Airbus A350 Flight JAL516 incident - Haneda airport 02 January 2024

TomcatViP said:
Something probably went wrong with the A350 landing sequence.
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No evidence of that. The Coast Guard plane was supposed to hold short of the runway and didn’t.

Good summary from Pprune here:
From what we know so far, a classic case of Swiss cheese that will likely make it into future textbooks. Investigation will take months to years, but I doubt any significant new information will be added other than a more elaborate analysis of the individual holes:
  • 34R was T/O only runway previously, JL516 was the first to use it for landing. The MA722 crew may have had a mental picture not to expect any landings on this runway. For same reason, they may not have expected the need to hold short.
  • Usage of "Number one" by ATC may have further reinforced the MA722 crew, missing the "abeam C5" or misunderstanding it as hold ON RWY abeam of C5 (which is exactly what they did). While usage of English in all ATC comms in Japan is commendable, in this case it probably just added to the confusion.
  • Stop bar and taxiway lighting INOP.
  • JL516 and MA722 on different frequencies
  • MA722 was sitting aligned on the runway for 45+ seconds. Probably Japanese culture at play, it is impolite to challenge authority or appear impatient, they were likely patiently waiting for ATC to clear them for T/O.
  • DL taxied past MA722 a good 20-25 seconds before the collision, it was already out of their view and expectantly on its t/o roll as the A350 was approaching, so no extra set of eyeballs to wave off JL, as it was done in SFO.
  • The combination of HUD and LED lighting probably prevented the JL crew from seeing MA722 even at close range, I'd wager they never saw what they hit.
  • Visibility of a DH3 from the rear in the dark is practically nil. The only visible tail light is white, probably flooded out by runway lights, and the flashing orange upper ACL is obscured by the high tail from the approach angle. The otherwise fully warranted SOP of not using strobes until the beginning of T/O roll did not help in this case.
The only important question remaining is why did the approach controller not notice that 34R was occupied ? Even if MA722 was not where it was supposed to be, surely HND has SMR, there should have been both visual and aural warnings as a measure of last resort.
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It's even written above... He should have seen the airplane right on the runway threshold.
 
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TomcatViP said:
It's even written above... He should have seen the airplane right on the runway threshold.
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The Coast Guard plane wasn’t on the threshold but halfway down the runway at point C5. Experienced pilots on PPrune are saying it’s almost impossible to see a plane sitting on the runway from the air at night, especially if that plane hasn’t turned on its strobe or landing lights.

I recommend properly reading what was posted and the whole linked thread as it is very informative (with comments by both experienced pilots and ATC controllers) and deals with facts rather than conspiracy theories.
 
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Regarding passengers emergency exit, it seems the port aft one was also used:

Screenshot_20240105_090223.jpg

Notice also how flames were spreading in the inner layer b/w the outside skin and internal fuselage, in effect protected and free to spread from the sprayed foam by the fire team. I see that as a lesson to learn in the future.
 
When it is not Murphy Law, then it's Swiss cheese. Both equally perverse.

And sometimes they work together to create the ultimate shitstorm: such as Tenerife 1977. That one was a maddening but - with hindsight - textbook case. Of the two SOBs working hand in hand, direction chaos and carnage.
Whatever could go wrong went wrong (Murphy Law) - and then all the wrongs aligned to perfection (Swiss Cheese). From the independantist bomb attack in the morning to the 747s slamming into each other. The whole thing stretched over 6 hours.
 
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- 18min grand total for the complete evacuation of the aircraft (remember 90secondes with half evacuation doors available, if my mem stands right).
- as intercom was down and rear crew were not able to communicate with Pilots and other members of the cabin crew, they took the initiative by their own to open the port aft emergency exit (the only rear one free of immediate fire risks)
- 3 pilots were in the cabin (did that play a part on them not paying attention scanning the front sector?)
- on the video above you can clearly see the Dash-8 nav and strobe lights. The strobe light would have appeared to the Airbus pilots flashing bright white right on the runway center line. Hard to miss.
- what is noteworthy is that the plane continued to burn from the inside for a considerable time despite all attempts by the fire brigade.

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Link in French.
www.air-journal.fr

Vol JL516 Japan Airlines : les pilotes ne savaient pas pour l’incendie de l’A350, mais l’évacuation a été parfaitement exécutée | Air Journal

Les pilotes de l’A350 de Japan Airlines entré en collision avec un avion plus petit à l'aéroport de Tokyo Haneda ignoraient initialement que leur avion était
www.air-journal.fr
 
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In the case of an aircraft collision at Haneda Airport, the Japan Transportation Safety Board has begun interviewing air traffic controllers.

The air accident investigator of the National Transportation Safety Board had been interviewing the crew of Japan Airlines, but it turned out that they had started interviewing air traffic controllers.

On the other hand, an interview with the Ministry of Land, Infrastructure, Transport and Tourism revealed that the monitor of the air traffic controller, who was communicating with both Japan Airlines and the Japan Coast Guard aircraft at the time of the accident, displayed in red that the Coast Guard aircraft had entered the runway.

