JAL incident at Haneda Airport
Pegase Driver
Ok first , I still do not believe adding new Phraseology or new lights , rings and bells ( sorry African Skies , good idea but .... ) would help and most probably will create new problems , like for instance. just to take one, increasing the risk of cross transmissions.
Back to basics investigation techniques :
Here we have a Captain who apparently strongly believed he was clear to enter a runway and take off. The TWR R/T does not show this. Then it stayed for 40 seconds idle on the runway for unknown reasons. That is the cause .of the accident . This has to be investigated first , fortunately we have the Capt alive and , according the latest info, the 4 recorders have been recovered . so that will be done quite soon
Then we have the failure of the redundancies , the open holes in the cheese layers if you like that need investigation I see at least a few of them '
1- The stop bars being U/S. maintenance or braking down can happen need repairs, etc..They were NOTAMed, Action from investigators : Was the NOTAM available during the Dash briefing and was it read ? Not buried and missed among 10-15 pages of other stuff ?
2- the non standard R/T by both ATC and Dash . Did this " number 1 " meant the same thing to the Controller and to the pilot ?. Was something mentioned during the briefing , or in the Ground Frequency that could leave the Capt believing that the " Nr 1 " would mean he had full priority and implying line up and take off ? Maybe, for instance , something like " expect priority departure and an intersection take off to put you ahead of the normal Departures" ( in C1) was mentioned or" promised " ? How as the IFR pre departure clearance issued and how was it read back ? this is what needs to be looked into.
3 . The 40 seconds . why ? Wake turbulence separation ? Was there a preceding Heavy or Super departing ( guys here who FR24 fans can maybe answer that one already ) that was known to the Dash ?
4- the SM R alerts not seen . Looks like tat the SMR was working , the Dash incursion was detected and alarms were issued but not seen . why ? was the display located in an area not visible by the TWR LOC controller ( like in Vnukovo) was it lack of staff ?
5- Differences between military and civil procedures : (There always are ) Were there any that could have contributed ? If yes were all the actors here , ATC and Cost Guard pilots aware of them ? Training issues ?
Until all points are investigated we can talk about changing things .
My wild guess here , having followed tis thread since the beginning , is that the , rush to depart plus this " Nr 1 " and the 40 seconds idle are the keys. If that is the case , we do not need to change procedures but enforce existing ones. (i.e. training)
Back to basics investigation techniques :
Here we have a Captain who apparently strongly believed he was clear to enter a runway and take off. The TWR R/T does not show this. Then it stayed for 40 seconds idle on the runway for unknown reasons. That is the cause .of the accident . This has to be investigated first , fortunately we have the Capt alive and , according the latest info, the 4 recorders have been recovered . so that will be done quite soon
Then we have the failure of the redundancies , the open holes in the cheese layers if you like that need investigation I see at least a few of them '
1- The stop bars being U/S. maintenance or braking down can happen need repairs, etc..They were NOTAMed, Action from investigators : Was the NOTAM available during the Dash briefing and was it read ? Not buried and missed among 10-15 pages of other stuff ?
2- the non standard R/T by both ATC and Dash . Did this " number 1 " meant the same thing to the Controller and to the pilot ?. Was something mentioned during the briefing , or in the Ground Frequency that could leave the Capt believing that the " Nr 1 " would mean he had full priority and implying line up and take off ? Maybe, for instance , something like " expect priority departure and an intersection take off to put you ahead of the normal Departures" ( in C1) was mentioned or" promised " ? How as the IFR pre departure clearance issued and how was it read back ? this is what needs to be looked into.
3 . The 40 seconds . why ? Wake turbulence separation ? Was there a preceding Heavy or Super departing ( guys here who FR24 fans can maybe answer that one already ) that was known to the Dash ?
4- the SM R alerts not seen . Looks like tat the SMR was working , the Dash incursion was detected and alarms were issued but not seen . why ? was the display located in an area not visible by the TWR LOC controller ( like in Vnukovo) was it lack of staff ?
