15th Jan 2024, 10:52
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Originally Posted by Sailplaneflier
I am proposing something safer ...
Maybe. Or maybe not. Your proposal of an additional safety barrier may actually lessen the effectiveness of other safety barriers and introduce new risks that overall might result in the opposite of 'something safer'.

I am by no means an expert in system safety, but even so, I can identify at least three potential pitfalls in your proposal:
  1. Frequency congestion. ATC frequencies are already often overloaded today, and adding more mandatory calls only adds to that problem. This increases the odds of crossed transmissions, and thus the likelyhood of adverse outcomes, including, ironically, the likelihood of runway incursions and the severity of their consequences. E.g. ref. Tenerife, 1977.
  2. Increasing confirmation bias. Routinely announcing that you 'own' the runway each and every time you're lining up may actually reinforce the conviction of having been cleared to do so, even when such a clearance was not given.
  3. Increasing the use of the term 'runway' in ATC calls, which might lead to miscommunications comparable to the over-use of the term 'take-off' prior to Tenerife.
We are dealing with a complex system here. While it is tempting just to add another safety barrier each time something bad happens, in reality new safety barriers can also lead to new pathways to failure. Looking at the Swiss Cheese visualizations, it's tempting just to add another slice to plug a hole. But the visualization is static, while the real world is dynamic and complex. Those holes in the cheese actually move, expand, shrink, disappear altogether and new holes may appear over time, like a 2-dimensional lava lamp. And the barriers may interact in unforseen ways.

Last edited by xetroV; 15th Jan 2024 at 11:08. Reason: Typo
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Old 15th Jan 2024, 14:04
  #1085 (permalink)  
 
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Nikkei Visualisation

Great visualisation of the whole incident by Nikkei. I think they must have read this discussion!
https://asia.nikkei.com/static/vdata...way-collision/
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Old 15th Jan 2024, 19:52
  #1086 (permalink)  
 
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Maybe it's now the time to start with - or continue to add - digitalization. Sensors everywhere and link it them via internet of things. by this you can use many different input and combine it. cameras, infrared sensors, acustic input, electric signals, existing data like ads-b, and data sent via airlinks. combine them, so if one is u/s you just miss a possibly redundant peace.

takes some work to program the combination and consequences. Or train Ki to consider all them and tell what combinations are critical.

then theres no overload of frequencies and less overload in human brains.
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Old 15th Jan 2024, 21:01
  #1087 (permalink)  
 
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Sailplaneflier
I'm curious about a fact, or maybe it's a set of them, of facts. My reason is, I'm observing the discussion your proposal has provoked, and I'm wondering, would you care to elaborate on your experience, specifically with regard to the inclusion in your description of such experience, reference to courtrooms? Were you an accident investigator? Attorney? Or what?

I've learned over the course of about 10 years here that it can be easy - tempting at least - to take on the role of "persuader". On the merits of your proposal, I'm merely a "follower" of the discussion (SLF/attorney that I am). But I have learned previously of the credentials and experience of some of the community members who disagree with you. I'm not asserting that you should concede the point - here at least; take it up with EUROCONTROL, every ANSP and CAA that will give you an audience, all day long. Yet, I do wonder what experience specifically you've acquired so that you see fit to spar with some true and literal worthies here.

(Just for completeness, more than a handful of my posts when I first discovered this forum had high cringe factor. But I learned to see, and observe, the lane markings. Or at least I've tried.)
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Old 15th Jan 2024, 22:26
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Sailplane Flyer: I admire your passion for the subject of safety and also your commitment to the idea you have proposed. Your tenacity is of the type that has in the past, saved lives. That said, after flying jets at busy International airports for 17 years, I don’t think your proposed idea is going to make aviation safer. You suggested that if it had been implemented after the KLM disaster five lives wouldn’t have been lost. I disagree, I think that more than five lives would have been lost through blocked frequencies and crossed transmissions and crews lining up on the edge lights instead of the centerline.
Also, I think ambiguity regarding which runway was being ‘claimed’ would have caused troubles.
xetroV said it better than I could have with;
Your proposal of an additional safety barrier may actually lessen the effectiveness of other safety barriers and introduce new risks that overall might result in the opposite of 'something safer'.

