Farrell
5th May 2005, 10:12
Tokyo air controllers 'forget' runway closed.
Daily Yomiuri
A Japan Airlines jetliner lands at Haneda Airport, Tokyo in this March, 2005 photo. (James Rowson/View Full Size)
An error by air traffic controllers at Tokyo's Haneda Airport on Friday night in which all 18 controllers on duty forgot about a runway closure has brought to light a number of problems that, if left unaddressed, could lead to disaster, analysts said Sunday.
The blunder took place minutes after one of the domestic airport's three runways closed at 9:30 p.m. for repair work to runway lights.
The information on the repair work--scheduled to continue through October after starting in April--was sent to Haneda's 136 controllers in early March.
Despite this, the controllers gave two incoming Japan Airlines planes wrong instructions to land on the airport's runway A, despite the fact that the planes' pilots--who also had been informed of the closure--queried the instructions four times.
The controllers admitted to repeatedly telling the pilots their landing clearance information was not mistaken. The first of the two JAL planes landed on the closed runway at 9:39 p.m., while the captain of the second plane, suspicious of the validity of the landing clearance information, landed on the airport's runway C, parallel to runway A, after forcing the issue with controllers.
The Construction and Transport Ministry's Aircraft and Railway Accident Investigation Commission has taken a dim view of the incident, saying if any repair vehicles had been on the runway, it could have led to a major accident.
"Under normal circumstances, it could never have happened," Haneda's air traffic control chief Masaaki Naito said at a press conference at the ministry Saturday.
Of the 18 air traffic controllers on duty at the time, three were directly responsible for radio contact with the approaching JAL planes, he said.
Two others were supposed to assist the three by confirming the accuracy of their instructions, but all controllers on duty had forgotten about the runway repair work, Naito said.
When questioned by Civil Aviation Bureau officials, one of the controllers reportedly said, "We mistakenly thought the repair work would be done late at night, not the hours we were on duty."
Runway A is closed for repairs from 9:30 p.m. through 7 a.m. Wednesday to Thursday.
Another was cited as admitting, "Although I had been well aware of the runway closure due to the repair work up until a week before, I forgot about it when on duty on Friday."
Another controller told officials the information-sharing arrangements among the controllers were badly insufficient, and only one controller was responsible for reconfirming air traffic safety information from the bureau or other sources.
Nothing learned from past incidents
An incident very similar to that at Haneda occurred at Niigata Airport in June.
After receiving faulty instructions, a small plane landed on a closed runway, almost colliding with a crane that was engaged in maintenance work on the runway.
In the wake of the incident at Niigata Airport, the Civil Aviation Bureau issued instructions to airports nationwide to review preventive steps against accidents involving runways closed for maintenance work or other reasons.
As analysts point out, Friday's incident at Haneda suggests that none of the 18 air traffic controllers on duty had learned from Niigata Airport's near miss.
The bureau regularly provides air traffic controllers with safety notices. In addition to the regular safety information, urgent information involving safety control operations, called "NOTAM (Notice to Airmen)," is issued by the bureau to all airports via a secure intranet.
Two other categories of information, that concerning permanent changes in airport conditions such as the length of runways, and temporary but long-term changes in airport conditions that last for three months or more are called "amendments" and "supplements." The bureau mails information to controllers across the country at least 28 days before the changes are implemented.
Information on the repair work at Haneda was sent to the chief traffic controller in early March, who conveyed it to all 136 controllers. The information also was put up on a notice board in the airport's briefing room, to ensure all controllers would know about the repair work.
But according to a ministry official who used to be an air traffic controller, the notice board is full of notices, making it difficult for controllers to find relevant and priority information.
"Any controller may well be unable to be careful about all the information put up on the board," he said.
New work schedule a factor?
Some analysts note that changes to the working shifts of Haneda's air traffic controllers' from early April may have had something to do with Friday's incident.
The old schedule had controllers working four shifts a day, but from April 6 it changed to six a day.
The team in charge of the control tower on Friday evening had never been at work during the runway closure hours before, analysts said. They were reminded about the closure by the group of controllers who were to take over duty at 10 p.m., they said.
Osamu Takeda, vice chairman of the central committee of the Federation of Public-Sector Transport Trade Unions (Zenunyu), who worked as an air traffic controller at Haneda for four years, noted, "Controllers pass on safety information for 20 to 30 minutes every time they start their shift. It's almost impossible that all 18 controllers forgot the runway closure."
"Such a serious mistake can hardly be put down to carelessness--behind the incident may be errors in the entire personnel management system, including arrangements to ensure double checks on safety."