5- Differences between military and civil procedures : (There always are ) Were there any that could have contributed ? If yes were all the actors here , ATC and Cost Guard pilots aware of them ? Training issues ?
Until all points are investigated we can talk about changing things .
My wild guess here , having followed tis thread since the beginning , is that the , rush to depart plus this " Nr 1 " and the 40 seconds idle are the keys. If that is the case , we do not need to change procedures but enforce existing ones. (i.e. training)
Pegase Driver
ATC Watcher, you may be familiar with the French BEA report about an incident that occurred in Bordeaux-Mérignac 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.
Here the error is obvious :and clear . Controller forgot an aircraft . happens once in a while unfortunately. , reason is he was overloaded /distracted by high number of VFR traffic on FIS, Problem they should have been 3 on duty at that time and he was alone .So nobody there to spot his error. Solution and recommendation : ensure that all the controllers that were planned to work that day were actually on duty . That is the main issue and quite controversial if you know the ATC background in France.
Unfortunately, the report is only available in French.
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.
- Where did the pilot get runway clearance from?
- Where did the pilot get takeoff clearance from?
- Where did all the crew get takeoff clearance from in order to achieve a consensus?
People who say a stoppbar would have prevented this incident forget that the JCG plane was a special case and the pilot could have easily disregarded the stopbar as well.
Last edited by JapanHanuma; 16th Jan 2024 at 16:55. Reason: Takeoff to runway
The ATCO had only cleared them to the hold, and wouldn’t have deselected the stop bar. The CG crew thinking they’re cleared to enter would have called to the tower the stop bars were still at “stop”. Without the illuminated bars there was no visual clue to break the ‘enter’ mindset.
For those unfamiliar when an ATCO gives the enter clearance be it take off or Line up, they simultaneously press OFF for the stop bar. That then turns off the red lights which are normally on a timer to automatically turn back on, E.g. one minute. If they forget or miss the button the stop bar stays on, and a crew must challenge ATC and not cross the line of reds.
I have a thought re the 40 secs. We know the CG crew almost certainly didn’t hear the JAL516 landing clearance, but heard the slow down for JAL116.
I’ve experienced similar type mission aircraft requiring 25secs or more stationary to align systems prior to departure.
My Tom Clancy bit :
So the line up mindset gets them on the runway, sensor operator says I need 25 seconds to align system X. CG Crew knows they have a gap as they heard tower making it for them by slowing Jal116 for the CG departure. The crew are lulled into a false sense of security, they have the gap, sensors are aligning, therefore no immediate threat. They don’t flag it up to tower because they’re just waiting for the sensor operator to confirm system’s alignment, before starting to roll. So there’s a scenario where they are happy, stationary, on the centre line for 30 seconds or so before any doubts flag up.
Join Date: Mar 2006
Location: Vance, Belgium
Age: 62
Posts: 272
Likes: 0
Received 5 Likes
on
3 Posts
I didn't mention the causes of the incident in Bordeaux because it was obviously completely different from what happened in Haneda and I didn't want to appear to disparage controllers.
I just wanted to highlight that lining up on a runway that receives arrivals and waiting is an uncomfortable situation.
From my standpoint, procedure adjustments that minimise the risks created by that situation are welcome.
I just wanted to highlight that lining up on a runway that receives arrivals and waiting is an uncomfortable situation.
From my standpoint, procedure adjustments that minimise the risks created by that situation are welcome.
A few comments that I want to add:
- The ultimate cause of this disaster is the pilot failing to follow ATC instructions (whether due to his own negligence or some other party's issue), but the other factors being mentioned are safety features that could mitigate the impact of the mistake (safety bags in a car does not make a driver speeding through a red light any less wrong). But ultimately it is cumbersome and overwhelming to have too many safety features over would could just be a problem with pilot negligence (and even features such as stopbars would not prevent a negligent pilot who genuinely thought he had special clearance).
- The Japanese are the most disaster prepared country in the world, but also face some of the worst natural disasters in the world. An issue such as Fukushima could only happen in a disaster the scale of the Great East Japan Earthquake And Tsunami. Similarly this crash was in the aftermath of an earthquake in Noto Prefecture (though I think the link is weak).