I am by no means an expert in system safety, but even so, I can identify at least three potential pitfalls in your proposal:
  1. Frequency congestion. ATC frequencies are already often overloaded today, and adding more mandatory calls only adds to that problem. This increases the odds of crossed transmissions, and thus the likelyhood of adverse outcomes, including, ironically, the likelihood of runway incursions and the severity of their consequences. E.g. ref. Tenerife, 1977.
  2. Increasing confirmation bias. Routinely announcing that you 'own' the runway each and every time you're lining up may actually reinforce the conviction of having been cleared to do so, even when such a clearance was not given.
  3. Increasing the use of the term 'runway' in ATC calls, which might lead to miscommunications comparable to the over-use of the term 'take-off' prior to Tenerife.
I agree 100% with the above quote but would add
4. Provision of an ATC clearance while entering the runway is a contributing factor to runway mis-alignment incidents and accidents. Adding a further cognitive requirement at this stage where flight crew are already switching between several cognitive tasks, is likely to increase the frequency of runway mis-alignment incidents and accidents.
We have been down this road before as an industry and learned this lesson before. Adding cognitive tasks to a phase of flight where the weak link is cognitive capacity, is not the answer. We already have a serious problem with crews departing with incorrect performance data in the FMC, or from an intersection that the data was not done for. It is approaching the runway environment that crews are being asked to double check the onboard performance tool and cross check it with the runway identification signs they see out the window, and then cross check that with the FMC, and then, verbalise their checks. Verbalising them takes cognitive processing power that is significant and often overlooked when solutions are offered up. Creating speech is not a cheap mental process.
This is not being done to a standard where we are catching more and more data entry errors, the opposite is occurring.
If the act of claiming the runway was to be enforced at an airport that achieves 60 movements per hour, and included the runway identification and the call sign, each transmission would take a minimum of three seconds, at most airports there would be at least one crossing runway that taxiing aircraft would need to make the transmission on so conservatively another 60 transmissions. That’s an extra six minutes of radio transmissions every hour……we don’t have the space for that and it doesn’t include the clearances that would have to be repeated due to blocked transmissions. If we did have the space for that, and there were twenty aircraft and a controller on the frequency, that’s 41 brains listening to and processing an extra six minutes of information, and then making a decision about how it does or doesn’t effect them, and sometimes even a conversation clarifying what was said would occur between crew members off frequency.The toll is real and will impact aviation safety.
Once again I admire your tenacity, but I think WillowRun has accurately identified the situation. I look forward to seeing how your campaign plays out. Best of luck, Framer
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Old 16th Jan 2024, 04:54
  #1089 (permalink)  
 
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xetroV and framer, Thank you.

You have both spelt out in detail exactly what I was alluding to when, in my answers to sailplaneflyer, I referrred to unintended consequences. The R/T channels are already almost overloaded at many busy airports and framer's explanation of the cognitive load is absolutely correct. I am sure ATC Watcher would agree too. When you also add to this the fact that that, for many of the participants, English is not their mother tongue, and that many cultural differences are involved, you have to take very great care when devising new procedures.

Chronic Snoozer, in a previous post, also mentioned the need not to put the cart before the horse. He is right. Before any changes are even contemplated we need to await the outcome of the accident investigation and, only then, very carefully analyse the findings.
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Old 16th Jan 2024, 09:27
  #1090 (permalink)  
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Originally Posted by Bergerie1
xetroV and framer, Thank you.

You have both spelt out in detail exactly what I was alluding to when, in my answers to sailplaneflyer, I referrred to unintended consequences. The R/T channels are already almost overloaded at many busy airports and framer's explanation of the cognitive load is absolutely correct. I am sure ATC Watcher would agree too. When you also add to this the fact that that, for many of the participants, English is not their mother tongue, and that many cultural differences are involved, you have to take very great care when devising new procedures.

