JL516: Airliner Collision at Tokyo Haneda Airport
January 3, 2024 4:19 PM   Subscribe

In the dark before dinner yesterday, two aircraft collided at Tokyo Haneda Airport. Around 17:47 on January 2nd, a Japan Airlines Airbus A350-900 was landing on runway 34R after a short flight from Sapporo on the northern main island of Hokkaido. Meanwhile a Coast Guard Dash 8 had acknowledged the Tower's order to hold short of the same runway at intersection C5. But something went wrong and a few seconds before JAL 516's wheels hit the ground a giant column of fire was captured by airport CCTV.

The story has headlined global news. The airliner amazingly withstood the collision and initial fire, allowing a heroic and safe evacuation of all 379 souls on board. The Coast Guard plane was aiding in relief efforts following the severe New Year's Day earthquake off the coast of the Noto Peninsula, and tragically lost 5 of the 6 souls on board that comprised its crew. There will be months of official investigation to determine details of "how" and "why." But, concerning for airports and pilots around the world, initial evidence indicates this collision resulted from a runway incursion. Unfortunately the collision on January 2nd was only one of many recent serious runway incursions (archive).

The UN's International Civil Aviation Organization and others have regularly highlighted runway incursions as a persistent threat to safe aircraft operation and pushed for a global overhaul in the approach to risk mitigation. And in the United States, Air Traffic Controllers are facing a more and more difficult task as understaffing worsens in the face of growing traffic and increasing numbers of serious incidents (archive).

Despite the clarity of the threat, it has not yet drawn serious coordinated intervention. Perhaps it's due to the relative safety of air travel, or maybe due to habituation to contentious relationships between pilots/ ATC/local governments, or perhaps its because, since 1977, the world has mostly avoided the mass fatality potential contained in each incident.
posted by midmarch snowman (60 comments total) 18 users marked this as a favorite
 
That picture of the wreckage of the Airbus, from the "column of fire" link, is stunning. That no one on the plane died (immediately) is mind-boggling. I mean, I get that it didn't collapse right away, but wow.
posted by Gorgik at 4:25 PM on January 3 [7 favorites]


So runway incursions are becoming more frequent due to air traffic controller shortages and more overall traffic, and nothing is really being done about it?
posted by grumpybear69 at 4:25 PM on January 3 [4 favorites]


I've been lurking in aviation safety publications, forums, youTube and podcasts for over half a decade- but I am not ATC or pilot, and with respect to the commendable tradition of safety culture in aviation I tried to be careful with sources and speculation in the post above. Even with preliminary ATC transcripts and copious smart phone cameras, there are, without a doubt, dozens of factors that the public does not have a fraction of the initial evidence for. One thing I cut out was my belief that the continued low number of fatalities from these collisions and near collisions is due, partly, from extreme luck and a difference of a couple meters.

I decided to leave in Blancolirio's video in the links above despite some very restrained speculation contained within because he has what looks like Runway Diagram for Haneda that's been updated since the 2018 version I found available for free. And in that diagram, it looks like intersection C5 is near the middle of the 34R's touchdown zone; Meaning JL516 could just as likely aimed to touch down earlier, resulting in a more significant collision- easily causing a much more severe loss of control as the Airbus skidded down the runway and ultimately prevent evacuation. But like I said, there's too many factors completely unknown to the public to speculate that in the main post.
posted by midmarch snowman at 4:46 PM on January 3 [8 favorites]


I can’t help but wonder if the ATC personnel shortage has anything to do with the pitch for new candidates being something like : “You’ll be in a high stress job with lives on the line, you won’t get paid commensurately, everyone around you & responsible for your training is overworked and underpaid. Come join us!”

$70-150k / year for an ATC at SFO is laughable considering what’s at stake

What’s even worse is some techbro who’s never stepped in a tower’s probably going to suggest that AI can solve this. And people will spend millions believing him.
posted by armoir from antproof case at 4:48 PM on January 3 [17 favorites]


70-150k / year for an ATC at SFO is laughable considering what’s at stake

Do you think that the people who save your life on a daily basis are paid anywhere near that? Let’s start with food sanitation folks, public and private, and work our way along.
posted by Galvanic at 5:00 PM on January 3 [21 favorites]


ATC salary and working conditions vary wildly around the world, though I'm sure Tokyo Haneda must be insane.