The system alerts air traffic controllers, but they may not have been aware of it.

As an emergency measure, the Ministry of Land, Infrastructure, Transport and Tourism will place a new controller at Haneda Airport from the 6th to constantly monitor this monitor.

TV Asahi
 
In an accident in which an aircraft of JAL and the Japan Coast Guard collided on the runway of Haneda Airport, the control tower was equipped with a function to alert if another aircraft entered the runway where the landing aircraft was approaching, according to an interview with the Ministry of Land, Infrastructure, Transport and Tourism on the 5th. If the approach of the Coast Guard aircraft had been detected, the entire runway would have flashed yellow on the screen of the display device used by the air traffic controller, and the aircraft would have been displayed in red.
　It is believed that the controller was unaware that the Coast Guard aircraft was on the runway until the collision, and the National Transportation Safety Board and the Metropolitan Police Department are investigating the details of the incident.
　According to the Ministry of Land, Infrastructure, Transport and Tourism, in September ~ November 2007, there were a series of incidents of aircraft entering the runway by mistake at airports in Osaka, Kansai, and Chubu. It was discussed at the countermeasure review meeting, and in the March 2008 report, it was included to promote the development of a "runway occupancy monitoring support function" as a backup to prevent human error by air traffic controllers.
　At Haneda, all four runways were put into operation by March 2011.
　The Ministry of Land, Infrastructure, Transport and Tourism explained, "The accident investigation will clarify whether the location of the Coast Guard aircraft was actually identified at the time of the accident and whether a warning sign was issued."
 
blackkite said:
The Airbus A350-900, JAL's flagship aircraft for domestic trunk routes, was used for JL516 flight. The number of seats on this aircraft is 369. From the announced number of passengers, it can be seen that it was almost full.

In addition, this aircraft has a total of eight doors, four on each side, and in the event of an emergency escape on the ground, an "escape slide" comes out from these doors, and passengers slide down from them. In passenger aircraft, when obtaining a "type certificate", which is indispensable for practical use, there is a so-called "90-second rule" that "all passengers and crew can escape from the cabin within 90 seconds using half of the escape doors in the cabin", and the aircraft is designed based on it.

However, according to the following JAL press release, not only was the flight full, but it was also a situation where "more than half of the escape doors were unusable".

"The cabin crew provided guidance with a megaphone and a voice to guide the passengers through a megaphone and a voice during the evacuation, and all passengers and crew members were evacuated through the three emergency exits," according to a JAL press release.
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I'm amazed that everyone in the A350 survived...

5/8 doors unusable for evac!


TomcatViP said:
Personally in the video above I see a touchdown 200m from the holding airplane (hence on the stopway?!) and the Dash-8 having its nav lights on (with beacon?).
Something probably went wrong with the A350 landing sequence. He should have noticed that someone was right on the runway threshold.
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Even if he did, may not have had enough time/distance to execute a go-around in that aircraft.
 
blackkite said:
In an accident in which an aircraft of JAL and the Japan Coast Guard collided on the runway of Haneda Airport, the control tower was equipped with a function to alert if another aircraft entered the runway where the landing aircraft was approaching, according to an interview with the Ministry of Land, Infrastructure, Transport and Tourism on the 5th. If the approach of the Coast Guard aircraft had been detected, the entire runway would have flashed yellow on the screen of the display device used by the air traffic controller, and the aircraft would have been displayed in red.
　It is believed that the controller was unaware that the Coast Guard aircraft was on the runway until the collision, and the National Transportation Safety Board and the Metropolitan Police Department are investigating the details of the incident.
　According to the Ministry of Land, Infrastructure, Transport and Tourism, in September ~ November 2007, there were a series of incidents of aircraft entering the runway by mistake at airports in Osaka, Kansai, and Chubu. It was discussed at the countermeasure review meeting, and in the March 2008 report, it was included to promote the development of a "runway occupancy monitoring support function" as a backup to prevent human error by air traffic controllers.
　At Haneda, all four runways were put into operation by March 2011.
　The Ministry of Land, Infrastructure, Transport and Tourism explained, "The accident investigation will clarify whether the location of the Coast Guard aircraft was actually identified at the time of the accident and whether a warning sign was issued."
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I am honestly, truly saddened and surprised that such a basic snafu could occur in a country as disciplined and cultured as Nippon.
 
martinbayer said:
I am honestly, truly saddened and surprised that such a basic snafu could occur in a country as disciplined and cultured as Nippon.
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Unfortunately, you'd be depressed at how often someone in Japan can be persuaded to look the other way.

Had a speaker for an International Business class give an example: he worked for a company that made elevator shaft smoke curtains, they had a patented design that was the best available. They wanted to expand internationally, because the US doesn't have that many high rises, relatively speaking, and fire codes weren't requiring curtains yet. But Japan is basically nothing but high rises, so they'd be perfect. They found a company to work with in Japan, came to a licensing agreement that the two companies liked, and went out to basically make no money. Despite the Japanese fire code requiring smoke curtains, buildings were somehow getting waivers for not having them.
 