Chronic Snoozer, in a previous post, also mentioned the need not to put the cart before the horse. He is right. Before any changes are even contemplated we need to await the outcome of the accident investigation and, only then, very carefully analyse the findings.
This looks rather polite now.

There might be other points to be made, but that would involve discussing longer discussion of now deleted posts, including the autonomy being claimed for wrong pilot decisions.

If I am stationary at a traffic light on the road, when it turns green I check that there is nobody about to come through the light that just turned red. But this pragmatism does not mean tacit recognition that this other vehicle has a legal right of way due to being in the junction first, or going faster; if it collides with someone else who was alongside me and moved off sooner the red light transgressor will be held liable.

Last edited by aox; 18th Jan 2024 at 16:15.
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Old 16th Jan 2024, 09:38
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Originally Posted by Bergerie1
xetroV and framer, Thank you.

You have both spelt out in detail exactly what I was alluding to when, in my answers to sailplaneflyer, I referrred to unintended consequences. The R/T channels are already almost overloaded at many busy airports and framer's explanation of the cognitive load is absolutely correct. I am sure ATC Watcher would agree too. When you also add to this the fact that that, for many of the participants, English is not their mother tongue, and that many cultural differences are involved, you have to take very great care when devising new procedures.

Chronic Snoozer, in a previous post, also mentioned the need not to put the cart before the horse. He is right. Before any changes are even contemplated we need to await the outcome of the accident investigation and, only then, very carefully analyse the findings.
I agree with the cognitive load, especially for the ATC. When no-one is talking on the frequency the ATC is doing or thinking about a lot of things, for example, but not limited to, coordinating traffic, juggling the departure sequence, scanning the radar (oops pun not intended), ensuring compliance with clearances, double checking data and information, heights and speeds on final, that the previous departure has coupled on radar and can be transferred to departures.
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Old 16th Jan 2024, 09:47
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Japanese comparatively intellectual magazine 'Aera' is running a special article on this incident in their 22 January issue. They say the investigators are focussing on those 40 seconds, how could the co-pilot of the Dash 8 not have picked up on the authorization receipt misunderstanding, and how a series of human errors from all involved seems to have compounded the original mistake.
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Old 16th Jan 2024, 10:07
  #1093 (permalink)  
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For a while now in the back of my pea brain, I've had the seeds of two simple ideas may improve situational awareness and thus safety.
First up, many, many years ago we were cleared to land 25 miles out at an airport that wasn't too busy, broad daylight. In the flare we noticed a white vehicle parked on the broad white TDZ keys which was very well camouflaged. We went around, mains bouncing off the runway, over the vehicle which had seen us and was trying to outrun us. Turns out that during the significant delay between us being given landing clearance, and the actual event (some 9-10 minutes), the tower controller had forgotten the landing clearance and had given permission for a runway inspection. I'm always a bit wary now of important clearances (line up, take off, land) being given too far in advance. If such clearances were only given shortly before the action were to be taken, there would be less chance of mistakes. So no line up clearances when an aircraft is not in a position to line up within the next 30 seconds, for example.

The second thing is so basic it may sound silly and even peculiar in today's digital world. A row of 3 small lights on the centre instrument panel or MCP, each push for on/off, 'on' to be confirmed by both pilots. For departure, first light to be illuminated when cabin secure is received. Second when line up clearance is received, third when take off clearance is received. For approach, first light to be illuminated when cabin secure is received. Second when cleared for the approach. Third when cleared to land. That way there is no memory to lapse, and no need to use other reminders such as exterior lights, scribbles, pegs (yes, I've seen this Not a brilliant idea but I've often thought that this would assist my little pea brain which is often saturated with other tasks.