I've got a cousin up on Vancouver Island who is basically living the ATC dream right now.
posted by ivan ivanych samovar at 5:11 PM on January 3


To respond grumpy, I struggled with wording in the last paragraph to try to be fair to airport managers and FAA officials who are working to improve Ground safety. Every serious incursion is investigated and often result in recommendations to address inciting factors. But I get a sense that many controllers may feel the situation isn't going to significantly improve until structural factors receive a commensurate response.

Also, I couldn't find numbers past 2016 for Runway Incursions internationally (admittedly, I only started looking this morning when I decided to post about this non-US collision on an ostensibly international Community Weblog) but international organizations are cranky about the rate of Incursions as well, and the ATC labor shortage seems to be a more US thing, I believe. So the problem is probably more complicated than "the US isn't doing anything about it." But on the other hand, listening to two pilots / controllers try to delicately talk around staffing and burn-out on the Opposing Bases podcast, I'm not sure the US at large actually is "doing anything about it."

And to respond to hippybear, regardless of what errors any pilot made, ideally the Swiss cheese approach would have systems make it hard for a single error to result on catastrophe. Ideally lighting would make it easier to spot conflicts and harder to mistake your position, ideally someone on ground could spot an incursion and issue an emergent "GO AROUND" before collision. Also the transcripts are preliminary. There's usually a lot more to the story of every incident.
posted by midmarch snowman at 5:15 PM on January 3 [3 favorites]


What’s even worse is some techbro who’s never stepped in a tower’s probably going to suggest that AI can solve this. And people will spend millions believing him.

Well shit, I think I just found my new startup idea. Gimme, oh, maybe 18 months or so and I'm reasonably sure I could secure at least twenty million in first-round financing. Probably have to strap a webcam on top of the radar display though, because to hell with trying to understand those data formats.

By the time it all blows up (literally) I'll be safely ensconced in the Rhaetian Alps (plus, y'know, obviously Dubai), where I'm pretty sure the US will just encourage me while the EU will make irritated clucking noises but do nothing to stop me. Lundin Oil gets to murder villagers wholesale, so I'm reasonably sure I can get away with the occasional "accident". Maybe get a contract with BAE while I'm at it, just to make sure I can hang out at Old Sunningdale with the boys, despite my knowing absolutely nothing about golf.
posted by aramaic at 5:31 PM on January 3 [10 favorites]


What’s even worse is some techbro who’s never stepped in a tower’s probably going to suggest that AI can solve this. And people will spend millions believing him.

They will spend millions of dollars and not a few lives, surely.
posted by ricochet biscuit at 5:37 PM on January 3 [1 favorite]


@Galvanic

Do you think that the people who save your life on a daily basis are paid anywhere near that?

No, I don't think that, I know that those people are also vastly undervalued and underpaid. I also know that planes full of hundreds of people have a bit more visibility in the public eye (almost no one gives more than a moment's thought to food safety or sanitation). My point was for such a high profile job where the risks due to shortage should have high visibility -- because unlike sanitation failures, generally people are more capable of envisioning plane crashes -- it's absurd the compensation isn't more competitive, especially when potential candidates can easily determine that many other jobs pay at least as well for commensurate levels of training, and far less stress. That ATCs aren't paid better isn't surprising given societies upside-down prioritization of resource allocation (paired with the low-tax circle jerk mentioned by philar) and it isn't surprising where it's currently at given there aren't enough planes crashing and people dying - yet.
posted by armoir from antproof case at 6:01 PM on January 3 [6 favorites]


They will spend millions of dollars and not a few lives, surely.

AI doesn't prevent pilots from assuming Tower just forgot to say "Line up and wait" 10 seconds after telling a different flight they were cleared to land (or whatever happened here), so you AI fear mongers are going to have to find something else you use.

midmarch snowman: I have the same Jeppesen charts he has, and I wouldn't say C5 is that far down the runway. Definitely not as far as where your diagram (kinda) shows it.
posted by Back At It Again At Krispy Kreme at 6:06 PM on January 3


AI doesn't prevent pilots from assuming

Some high-on-his-own-supply TechBro will propose, "You know what, let's just take the whole pilots making assumptions question out of the equation entirely, and automate this.." Whether that does or doesn't decrease the risk of accidents doesn't matter, because the gravy train will have started down the tracks. While all the money's being spent on the new and shiny and misleading and distracting, less money and attention will be paid to the parts of the existing system that could benefit (to all our benefit) from some investment towards shoring up... which won't be available because people/organizations prefer to shovel as much as they can to Silicon Valley savior types.
posted by armoir from antproof case at 6:22 PM on January 3 [1 favorite]


This is a reply in relation to AI being more utilised in ATC systems safely.
From what I can see of this example, I don't think the ATCs were to blame. But at least one person looks to have been overworked / stressed, to miss some messaging or understanding. Plus the 'stop lights' at the runway itself not being fixed immediately, etc. so a likely possible cascade of small errors & issues.