- Furthermore the Japanese have a strong history of aviation and ultimately fought a very strong fight in WW2. I think most of the issues raised here tend to be tinkering on the edge of what is largely a non-problem that are just exaggerated by a combination of the severity of natural disasters in Japan and the social media conflict between certain communities (Chinese etc...) or politics.
Stopbars are a system that are in use worldwide and are in place at Haneda. A stop bar won’t of course physically prevent a runway incursion. How likely is it that if the crew had seen an illuminated red stop bar on that night, that they would have crossed it?
If the airport currently uses them in visibility of less than 600 metres, there’s nothing to prevent them being used 24/7 in any weather conditions, the same as many other airports worldwide. The changes to make that happen would be extra ATCO training, and a reconfigured (obviously at a cost) lighting system.
As a general side-note:
Originally Posted by / in recent posts
So the line up mindset gets them on the runway
the Dash-8 crew thought to have received a clearance to line up and wait
the Dash-8 crew thought to have received a clearance to line up and wait
Last edited by DIBO; 16th Jan 2024 at 18:00. Reason: typo
Firstly there is no special clearance, you are either cleared to enter a runway or not.
Stopbars are a system that are in use worldwide and are in place at Haneda. A stop bar won’t of course physically prevent a runway incursion. How likely is it that if the crew had seen an illuminated red stop bar on that night, that they would have crossed it?
If the airport currently uses them in visibility of less than 600 metres, there’s nothing to prevent them being used 24/7 in any weather conditions, the same as many other airports worldwide. The changes to make that happen would be extra ATCO training, and a reconfigured (obviously at a cost) lighting system.
Stopbars are a system that are in use worldwide and are in place at Haneda. A stop bar won’t of course physically prevent a runway incursion. How likely is it that if the crew had seen an illuminated red stop bar on that night, that they would have crossed it?
If the airport currently uses them in visibility of less than 600 metres, there’s nothing to prevent them being used 24/7 in any weather conditions, the same as many other airports worldwide. The changes to make that happen would be extra ATCO training, and a reconfigured (obviously at a cost) lighting system.
Maybe I should reword it as "special exception". But if the JCG pilot genuinely thought his plane was an exception (having already been allowed to enter the runway further down from the normal taxiway AND being given No.1 for departure) then it is also possible that he could have disregarded the stopbar as well.
Furthermore how would a pilot react is the stopbar was off due to a malfunction, but no ATC clearance had been given? The key thing is that the ATC controls both the stopbar and radio instructions, and following ATC is the only way to avoid this disaster.
Furthermore the stopbars may in fact have been off to allow for planes and vehicles to cross the runway, and turned on only when the plane was about to land. This would also have not stopped the JCG plane from entering the runway. Many vehicles would not have to obtain permission to cross a runway if they operate on it and stopbars are irrelevant for them when turned off.
But generally I agree with the three following safety recommendations:
- Retraining pilots more to emphasize the terminology for entering a runway and takeoff clearance, assuming that there are no exceptions to the terminology.
- Full time monitoring of runway radar for any unwarranted incursions.
- Stopbars in use at all times
DIBO;
If I understand what you are trying to convey correctly, this is a mindset/ opinion that I am seeing more and more over the last decade and it erodes flight safety. What is the purpose of the correction you have made? Is it to transfer or smooth out the responsibility of the Captain? To spread it over ‘ the flight crew’ rather than have it just sit with the Captain? There is a very good reason that the Captain is responsible for the safe outcome of the flight. If we start diluting the responsibility of the Captain with attitudes like that the behaviour of Captains starts to change. It is very important that the Captain of a ship or aircraft feels ‘wholly responsible for the safe outcome of the flight’.
The very fact that the Captain is wholly responsible is what creates clear cut safety related decision making. It is human nature that makes this so and the reason why, whenever we have high consequence environments, we have one person who carry’s the can, not a committee, not a round- table, one person.The weight of that responsibility is what allows difficult decisions to be made quickly and with conviction.
