JAL captain indicted in MD-11 death.

[ORAC]

AWST 27th May:

JAL Captain Indicted
In Fatal Pitchup
EIICHIRO SEKIGAWA/TOKYO and
MICHAEL MECHAM/SAN FRANCISCO

The captain of a Japan Airlines MD-11 that experienced severe air turbulence leading to the death of a cabin attendant has been indicted on a charge of "professional negligence resulting in death."

Capt. Koichi Takamoto, 52, was indicted by the Nagoya District Prosecutor's Office on May 14 for making manual flight control inputs while the autopilot system was engaged. The incident occurred on June 8, 1997, as JAL Flight 706, was on a too-fast approach to Nagoya International Airport on a flight out of Hong Kong.

The indictment said he was flying the aircraft on autopilot as it descended at 4,500 ft./min. at 350 kt. The aircraft's airspeed increased to 368 kt., exceeding its maximum operating speed (Vmo) of 365 kt. The captain, intending to decelerate by pulling up the nose, tried overriding the autopilot system by pulling back on the yoke and deploying the speed brake.

The autopilot was disengaged but a moment later the aircraft began 15 sec. of violent bucking at an altitude of 16,700 ft. In all, the MD-11's nose pitched up and down five times. Its pitch angle changed from *3 deg. to +10 deg. and vertical acceleration changed from 2.8g to *0.5g. Four passengers and seven crewmembers were injured. A 34-year-old flight attendant, Atsuko Taniguchi, was walking the aisle to check seat belts. She was thrown against the ceiling, hit her head, entered a coma and later died.

When the pitching was brought under control, the aircraft landed 26 min. later without incident.

The indictment faulted Takamoto for attempting to manually override the autopilot before disengaging it. Had he disengaged it first and then pulled on the yoke to achieve a nose up, the aircraft would not have reacted so violently, prosecutors said, making him responsible for the death and injuries.

The prosecutor's action contradicts a report from Japan's Aircraft Accident Investigation Committee (AAIC) of the Ministry of Transport. It faulted Takamoto's actions with regard to the autopilot and speed brake, but is considered sympathetic to the captain because it focused on the longitudinal stability of the aircraft.

The indictment drew the ire of the Japan Pilot Assn., Japan Airlines and the Air Line Pilots Assn. Referring to Annex 13, which governs accident investigations under the Convention on International Civil Aviation, ALPA says investigators cannot expect full disclosure by everyone involved in an investigation if the threat of prosecution is present.

"Pilots have agreed to be honest in describing what actions they took, right or wrong," ALPA First Vice President Dennis Dolan said. "But when you lay the threat of criminal prosecution on, it's going to have a chilling effect."

In their report, the Transport Ministry's accident investigators said:


The smaller tailplane of the MD-11, when compared to the DC-10, decreases its longitudinal stability in high-altitude flight. Because longitudinal control at high altitude requires less power than at low altitude, it sometimes induces overcontrol in an MD-11.
In its own comment on the incident, the U.S. NTSB said pitch upsets in the MD-11 may be more severe than in other aircraft because control column forces needed for manual control in cruise flight can be much lighter than on other aircraft models. They are "considerably lighter than those normally used at lower speeds and altitudes," it said.


McDonnell Douglas' MD-11 Flight Crew Operating Manual said overpowering the autopilot with control forces can cause the autopilot to disengage with too much control input, which could result in over-control during recovery. But it does not mention severe pitchups.

The manual prohibits overriding the autopilot in severe turbulence. It warns pilots to drop power to minimum when flying under manual control in turbulence, but states nothing about overriding the autopilot and control power in calm air.

The pilot should have reduced power or let go of the column in a violent pitchup, but the MD-11 manual doesn't mention this. It also says nothing about recovery from an unusual attitude or what to do when the aircraft exceeds Vmo.

JAL's MD-11 simulator program does not include training for overriding or automatic disengagement of the autopilot.
The AAIC recommended that the FAA require Boeing (which bought out McDonnell Douglas) improve the MD-11 autopilot and review its flight simulation training program.

The flight control computer was later changed, as part of an effort to give a common type rating between the MD-11 and the FedEx "MD-11" DC-10 conversion program, according to a Boeing official.

The Nagoya action is the first prosecution of a Japanese pilot since 1971 when an air force captain was convicted of providing insufficient supervision of a wingman who collided with an All Nippon Airways 727 that killed all on board. The wingman bailed out and was acquitted; the pilot received three years in prison.

[Desert Dingo]

How about also indicting the autopilot for allowing the speed to get off target by 18 kts. Gross negligence I say! :rolleyes:

(Prosecuting someone seems to be a standard response in this part of the world - fixing the blame, not the problem.)

[jrs2-benson]

I agree!

Althought the Captain is ultimatly responsible for the death of one of the cabin crew (voluntary elevator control input) the training obviously did not instill SOP critically enough.