I have a friend who has a very senior position in Air Traffic Control IT systems (the kind of role that can sidestep into banking systems for a massive salary).

I caught up with him last about 5 years ago (so maybe things have changed) but he explained that parts of the ATCs role could so easily be IT integrated with comparatively simple tech, parficularly the larger routes on the way to holding patterns, that could be largely automated and integrated with pilot messaging, much like the auto-pilot aspects of the aircraft itself.

There would obviously be many redundancies and safety systems (as with everything he currently does). But in terms of just one aspect of smoothing the flow of aircraft on route to the airport, these could be adjusted automatically for weather changes, etc, it would reduce or even eleminate holding patterns directly around the airport, increase fuel effeciency for all aircraft, and take some of the load of the ATCs.

So in terms of softening the ATC's workload it would be an 'easy' implementation to incorporate the IT needed. But This kind of tech is apparently being blocked by ATCs as a concern that more of their role would then be reduced, or other workload added, staffing reduced, efc. rather than simply have the IT supporting them in what they already do for no negatives to what they do.
But like I'm sure the ATCs have seen, when you can get IT to help someone's role, the capatalists like to reduce funding or support to the humans involved because 'now their job is easier'.
posted by many-things at 6:32 PM on January 3 [4 favorites]


... ideally someone on ground could spot an incursion and issue an emergent "GO AROUND" before collision.

There are newer systems (Autonomous Runway Incursion Warning Systems) that detect things on the runway and then signal the landing pilot to abort if possible by changing the runway lights. It might have helped here: the Coast Guard airplane seemed to be on the runway for half a minute or so before the crash. I think it's likely the Airbus saw them and tried to avoid them, but it was too late.

It's a tragic situation all around, especially given the earthquake relief efforts. Any death is terrible, but only 5 dying (so far) out of such a terrible accident is about the best that can be hoped for when planes crash into each other like that. Hopefully it will lead to changes to make everyone safer still.
posted by netowl at 6:44 PM on January 3 [4 favorites]


Carelessly dismissing that that effort by declaring it a "miracle" in the coverage I saw yesterday immediately annoyed me. Not seeing the same here is why Metafilter is one of the few places I still engage with.

It's not that surprising to me considering that so little of the discussion has been about the incident at Haneda and so much about the US, as usual, along with baseless speculation about techbros and AI.
posted by Umami Dearest at 6:46 PM on January 3 [30 favorites]


I'd like to commend everyone here for avoiding use of the word "miracle" in relation to the 100% survival rate on the commerical passenger aircraft. The amount of hard work, really hard work, that goes into saving lives in an aircraft emergency is staggering and spans decades.

I understand what you're saying, but I don't think I agree.

Teller, of Penn And Teller fame, once said that "sometimes, magic is just someone spending more time on something than anyone else might reasonably expect." He was talking about magic, of course, but this is true of a surprising amount of modern life, particularly around civil infrastructure and safety.

There are hundreds of examples of this all around us, all the time. I can turn on the tap and drink whatever comes out of it fearlessly, not because of any supernatural occurrence but because of generations of disciplined effort, hard work and learning from failures. Here, 379 people walked out of a burning tube of carbon fiber alive for the same reasons. Yes, it's a staggering amount of hard work spanning decades, that's true. But it's also a goddamn miracle.
posted by mhoye at 6:57 PM on January 3 [16 favorites]


Posts like this are why I have been coming here for 20 years, midmarch snowman. Flagged as a fantastic post. It's so frustrating to wade through the deluge of coverage and commentary about something as gripping as this, to basically learn nothing. I don't talk here very much, but I read a lot every day because of contributions like this.

Best Of the Web™, indeed.
posted by PareidoliaticBoy at 7:06 PM on January 3 [7 favorites]


I'm not sure why this isn't more of the focus, but news in Japan very quickly (within a couple hours) reported that the incursion was an error on the part of the coast guard plane. The tower had not given it permission to enter the runway, but the plane did so anyway. The incident was pilot error, not a control tower issue.

(Edited because I missed acknowledgement of it in the post)
posted by Ghidorah at 7:07 PM on January 3 [9 favorites]


CBS news reports that Japanese authorities have released transcripts of tower convos with both planes. Apparently the coast guard plane's pilot disagreed on whether he had permission to get onto the runway or not?
posted by kschang at 7:18 PM on January 3


Closing my unintentional derail...

baseless speculation about techbros and AI

Have worked in technology and around tech bros for 30 years, within tech companies and in venture capital firms, most of which time Silicon Valley has been my base.