I may have misunderstood what you were trying to point out by changing pilot to ‘flight crew’. Please correct me if it wasn’t meant as a dilution of responsibility.
Allow me to correct you, and which will make the investigation even more complex: "The ultimate cause of this disaster is the pilot flightcrew failing to follow ATC instructions"
If I understand what you are trying to convey correctly, this is a mindset/ opinion that I am seeing more and more over the last decade and it erodes flight safety. What is the purpose of the correction you have made? Is it to transfer or smooth out the responsibility of the Captain? To spread it over ‘ the flight crew’ rather than have it just sit with the Captain? There is a very good reason that the Captain is responsible for the safe outcome of the flight. If we start diluting the responsibility of the Captain with attitudes like that the behaviour of Captains starts to change. It is very important that the Captain of a ship or aircraft feels ‘wholly responsible for the safe outcome of the flight’.
The very fact that the Captain is wholly responsible is what creates clear cut safety related decision making. It is human nature that makes this so and the reason why, whenever we have high consequence environments, we have one person who carry’s the can, not a committee, not a round- table, one person.The weight of that responsibility is what allows difficult decisions to be made quickly and with conviction.
I may have misunderstood what you were trying to point out by changing pilot to ‘flight crew’. Please correct me if it wasn’t meant as a dilution of responsibility.
Yes, there's no such thing as "no.1 for departure" meaning runway clearance and takeoff clearance, but obviously this pilot may have thought he had an exception.
Maybe I should reword it as "special exception". But if the JCG pilot genuinely thought his plane was an exception (having already been allowed to enter the runway further down from the normal taxiway AND being given No.1 for departure) then it is also possible that he could have disregarded the stopbar as well.
Maybe I should reword it as "special exception". But if the JCG pilot genuinely thought his plane was an exception (having already been allowed to enter the runway further down from the normal taxiway AND being given No.1 for departure) then it is also possible that he could have disregarded the stopbar as well.
No, there was and is NO special exception. The intersection departure the controller appeared to be planning is an absolutely normal operation to aid an expeditious flow of traffic.. There is nothing unusual about the procedure for ATC or aircrew. From the published transcripts there is nothing to suggest ATC gave the crew any expectation or reason to enter the runway.
Furthermore the stopbars may in fact have been off to allow for planes and vehicles to cross the runway, and turned on only when the plane was about to land. This would also have not stopped the JCG plane from entering the runway. Many vehicles would not have to obtain permission to cross a runway if they operate on it and stopbars are irrelevant for them when turned off.
JapanHanuma:
Im confused, are you suggesting that airport vehicles sometimes don’t need a clearance to enter or cross a runway?
Furthermore the stopbars may in fact have been off to allow for planes and vehicles to cross the runway, and turned on only when the plane was about to land. This would also have not stopped the JCG plane from entering the runway. Many vehicles would not have to obtain permission to cross a runway if they operate on it and stopbars are irrelevant for them when turned off.
No, that was not the intention, but you are absolutely correct stating the "ultimate/accountable/legal" responsibility lies with the captain (unless ruled otherwise - but that's not relevant here).
My intention was solely regarding this accident and its main cause, which (almost certainly) lies within the Dash8 crew's decision process and actions
* my initial intended correction was 'pilots', as both pilots should normally have been in agreement over the ATC instructions (and other flightdeck actions)
* again 'pilots', as the RH-seater had the best view on the 34R final
* but in reference to this thread and the many references to the 'crew' being in agreement over the ATC instructions, I changed it to 'flightcrew':
My intention was solely regarding this accident and its main cause, which (almost certainly) lies within the Dash8 crew's decision process and actions
* my initial intended correction was 'pilots', as both pilots should normally have been in agreement over the ATC instructions (and other flightdeck actions)
* again 'pilots', as the RH-seater had the best view on the 34R final
* but in reference to this thread and the many references to the 'crew' being in agreement over the ATC instructions, I changed it to 'flightcrew':
- adding 'flight' to differentiate from the 'mission crew' on board this MPA configured Dash8
- and remaining on purpose, a bit vague over the composition of the 'flightcrew', until someone confirms the flightcrew consist only of the 2 pilots (and not for example, including the onboard 'radio operator')
- and remaining on purpose, a bit vague over the composition of the 'flightcrew', until someone confirms the flightcrew consist only of the 2 pilots (and not for example, including the onboard 'radio operator')
Last edited by DIBO; 16th Jan 2024 at 22:50. Reason: typo
Maybe I should reword it as "special exception". But if the JCG pilot genuinely thought his plane was an exception (having already been allowed to enter the runway further down from the normal taxiway AND being given No.1 for departure) then it is also possible that he could have disregarded the stopbar as well.