Daily Yomiuri
A Japan Airlines jetliner lands at Haneda Airport, Tokyo in this March, 2005 photo. (James Rowson/View Full Size)
An error by air traffic controllers at Tokyo's Haneda Airport on Friday night in which all 18 controllers on duty forgot about a runway closure has brought to light a number of problems that, if left unaddressed, could lead to disaster, analysts said Sunday.
The blunder took place minutes after one of the domestic airport's three runways closed at 9:30 p.m. for repair work to runway lights.
The information on the repair work--scheduled to continue through October after starting in April--was sent to Haneda's 136 controllers in early March.
Despite this, the controllers gave two incoming Japan Airlines planes wrong instructions to land on the airport's runway A, despite the fact that the planes' pilots--who also had been informed of the closure--queried the instructions four times.
The controllers admitted to repeatedly telling the pilots their landing clearance information was not mistaken. The first of the two JAL planes landed on the closed runway at 9:39 p.m., while the captain of the second plane, suspicious of the validity of the landing clearance information, landed on the airport's runway C, parallel to runway A, after forcing the issue with controllers.
The Construction and Transport Ministry's Aircraft and Railway Accident Investigation Commission has taken a dim view of the incident, saying if any repair vehicles had been on the runway, it could have led to a major accident.
"Under normal circumstances, it could never have happened," Haneda's air traffic control chief Masaaki Naito said at a press conference at the ministry Saturday.
Of the 18 air traffic controllers on duty at the time, three were directly responsible for radio contact with the approaching JAL planes, he said.
Two others were supposed to assist the three by confirming the accuracy of their instructions, but all controllers on duty had forgotten about the runway repair work, Naito said.
When questioned by Civil Aviation Bureau officials, one of the controllers reportedly said, "We mistakenly thought the repair work would be done late at night, not the hours we were on duty."
Runway A is closed for repairs from 9:30 p.m. through 7 a.m. Wednesday to Thursday.
Another was cited as admitting, "Although I had been well aware of the runway closure due to the repair work up until a week before, I forgot about it when on duty on Friday."
Another controller told officials the information-sharing arrangements among the controllers were badly insufficient, and only one controller was responsible for reconfirming air traffic safety information from the bureau or other sources.
Nothing learned from past incidents
An incident very similar to that at Haneda occurred at Niigata Airport in June.
After receiving faulty instructions, a small plane landed on a closed runway, almost colliding with a crane that was engaged in maintenance work on the runway.
In the wake of the incident at Niigata Airport, the Civil Aviation Bureau issued instructions to airports nationwide to review preventive steps against accidents involving runways closed for maintenance work or other reasons.
As analysts point out, Friday's incident at Haneda suggests that none of the 18 air traffic controllers on duty had learned from Niigata Airport's near miss.
The bureau regularly provides air traffic controllers with safety notices. In addition to the regular safety information, urgent information involving safety control operations, called "NOTAM (Notice to Airmen)," is issued by the bureau to all airports via a secure intranet.
Two other categories of information, that concerning permanent changes in airport conditions such as the length of runways, and temporary but long-term changes in airport conditions that last for three months or more are called "amendments" and "supplements." The bureau mails information to controllers across the country at least 28 days before the changes are implemented.
Information on the repair work at Haneda was sent to the chief traffic controller in early March, who conveyed it to all 136 controllers. The information also was put up on a notice board in the airport's briefing room, to ensure all controllers would know about the repair work.
But according to a ministry official who used to be an air traffic controller, the notice board is full of notices, making it difficult for controllers to find relevant and priority information.
"Any controller may well be unable to be careful about all the information put up on the board," he said.
New work schedule a factor?
Some analysts note that changes to the working shifts of Haneda's air traffic controllers' from early April may have had something to do with Friday's incident.
The old schedule had controllers working four shifts a day, but from April 6 it changed to six a day.
The team in charge of the control tower on Friday evening had never been at work during the runway closure hours before, analysts said. They were reminded about the closure by the group of controllers who were to take over duty at 10 p.m., they said.
Osamu Takeda, vice chairman of the central committee of the Federation of Public-Sector Transport Trade Unions (Zenunyu), who worked as an air traffic controller at Haneda for four years, noted, "Controllers pass on safety information for 20 to 30 minutes every time they start their shift. It's almost impossible that all 18 controllers forgot the runway closure."
"Such a serious mistake can hardly be put down to carelessness--behind the incident may be errors in the entire personnel management system, including arrangements to ensure double checks on safety."