There are many interesting things happening in the AI space and some of those will create significant real benefits for humans, but the current AI market is soaking in snake oil and is optimized to solve one 'problem': a small number of people with large amounts of money who feel they don't have quite enough of it.

I do now regret my comment that kicked this tangent off and derailed a FANTASTIC post. I do also believe that, much like Melon Husk trying to sell a submersible to save some kids stuck in danger in a cave, someone's going to announce a strong belief that what happened at Haneda could be fixed with just swing of the AI stick. Regardless of whatever the root cause turns out to be.

But with apologies I'm going to STFU about that now.
posted by armoir from antproof case at 7:22 PM on January 3 [4 favorites]


Apparently the JAL cabin crew needed permission from the pilots to open the emergency doors.

the Japan Airlines pilots in the cockpit did not know about the fire before being informed by the cabin crew.

The chief flight attendant reported to the cockpit that the plane was burning, as the cabin crew needed permission to open the emergency exits, NHK reported.

By this time, the cabin was filling with smoke and getting hotter, with babies crying and people begging for the doors to be opened, footage showed.

In one video clip, a young voice can be heard shouting: “Please let us out. Please. Please open it. Just open it. Oh, god.”


Also, a dog and a cat died that were in cargo died in the fire.

Guardian

At least 131 Haneda flights are canceled today, and Shinkansen service is being ramped up to take care of some of the demand. This happens to be a very busy period for domestic travel in Japan.

Yomiuri
posted by Umami Dearest at 7:31 PM on January 3


Wow.

…so, speaking as someone with experience in industrial safety at a level FAR below that of an airliner (the most people I could have reasonably killed was on the order of fifteen or so), I’m stunned.

We had far more rigorous controls for one single critical lift than seem to have been in place here. Shit, we literally always had an outboard guy (nowhere near the lift itself) who had authority to shut everything down if the lift teams ever disagreed with each other, and that’s just for a couple hundred tons of steel, never mind a fricking airplane. All he did was sit in a trailer and listen to what the teams were saying, waiting for an inconsistency.

Guy disagrees with our version of “Tower”??

…everything stops, loads go down, everybody clears the site and figures out wtf happened. People may still die, of course, but really wtf. I kinda feel like maybe I should blame Boeing, but that’s probably not fair. Maybe.
posted by aramaic at 7:35 PM on January 3 [4 favorites]


The amount of hard work, really hard work, that goes into saving lives in an aircraft emergency is staggering and spans decades.

Admittedly, I did not read every link, but the last one on the front page (“giant column of fire”) notes approvingly that the survival of everyone aboard the Airbus is due to excellent design (“It’s such a testament to how well built aircraft are that everyone could safely evacuate the A350, despite there being an impact at over 100+ miles per hour, plus this plane ultimately burning to the point of a hull loss”). It says zero that I could see about the aircrew.

As I noted once before, in the context of a different runway incident, there is possibly no job anywhere where the public perception of what the job entails and the reality are so far apart as airline cabin crew. The plane was on fire, sliding down the runway, with about half the exits out of service, no PA working, and they got 367 passengers to safety, with a dozen minor injuries.
posted by ricochet biscuit at 7:40 PM on January 3 [11 favorites]


>there is possibly no job anywhere where the public perception of what the job entails and the reality are so far apart as airline cabin crew.

100% this. Flight attendants were mandated by Goverments for safety reasons. This is their primary function. After the airline industry was forced to create these jobs, they immediately leveraged this sunk cost to extract every scintilla of possible labour from their captive crew. These safety professionals are not there to act as untipped wait staff, but to save your freaking life in the event of everything going pear-shaped. That is why they are there.

Among the many things that I admire about Chesley Sullenberger, Captain of Flight 1549, of Miracle On The Hudson fame, was his insistence that the press acknowledge the role that the cabin crew played in saving the lives of all those passengers. He wouldn't stop talking about it.

I not going to look for it now, but at the time, one of the things he said was, "I just landed the plane. The crew saved the passengers".

I like to hope that the passengers going ballistic on aircrew would pause for a moment to reflect on flight attendants such as Neerja Bhanot.
posted by PareidoliaticBoy at 8:43 PM on January 3 [10 favorites]


How safety rules ‘written in blood’ saved lives in Tokyo plane crash
Obviously it’s too soon to know what happened in Tokyo, and how both aircraft came to be on the runway at the same time.