Last edited by AfricanSkies; 16th Jan 2024 at 10:19.
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Old 16th Jan 2024, 10:42
  #1094 (permalink)  
 
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I like it AfricanSkies. It would actually reduce frequency congestion by a tiny fraction as well because I wouldnít have to onfirm my landing clearance once a month like I do now
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Old 16th Jan 2024, 11:20
  #1095 (permalink)  
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Originally Posted by AfricanSkies
The second thing is so basic it may sound silly and even peculiar in today's digital world. A row of 3 small lights on the centre instrument panel or MCP, each push for on/off, 'on' to be confirmed by both pilots. For departure, first light to be illuminated when cabin secure is received. Second when line up clearance is received, third when take off clearance is received. For approach, first light to be illuminated when cabin secure is received. Second when cleared for the approach. Third when cleared to land. That way there is no memory to lapse, and no need to use other reminders such as exterior lights, scribbles, pegs (yes, I've seen this Not a brilliant idea but I've often thought that this would assist my little pea brain which is often saturated with other tasks.
Maybe as well as verbal ATC, maybe there could be some development of a data channel alongside, and some of the those lights might come from the tower or maybe also with logic input from other aircraft positions
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Old 16th Jan 2024, 11:51
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ATC Watcher, Bergerie1, framer,
I read and respect your reluctance to modify radio procedures.

However, I still think that, when a runway clearance has been issued long before executing it, it can't hurt to announce on the radio "JA722A, lining up and waiting runway 34R" or "ABC23, crossing runway 34R" when entering the runway.
I may reconsider it if the frequency is congested though.
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Old 16th Jan 2024, 11:57
  #1097 (permalink)  
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Originally Posted by Luc Lion
ATC Watcher, Bergerie1, framer,
I read and respect your reluctance to modify radio procedures.

However, I still think that, when a runway clearance has been issued long before executing it, it can't hurt to announce on the radio "JA722A, lining up and waiting runway 34R" or "ABC23, crossing runway 34R" when entering the runway.
I may reconsider it if the frequency is congested though.
The first half of that sentence doesn't apply to this case. You aren't making the same assumption as the pilot seems to have made, by any chance?

Just to clarify, this time there was no runway clearance. As published, the last clearance for this aircraft was taxi to the holding point. This was not reported when reached. It wouldn't have hurt to do that.
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Old 16th Jan 2024, 12:15
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aox,
the circumstances of the Haneda accident look to be that the Dash-8 crew thought to have received a clearance to line up and wait while they actually had received and read back a clearance to hold at C5.
I don't know why this mistake was made or what little details have promoted its occurrence.

However, if the radio announcement I mentioned had been a common habit for aircrews executing a runway clearance received a while ago, and if the Dash-8 crew had made such an announcement, the accident would very probably have been averted.


As an aside, I always feel uncomfortable when I receive a clearance to "line up and wait, cause wake turbulence" which leaves me standing on an active runway for 1 minute or more with no possibility of looking in the direction of arriving aircrafts.
I much prefer "expect departure in 2 minutes; are you able to make a rolling take-off?"

ATC Watcher, you may be familiar with the French BEA report about an incident that occurred in Bordeaux-Mťrignac on December 22nd, 2022 and where an Airbus A320 was cleared to land on a runway where a DR400 was awaiting a take-off clearance?
The A320 crew performed a late missed approach on the controller's request but they never saw the DR400, in daylight VMC conditions.
Unfortunately, the report is only available in French.
https://bea.aero/fileadmin/user_uplo...NE_OACI_FR.pdf
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Old 16th Jan 2024, 12:45
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For what its worth; in the days when UK railways were manually signalled, if a train had been stopped at a red signal for more than (I think ) 3 minutes, it was mandatory for the driver to call the signalman to confirm that his train had not been forgotten. This procedure saved more than a few accidents. Something similar might help situational awareness of both pilots and ATC..
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Old 16th Jan 2024, 12:50
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I think, Luc Lion, that the Quebec provincial authorities who are wreaking havoc with bilingual universities, such as McGill in Montreal, would shudder with disdain and disapproval at your "unfortunately" usage.

The provincial government is dramatically increasing requirements for non-QC university students to learn French. And hiking tuition fees, also dramatically, for non-QC students.

Why isn't this thread drift? Simple. ICAO world hq office is in Montreal QC; so is McGill's world preeminent Institute of Air and Space Law (the IASL, which happens to be historically linked to ICAO since the Organization's inception).

And ya know, like, English . . . Something about the world-wide official language of .....
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