In response to the accident in which two planes collided at Haneda Airport, the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) has put together emergency safety measures, such as not using the word "number 1" to indicate the order of departure when air traffic controllers issue takeoff clearances.

Five people were killed when a Japan aircraft that landed at Haneda Airport collided with a coast guard aircraft that entered the runway to take off.

The Ministry of Land, Infrastructure, Transport and Tourism (MLIT) has compiled emergency safety measures, such as issuing takeoff permission without informing the departure order in advance, as there is a possibility that the Coast Guard may have misidentified the word "number 1," which means the order of departure, as it was mistaken for a takeoff permit conveyed by the air traffic controller before the accident.

In addition, a committee will be set up with external experts to consider the review of communications. (ANN News)
 
At the time of the accident, Runway 34R was used for both takeoff and landing.
Because the control tower called out number one to the Coast Guard aircraft, the captain of the Coast Guard plane may have mistakenly thought that his plane was the first to use the runway. Therefore, it is a policy not to tell the order of takeoff to the aircraft scheduled to take off in the future.
 
Thank you. But it does not make sense. Radio Communication during g landing and takeoff routine is already very codified to make sure there is no misunderstandings.

Here we understand that the Dash-8 breached the runway for 45 seconds without anyone at the tower noticing it, despite clear visibility conditions. This is simply unacceptable. IMOHO, there is no needs to start trimming/altering international safety usage to make the matter more confusing locally.
 
TomcatViP said:
-- on the video above you can clearly see the Dash-8 nav and strobe lights. The strobe light would have appeared to the Airbus pilots flashing bright white right on the runway center line. Hard to miss.
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Don't be so sure. In this similar accident at Los Angeles in 1991, it was later experimentally determined that the aircraft on the runway was indeed nigh impossible to see for a crew on short finals:


Depending on ambient lighting conditions, the configuration and intensity of the ground and onboard lights, it's entirely possible for a fairly sizeable aircraft to blend in with the background.
 
Talked to a commercial pilot and he confirmed that the A350 crew would struggle to see the Dash-8 but that the Dash-8 crew would easily see the A350. Even if given clearance by the tower to enter a runway, crews should maintain situational awareness and look out for something on final.
 
OliverSedlacek said:
Talked to a commercial pilot and he confirmed that the A350 crew would struggle to see the Dash-8 but that the Dash-8 crew would easily see the A350. Even if given clearance by the tower to enter a runway, crews should maintain situational awareness and look out for something on final.
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Only if they were facing the A350, I'm under the impression that the Dash-8 had the A350 behind it.
 
OliverSedlacek said:
Talked to a commercial pilot and he confirmed that the A350 crew would struggle to see the Dash-8 but that the Dash-8 crew would easily see the A350. Even if given clearance by the tower to enter a runway, crews should maintain situational awareness and look out for something on final.
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30 seconds from final makes the A350 quite far from runway threshold (roughly 2km). But true, they could have seen it. But then, how could have they figured it was not landing on a parallel runway?

But I regret to say that the A350 touched down quite close to the Dash-8. It's inexcusable that they didn't see an aircraft park there... until we learn of any defficiency with the Dash-8 lights, something that was rullled out by the videos available.

@Scott Kenny : they are supposed to check approach glide path before entering the runway.
It basically works like that:
- authorized to roll to the runway threshold
- acknowledge permission
- check glide path
- roll-in, align and stop
- wait for takeoff authorisation
- (go through short takeoff check list)
 
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TomcatViP said:
30 seconds from final makes the A350 quite far from runway threshold (roughly 2km). But true, they could have seen it. But then, how could have they figured it was not landing on a parallel runway?

But I regret to say that the A350 touched down quite close to the Dash-8. It's inexcusable that they didn't see an aircraft park there... until we learn of any defficiency with the Dash-8 lights, something that was rullled out by the videos available.
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It's still been conclusively proven in another crash incident like this that a Dash-8 facing the same direction you are attempting to land is almost invisible until it's too late to safely execute a missed-approach.


TomcatViP said:
@Scott Kenny : they are supposed to check approach glide path before entering the runway.
It basically works like that:
- authorized to roll to the runway threshold
- acknowledge permission
- check glide path
- roll-in, align and stop
- wait for takeoff authorisation
- (go through short takeoff check list)
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So, looking for landing lights ~3000m away, that aren't playing the optical trick of "sitting there" when they're actually on a constant bearing decreasing range course that doesn't change the apparent size/space between lights quickly enough for a human to see.

And I'm willing to bet that there are buildings that appear to be on the glideslope (but are actually like 5-10km away from the runway threshold).
 
I don't know any building that have something like a landing light on the top.

Aircraft as seen from the rear have very distinctive lights: Red, white Green (blinkering).

LH1p2.png



Screenshot_20240211_171947.jpg

Img Source
 
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I'm aware.

1) Blinking red anticollision lights are on the top corners of damn near every tall building in Japan.

2) a large white light, like your landing lights, is also on many tall buildings.
 
TomcatViP said:
Don't understand here. What´s wrong with that number? Is there someything specific to Japanese language?
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All air traffic instructions are given in the English language, world wide.
 

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