Yet the message from the aviation industry is the same: it appears to have been the fast reactions of the crew that saved hundreds of lives. Within seconds of the plane coming to a standstill, escape chutes were inflated and those on board were quickly ushered off, even as the cabin filled with smoke.

“I’m exceptionally impressed with the pilots, crew, and passengers for what seems to have been a textbook evacuation in the most extreme of conditions,” said one pilot for a major European airline who wished to remain anonymous as they are not authorized to speak for their airline...

Steven Ehrlich, chair of PilotsTogether – a charity set up in the pandemic to support crew – agrees.

“It’s too soon to comment on the specifics of the incident, but what’s clear is that the crew performed in an exemplary fashion,” he says.

“The safety training that airlines - in this case JAL - put the crews through on a continuous basis paid off allowing for evacuation within 90 seconds. The takeaway from my point of view is that passengers need to pay attention to the safety briefings and remember that the crews are not glorified food service staff but are well-trained safety professionals.”
posted by BungaDunga at 8:56 PM on January 3 [6 favorites]


Former Navy/FAA controller here. Retired in 2006 with about 30 years of various tower/radar jobs in several towers and facilities.
The "runway incursion issue" has been worked hard since the mid 1990's. I worked at an airport (Long Beach) that had major issues with runway and taxiway layouts that confused pilots endlessly. The FAA instituted new lighting, runway markings, changed ATC phraseology, changed procedures. You can only do so much of these things. (Long Beach issues declined dramatically by the time I left in 2006).
There is a lot of discussion recently about ATC staffing, which, yes, has been problematic for years. The hiring and training of new controllers is an expensive, time intensive, longer that it should be process. Only after a ton of paperwork and red tape...then the real training starts.....and only THEN do new controllers actually begin training at a real airport....and that all takes years. The FAA is simply horrible at this process, and always has been. New controllers are set up to fail from the outset...and a lot do, sadly.
No, it isn't as stressful as everyone talks about.
Last: pilots make mistakes. Sometimes, the mistakes can be caused by things that I mentioned above: lighting, runway configurations, etc. Sometimes pilots can simply have their heads up their ass. Remember that mid air at Houston a couple of months ago? Pilot took off without a proper clearance, and ignored controllers telling him to stop. He claimed he was diagnosing several problems with the airplane while he was rolling merrily down the runway! Read the NTSB preliminary here.: https://www.khou.com/article/news/local/ntsb-report-hobby-airport-plane-crash/285-5088688d-3424-4cc0-9075-ff0ff3781b5e
At JFK early last year, an American 777 crossed a runway after being told to hold short of the runway. Controllers spotted it and stopped a Delta jet on take off roll. After the incident (as serious as an incursion gets) the American pilots refused to be interviewed by the NTSB...and, wait for it.....someone recorded over the cockpit tapes of the incident. This is criminal behavior. (I've tried finding out more about this, but the news cycle moves on and I don't know how it all came out.)

The point of all this is: stuff happens. Not trying to downplay the serious issues involved. The FAA has armies of dedicated people working on these things. Technology and a tower full of people would certainly be wonderful, but there are humans involved. And, humans make mistakes. Not many, but they do.
But, honestly, incidents like the one in Japan are nightmare fuel.
posted by pthomas745 at 9:09 PM on January 3 [26 favorites]


"Ah, so it was pilot error then" is the beginning of the root cause analysis, not the conclusion of it. The interesting stuff, the actionable stuff that will save lives will come out over the next couple years.
posted by tigrrrlily at 9:25 PM on January 3 [9 favorites]


Within seconds of the plane coming to a standstill, escape chutes were inflated and those on board were quickly ushered off, even as the cabin filled with smoke.

I'm confused by that quote from the CNN article. There's a WSJ article (unpaywalled) which says it took 18 minutes for the last person to come out — a statement which I think is confirmed by official reports — and that also shares a passenger's perception: “Hayashi estimated it took about three to five minutes for the doors to open.”, which suggests that the evacuation didn't start quickly enough, and it was the fireworthiness of the A350 that meant there were no passengers injured by fire.

Hopefully the reasons behind that are addressed, because that seems concerning. There certainly have been aircraft fires where the delay to evacuation after landing was long enough that no one survived: Saudia flight 163 would be the worst example of this.