Two areas of Mis- training exest here in "My Opinion".

1. The Captain was not trained properly. Therefore the Captain would be un-aware of the effect of the elevator control input wilst the AP was engaged. Unless as in this case the Captain employed the trial and error methology.

2. The F/O was also sitting in the cockpit. The apparent lack of awarness or pressure the F/O may have been under at the time prevented the ACTION from the F/O necessary to ovoid a potential deviation from the required flight path in the first place. This in itself would have prevented the Captains misfortune.

[bugg smasher]

The captain in question was properly trained.

Those of us that have been flying the MD-11 for many years have followed the various software updates, and have necessarily absorbed changes dictated by incidents on the line such as the one described above. I am unable to name any civil transport aircraft that has not experienced the same in one form or another.

At the time of the JAL incident, ****** was in the final process of disseminating newly modified control laws, designed specifically to mitigate high-altitude flight path excursions in heavy turbulence. This was a direct response to data recorder information that indicated aforesaid upsets were attributed in part to pilot input during autoflight system control of the aircraft.

The Mad Dog, in my opinion, has always been a very much hands-on, or hands-off aircraft; you venture into the twain at your peril. The Japanese captain in question was procedurally caught in the middle of this process, we have all learned a great deal since then.

The MD-11 remains a magnificent and admirably capable flying machine; she continues to profit her operators handsomely, and safely. The fact that her teething troubles may have been somewhat more extended than most other types does not detract from the brilliance of her basic design

I am appalled at the tragic loss of a cabin crewmember. In contrition, God grant an ancestral curse on Japanese lawyers.

[start sequence 312]

There were two serious MD-11 in-flight upsets (American Airlines, 07/13/96, and JAL, 06/08/97) in different circumstances, and only after those incidents the MD-11 FCOM has changed.
In the AAL upset the F/O, who was the PF, adjusted the pitch thumbwheel 7 times as the A/P was attempting to level the airplane after descending. The captain became concerned that the airplane might not level off at assigned altitude (24,000ft) and took manual control of the airplane, applying back pressure to the control column with the A/P engaged. Only after that command he disconnected the A/P. The airplane, based on FDR, experienced an immediate 2.3G pitch upset followed by additional oscillations. 1 passenger received serious injuries and 1 passenger and 2 FA received minor injuries.

Then, two FCOM Temporary Revisions were issued:
First: Dated June 18, 1997 - an expanded information to operators concerning pitch wheel command. MD-11 V/S control, with the A/P engaged, cancels the altitude capture mode if the pitch thumbwheel is moved and will not re-engage in altitude capture until the pitch wheel has come to rest for at least 2 seconds. The selected altitude will not be captured if the pitch wheel is repeatedly adjusted. AAL operations and training staff were not aware of this time-delay.
Second: Dated December 2, 1997 - inserting a warning in the Automatic Flight System section, to clarify airplane reaction when applying force to the control wheel or column while the A/P is still engaged. Prior to that TR there was only a mention in the ‘Severe Turbulence and/or Heavy Rain Ingestion’ section, which stated:
"Do not attempt to overpower the autopilot with control forces. This cause the autopilot to disengage with too much control input, which could result in over control during recovery. Every attempt should be made not to over control".

[bugg smasher]

Excellent post SS312, thank you for pinning down dates and details.

I seem to recall a serious incident regarding China Eastern on a NoPac flight in heavy turbulence. Crew attempts to override the autoflight system resulted in a sudden and violent disconnect, that then progressed to airspeed deviations of a magnitude sufficient to cause autoslat deployment. The ensuing loss of control and altitude make for a riveting read. I’m not sure of the dates.

I would be very interested to hear what the Boeing and the Busboys have to say about over-riding the autopilot. The A300, for example, appears to be a quixotic and dangerous animal in this regard.

[Kaptin M]

If the prosecution is successful in achieving a conviction in this case, the consequences for ALL PROFESSIONAL PILOTS EVERYWHERE could be disastrous!

This charge - as was also the case in New Zealand - is the equivalent of a "malpractice" suit, tens of thousands of which are filed against doctors annually, thereby requiring surgeons to outlay massive amounts of their own money in insurance, to protect themselves. (As an aside, Australia's largest insurer protecting doctors has just announced bankruptcy, due to the massive increase in claims, and hence leaving thousands of doctors PERSONALLY LIABLE for damages claims by patients.)

Pilots are AGENTS of their employer airlines/companies, and as such operate under the rules and procedures taught, and regularly checked by company checkers, and OVERSEEN and REGULATED by the country`s REGULATORY AUTHORITY - in this case the Japan Civil Aviation Bureau (JCAB).


If ANYONE should be on trial, it MUST come back to Japan Air Lines (JAL AND the JCAB. The Captain concerned was flying the aircraft (regardless of type) IN ACCORDANCE with practices, techniques and procedures he had been DIRECTED TO FOLLOW.