Furthermore how would a pilot react is the stopbar was off due to a malfunction, but no ATC clearance had been given? The key thing is that the ATC controls both the stopbar and radio instructions, and following ATC is the only way to avoid this disaster.
Furthermore the stopbars may in fact have been off to allow for planes and vehicles to cross the runway, and turned on only when the plane was about to land. This would also have not stopped the JCG plane from entering the runway. Many vehicles would not have to obtain permission to cross a runway if they operate on it and stopbars are irrelevant for them when turned off.
But generally I agree with the three following safety recommendations:
- Retraining pilots more to emphasize the terminology for entering a runway and takeoff clearance, assuming that there are no exceptions to the terminology.
- Full time monitoring of runway radar for any unwarranted incursions.
- Stopbars in use at all times
- Stop bars would be helpful, however, the operational flow control of the airport which permits TO and LDG on the same runway when multiple runways are operational sets the stage for this type of event.
- Having intersection TO's where there is LDG increases risk as well.
As for enabling permanent use of runway stop bar lights, this document goes into (some of) the ramifications:
EUROPEAN ORGANISATION FOR THE SAFETY OF AIR NAVIGATION: September 2008: Runway Safety - Use of Stop Bars 24H
I recommend reading at least the Executive Summary. It might be useful as input for Haneda Airport.
EUROPEAN ORGANISATION FOR THE SAFETY OF AIR NAVIGATION: September 2008: Runway Safety - Use of Stop Bars 24H
This study and consequent work was undertaken by the Local Runway Safety Team of Manchester Airport. Due to the successful outcome of the trial, the use of stop bars 24 hours per day to protect the runway will be continued as part of normal operations at Manchester Airport.
Last edited by Saab Dastard; 18th Jan 2024 at 16:35. Reason: Irrelevant private argument removed
My point was that stopbars alone would not stop an incident where the pilot genuinely believed he had a special exception to enter the runway. A negligent pilot could easily overlook a stopbar.
I agree that what I wrote was poorly written. I apologize.
Just to expand on my point:
https://pointsixtyfive.com/xenforo/t...rossings.2316/
My understanding is that there are certain cases where a vehicle can cross a runway without ATC approval in FAA land (not inherently Japan).
As for enabling permanent use of runway stop bar lights, this document goes into (some of) the ramifications:
EUROPEAN ORGANISATION FOR THE SAFETY OF AIR NAVIGATION: September 2008: Runway Safety - Use of Stop Bars 24H
I recommend reading at least the Executive Summary. It might be useful as input for Haneda Airport.
EUROPEAN ORGANISATION FOR THE SAFETY OF AIR NAVIGATION: September 2008: Runway Safety - Use of Stop Bars 24H
I recommend reading at least the Executive Summary. It might be useful as input for Haneda Airport.
In the event of a stopbar failure, the holding point/ entry is withdrawn from service, notamed if required, until fixed.
Systems are designed with fail safe modes, and dual power supply so the stopbar should fail to ON/illuminated red. If there is no way round using the failed holding point, a risk assessment is made for an alternate procedure, such as “Follow Me” vehicles being used for every stop bar crossing. This is extremely rare, I’ve only seen it once in about 20 years.
Last edited by jumpseater; 18th Jan 2024 at 18:51.