It does say that the PA failed on the Japan Airlines flight, which is reported to have meant that the flight attendants were waiting by the doors unsure whether to open, so it would be interesting to know what procedures exist for evacuation where there's no communication from other parts of the aircraft, especially as the left rear door was opened, apparently without pilot permission, but the right side door was not opened, which was good as the right engine was not shut down (reportedly because the engine controls were destroyed in the initial collision).

There will certainly be a lot to learn from the full investigation, at least.
posted by ambrosen at 12:46 AM on January 4 [2 favorites]


I'm confused by that quote from the CNN article.

That CNN article read like a JAL press release.

I think locally JAL has more of a reputation for drunk pilots than for rigorous safety procedures.
posted by Umami Dearest at 1:12 AM on January 4


From Reuters, the coast guard plane was on its third relief flight to the Noto peninsula within the previous 24 hours.

Something else worth noting is just how crowded Haneda was. It was essentially the peak of the “u-turn” rush, with everyone returning to Tokyo from their hometowns as the new year break was ending, with, from what I’ve heard, more flights added to make up for the trains that had been stopped due to the earthquake.
posted by Ghidorah at 4:50 AM on January 4 [1 favorite]


Another factor that's worth talking about here is that the passengers reportedly did exactly what they were supposed to: followed crew instructions, exited quickly and efficiently, leaving everything behind.

This has been contrasted to, for instance, the video of the shambolic EK521 evacuation from 2016, where people can be seen blocking the aisles while taking their luggage from the lockers before heading for the slides, then hanging around near the aircraft... which exploded not long afterwards, killing one firefighter.
posted by automatronic at 4:56 AM on January 4 [2 favorites]


Mod note: Several comments removed. Please avoid making this post USA centric, thank you.
posted by Brandon Blatcher (staff) at 5:05 AM on January 4 [3 favorites]


It reminds me of KLM Panam at Tenerife disaster in the 70s. Forty years and we still can't institute sufficient protocols to avoid these kinds of things.

The only take away I have is that both incidents had an external social or natural super-event occur before the accidents. Airports are delicate institutions. I'll be staying away from them next time big things go wrong else where.
posted by coolxcool=rad at 5:19 AM on January 4 [1 favorite]


The point of all this is: stuff happens. Not trying to downplay the serious issues involved. The FAA has armies of dedicated people working on these things. Technology and a tower full of people would certainly be wonderful, but there are humans involved. And, humans make mistakes. Not many, but they do.

It makes me feel we should have fewer planes to track in the first place. Why would you ever want planes landing and taking off within seconds of each other on shared runways?

I mean, I know the answer is capitalism and the wills of men, but it's absurd. If safety was first, it would be.
posted by tiny frying pan at 6:00 AM on January 4 [2 favorites]


The stop bar light was out of service at the taxiway. It's more likely the Coast Guard pilot would have held short at the runway if they had seen a bright red line over its entrance.

It would be interesting to know whether the pilot, accustomed to seeing the stop bar light at Haneda, somehow thought that they were clear to enter the runway when they didn't see it. Yet another hole in the Swiss cheese.
posted by swift at 6:27 AM on January 4 [7 favorites]


The replies to the post pointing out that the stop light is out (nitter link) are a case study in themselves. "It's normal, therefore it's fine" is the same attitude that brought down Columbia.

It's comedy gold if you know what to look for. I didn't check, but I bet several of those people are actual pilots. Which is why we don't have pilots vote on air travel regulation.
posted by tigrrrlily at 8:11 AM on January 4 [1 favorite]


ISTM that maybe the pilot error wouldn’t have occurred if they were communicating in Japanese.

Wonder if the JSDF communicates in English to their towers.
posted by torokunai at 12:32 PM on January 4


I remember the Tenerife disaster well; I was 13 when it happened and it dominated the news for about a month. And the medical profession is often compared to/looks for inspiration from aviation in terms of a culture of safety, so I find it worthwhile to read NTSB reports looking for human factors that would also apply in the operating room. Alarm fatigue, for example. So it really boggles my mind that lights designed to prevent runway incursions would be inoperative without physically blocking the runway or otherwise making it close to impossible for this sort of accident to occur.
posted by TedW at 12:39 PM on January 4


Eh sure, in the swiss cheese model, the language thing (speaking in their native language) could have been one more *absent* thing that could have helped. On the other hand, I don't think language confusion significantly contributed. The terms of art they use in English are unambiguous and have specific meanings that the pilots are trained on. Taxi to runway 34R is NOT the same as taxi to hold point C5, and every pilot knows you don't go farther than they told you (and you repeated back correctly). "hold short" and "line up and wait" or "cleared for takeoff" are very different things, and don't depend on you understanding nuance.