In typical Japanese knee-jerk reaction style, Japan Air Lines has issued - THIS YEAR, almost 5 years after the accident - an instruction to their crews not to manually override the autopilot.

Akin to the New Zealand accident a few ago, the LOCAL POLICE are immediately involved in any aircraft incident/accident As an example of how ridiculous and ignorant of aviation the laws pertaining to these incidents are, I shall cite an example of which I had first hand experience. I was due to depart (as operating crew) on an internal flight in Japan, and having completed the flight planning and crew briefing advised the ground staff of our readiness to proceed to the aircraft. At this juncture, I was advised that we were not ALLOWED to go the aeroplane :confused: . Finally it was revealed (and for those who have worked in Asia, you will understand just how HARD it can sometimes be, to get to the truth when "locals" are involved) that the aircraft we were to take, had had an encounter with turbulence during descent - around FL270 from memory - and one Flight Attendant had suffered a leg injury.

The local police had now IMPOUNDED the aircraft, with the instructions that NOTHING in the cockpit was to be touched!! The "scene of the crime"!!!
Although the incident had occurred during descent, and the aircraft had subsequently been configured for landing, and later, post landing, shutdown, and parking, it was NOW a "sterlie area".
This is the mentality one is dealing with!

Now, under JCAB law, it is only classified as an incident if the person injured is required to stay in hospital for a period exceeding 48 hours (or, of course, a death), and so presumably the aircraft would also have to remain impounded by the police for that length of time, until the qualifying 48 hours had been reached.
Fortunately in my case, the F/A declared herself fit after only 45 minutes or so, however it did highlight the ludicrousy of the "system".

[bblank]

bugg smasher, for reasons I need not go into here I happen to have
accumulated a bunch of MD-11 data (but I've never been in the beast).

The earliest incidents of PIO happened to Alitalia, China Eastern,
and CI. They were different from AA 107 and JAL 706 in that the
PIO was not initiated by intentional pilot input while the A/P
was engaged. I think that you were referring to these
incidents/accidents in your first post. China Eastern 583
(April 6 1993) started with an inadvertant slat deployment. Two
passengers died during the oscillations. There is a passage in the
NTSB final report (AAR93-07) that was relevant to AA 107 and JAL 706,
namely

"If the pilot attempts to override the autopilot by direct control
column force, all of the elevators will move, and the pilot will
experience significant resistance. If the autopilot is disconnected
while the pilot is exerting force on the control column to counter
the autopilot resistance, an abrupt change in the elevator position
will be induced by the pilot before he is able to react to the
lessening control column load. DAC test pilots state that pilots
typically react to this abrupt elevator command by overcorrecting in
the opposite direction, with larger than normal control column
movement that translates into more elevator deflection than would
have been commanded by the autopilot."

But this did play any part in the recommendations (which concentrated
on redesigning the flap/slat handle system and on requiring training in
high altitude upset recovery).

Note that the report is dated October 27 1993. Very timely!

The other incident happened to CI-012, December 7 1992. The upset was
caused by severe turbulence and the A/P automatically disconnected.
The very passage quoted above appeared verbatim in the final report
(AAR94-02). The NTSB repeated the recommendation to "Require operators
to provide specific training for recovery from high altitude upsets"
but they did not address pilot input while the A/P was engaged because
it did not happen.

That report was dated February 15,1994. Quite timely!

If I were a defence lawyer, God forbid, for the JAL Captain I would cite
the NTSB's first probable cause for AA 107:
"insufficient information from the manufacturer in the airplane flight
manual and flightcrew operating manual regarding the hazards of applying
force to the control wheel or column while the autopilot is engaged and
adjusting the pitch thumbwheel during a level off."

Also in the recommendations to the FAA (A-99-39 through -44):

"Require Boeing to revise the MD-11 Airplane Flight Manual and all
MD-11 operators to revise their company flight manuals to ensure that
pilots are warned about the hazards of applying force to the control
wheel or column while the autopilot is engaged. (A-99-39)

Issue a flight standards information bulletin that directs principal
operations inspectors to ensure that MD-11 training programs provide
simulator instruction in the proper procedure for autopilot
disengagement and the subsequent manual control of the airplane.
(A-99-40)"


From the same letter I'd probably also mention:

"The Safety Board concludes that the current MD-11 autopilot
design, which allows for upsets to occur when pilots apply
force to the flight controls, is not acceptable.

This letter was dated May 1999, nearly three years after AA 107 and
two years too late for the Japanese FA. Sad because the NTSB already
knew the cause, had only to make some calls to McDonnell Douglas
to confirm it, and an interim fix, an FCOM revision, could have been
accomplished quickly and cheaply. (I suppose the NTSB was preoccupied
with US Air 427 which was dragging and TWA800 which happened a few
days after AA 107).