The stop bar light, while not being a direct cause, could very well have been the one thing that snapped the pilot out of his mistake in progress. But his insistence after the fact seems to indicate he would have ignored that too. (Or it's human nature refusal to admit fault in public even when you know you're wrong.)
posted by ctmf at 1:18 PM on January 4


Does anyone have ATC tapes for this yet? Some dude on the internet was saying something about "non-standard phraseology", which is a hallmark of US aviation but I naively wouldn't have expected it in Japan.
posted by tigrrrlily at 2:49 PM on January 4




Good old VAS.
posted by tigrrrlily at 3:33 PM on January 4


I really, really badly wanted to hear (or read, in this case) a "hold short". Damnit.

Like, why.
posted by tigrrrlily at 3:38 PM on January 4


IIRC, most air traffic control is done in English, except for VERY edge cases in Asia (interior of China may be in Chinese) and some parts of Europe.
posted by kschang at 6:04 PM on January 4


tigrrrlily: yeah, I didn't reference any NOTAMs because, like you said, it's hard to filter out editorializing from cranky pilots!

That said, it's interesting how searching FAA's Federal NOTAM System search right now there's 127 NOTAMs for Haneda, 141 for LAX, 114 for DFW, but a fraction of notices for similarly busy airports in Atlanta, Istanbul, Delhi. Perhaps sorting by class?, or different display methods?, make them easier to parse and note the ones relevant to your operation. But I admit, when someone comments "there was a NOTAM about this very issue!" it has to same flavor to me as when someone complains about error in procedure at my workplace with a line like "the person from a completely unrelated department should know better, we sent a subjectless e-mail about this obscure process 9 months ago!"

More broadly, some of these issues remind me of Best Practice Advisories in electronic medical records. In my workplace we have a pretty good staff that is absolutely loath to use a BPA to advise providers, and work really hard to keep BPAs from firing in irrelevant situations. But *several* hospitals in my recent past were less vigilant, and uploaded some default pharmacy dosage guardrails that were horrid at recognizing the range of different appropriate pediatric dosages. Ultimately the result was many residents developed the habit of clicking through multiple pop-ups as quickly as possible every time they signed an order.
posted by midmarch snowman at 6:23 PM on January 4 [2 favorites]


If failure to recognize a NOTAM played a role, I do hope it gets some attention. One thing I really respect about the investigation into Air Canada 143 *†‡ is the way it highlighted how 55 changes had been made to the aircraft's Master Minimum Equipment List in the four months since the plane had been put into service and the number of these changes could understandably result in a TLDR situations, even among professionals who relied on the MMEL to keep them alive.

*aka "the Gimli Glider"
† aka "The One Where The Gang Ran Out of Fuel Because They Fucked Up Metric Conversion"
‡ aka "Y'know, through much of Aviation History being bad at math didn't prevent you from being an amazing pilot. "
posted by midmarch snowman at 6:36 PM on January 4 [2 favorites]


most air traffic control is done in English

This is a source of a bunch of mishaps. Most ATC is not done in English per se, but something that is mostly comprehensible to an English speaker, using words borrowed from English.
This might sound like splitting hairs, but outside of the US great emphasis is placed on "standard phraseology", meaning that to communicate a particular piece of information concerning a flight, you use a particular sequence of words. Yes, it is "English", but rephrasing it into a different English sentence is no longer what people's brains are hardwired to expect. Again, this is the case in most places... except the US. In the US some ATCs in particular take great delight in phrasing things in as folksy a way as possible. At least they still mostly say "cleared to land" and "hold short 34R" in the same way. Mostly.

English proficiency really only comes into play when there is a departure from normal operation, at which point great confusion may result if none of the flight crew are particularly fluent in what we would recognize as English.
posted by tigrrrlily at 6:39 PM on January 4 [3 favorites]


Any time an aircraft accident happens, I go over to pprune.org. Seems like the Japanese Coast Guard aircraft did not stop at its hold point, and went on to the active runway. Why? to be determined.
posted by baegucb at 8:07 PM on January 4


PIC hearing "#1" from the tower and thinking he was good to go ??
posted by torokunai at 10:36 AM on January 5


Tower clearing traffic to land on his runway should have been a tip-off, but I'm wondering if operating at a civilian airport was usual for him.
posted by torokunai at 10:38 AM on January 5


It's so easy to lose situational awareness when you're even the least bit exhausted. We've all lost the plot for a few seconds at a time, only to have to then dig through our recent memories for what exactly is going on.

I have no reason to claim that this is what has happened, but if the slice of swiss cheese that's the pilot's proficiency has a larger than normal "tired" hole in it, it helps if at the top of their auditory memory there's the keyphrase "hold short" to make them slam on the mental (and thus the metatarsal) brakes.
posted by tigrrrlily at 11:01 AM on January 5 [1 favorite]


I was wrong, apparently. "holding point" is standard in some places outside the US. Shows what I know.
posted by tigrrrlily at 6:31 PM on January 5


I would like to celebrate…

1. the flight attendants only opened the non-flaming exits (good call) TBH, which seemed to freak people out, but that pause for assessment was a saving-people decision.

2. Japan’s unique and beautiful culture values social cohesion and cooperation (in my personal experience) so the passengers kept it calmesque, and listened. Also, they seem to be good at prepping for earthquakes / tsunamis, so I’m sure that helps the mindset.

3. no one tried to keep their luggage - as directed, but they actually listened and followed directions!!

Proud of the crew, the people, the rescue persons, and I hope they go on some kind of anti- Air Traffic Disasters documentary. Let’s make that, creators. I’d subscribe. Call it: some bad things that DID NOT happen because people are awesome. Sounds better than true crime to me.

My truest condolences to the families of those who were lost. (In the empathy, it doesn’t matter whose fault it was.)
posted by beckybakeroo at 12:44 AM on January 6 [2 favorites]


The NOTAM system is deeply flawed and broken. Pilots have to wade through hundreds of non-essential and non-relevant NOTAMS to find out about things like stop bars being inoperative or an approach procedure that isn't allowed. That's of secondary or even tertiary importance here, though.

If you add in threats like night operations, maybe a dash of fatigue and the fact that it is really difficult to see another airplane in the runway environment at night, you have a recipe for a disaster.

In a flight deck crew, one of the things I am doing - especially landing at night - is listening to the departing traffic/tower on the radio to make sure that I know who is doing what, so that I know what to look for. If I don't catch that an aircraft was given a hold short at an intersection well-past the touchdown zone on the runway, I'm not necessarily looking for it. I am most assuredly looking for traffic at the departure end. It is very easy, as someone said, to lose the thread because the workload is high at this time.

I'd need to look up the relevant regulation, but I believe in the US at least - that ATC is prohibited from issuing a line-up-and-wait (LUAW) for a runway intersection takeoff for precisely this reason; I don't know the regulations in Japan, though.
posted by Thistledown at 6:06 AM on January 6 [1 favorite]


“Runway entry alert operating normally during Tokyo airport collision,” Kyodo News, The Mainichi, 06 January 2024
posted by ob1quixote at 6:55 AM on January 6


"The function causes the entire runway to flash yellow on the controller's display, with the aircraft in red, when it detects an entry (...) there is no rule that requires them to constantly monitor the screen"

Why no annunciator or alarm? My guess is that the system can't quite tell apart normal runway entries from potential conflicts reliably, and there would be lots of spurious alarms.

How can that be? One way is described in this 20-min video on one case of a runway incursion system totally failing to alert in a perfectly clear-cut case of runway conflict.
posted by tigrrrlily at 10:06 AM on January 6


“Coast guard pilot likely did not hear JAL-tower comms before crash,” Kyodo News, The Mainichi, 07 January 2024
posted by ob1quixote at 7:03 PM on January 6


Japan’s unique and beautiful culture values social cohesion and cooperation
so uh from what I have heard from Japanese Twitter the flight attendants had to yell at (Japanese) people to remind them to follow instructions and not take their luggage from the overhead compartments

Japan is in fact full of people, who are generally just normal human people

the rapid evacuation has a lot more to do with the fact that the airline regularly does training drills to ensure that they could evacuate a full plane's worth of passengers in, what, ninety seconds than it is because The Japanese™ are these noble high elves or whatever, unsullied by our impure world
posted by DoctorFedora at 9:47 PM on January 6 [4 favorites]


DoctorFedora yeah, I think that's over-stated quite a bit, but it would be pretty shocking when the normally excessively-polite japanese customer-service people start barking orders. And confused and shocked people normally do what authority figures tell them to. Ornery selfish Americans notwithstanding.
posted by ctmf at 9:52 PM on January 6


It's like when you write everything in bold, is anything emphasized? It's the contrast. I'm American and I would also have done exactly what the angry japanese flight attendant told me to, because that's uh, unusual. Cranky Delta attendant, not quite the same effect because that's almost normal.
posted by ctmf at 9:55 PM on January 6 [1 favorite]


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