TOKYO -- Multiple human errors contributed to the deadly January collision between a Japan Airlines jet and a Japan Coast Guard aircraft at Tokyo's Haneda Airport, an investigation by the Japan Transport Safety Board (JTSB) says in an interim report released on Wednesday. The incident has exposed weaknesses in Haneda's safety precautions, even as the airport has added traffic and assumed a greater role as a hub for international flights.
Flight voice recordings from the Japan Coast Guard plane involved reinforced the view of investigators who concluded the crew likely erroneously believed their aircraft was allowed to enter the runway. The co-pilot correctly repeated the traffic controller's instruction to taxi to holding point C5, but subsequent exchanges suggest they thought they had been granted entry. A traffic controller had told the Coast Guard plane it was "No. 1" for takeoff and told it to proceed to holding point C5. After acknowledging the order, the crew jumped to the mistaken conclusion they had clearance to enter the runway.
That tragic fateful decision left five of six people aboard the coast guard's Bombardier DHC8-300 dead when it collided with the JAL Airbus A350, though all 379 aboard the JAL flight escaped even as flames engulfed their plane. According to the report, the air traffic controller monitoring the situation was focused on the approaching JAL aircraft and did not see the Coast Guard plane's erroneous runway entry.
"The crew members of the JAL aircraft could not visually confirm the presence of the Coast Guard plane on the runway before touchdown," noted the report. This was compounded by visibility issues, as the accident occurred after sunset with little to no moonlight. Both aircraft were illuminated, but their conflicting light signals and the circumstances made identification difficult.
The air traffic control system, including runway entry alerts, was functioning, but JTSB's investigation concluded the controller failed to notice the alert. The president of the board stated, "The Coast Guard crew mistakenly believed they had been cleared for takeoff by air traffic control," indicating broader communication issues on the airport's part.
By all accounts, the accident also raised significant concerns about the operational dialogue between air traffic controllers and aircraft crews. The JAL flight, which had departed New Chitose Airport on routine rounds, contained 367 passengers, including children and elderly passengers, along with three pilots and nine cabin crew members on board. When the collision occurred at 5:47 p.m., chaos erupted inside the JAL aircraft.
A passenger of the JAL flight reportedly stated, "I was really lucky to be alive. I just hope this never happens again," underscoring the emotional impact of the incident. The JAL crew's efforts to corral passengers amid flames and smoke were notable. They instructed passengers to assume protective positions to mitigate injury and soon initiated an emergency evacuation as soon as they were able.
From the moment of collision, things worsened. Flames were visible near both wings, and shouting instructions challenging the noise from the lurch of the aircraft characterized the experience of passengers. Panic spread as emergency smoke filled the cabin. Crew members attempted to utilize the intercom to communicate urgent evacuation orders but to no avail.
Instead, the captain and crew resorted to personal calls to those onboard to facilitate the orderly exit. They worked alongside JAL employees onboard as they methodically guided everyone to safety, as not all followed directions immediately. Seven minutes post-collision, flames filled the cabin, transforming the aircraft from what once functioned as their home for the flight to sheer chaos.
The systematic approach to evacuate played out under severe time constraints, yet the crew successfully navigated through confusion, utilizing emergency exits as carefully as possible. Although 77 passengers reported smoke-related ailments, none perished – making the expansive evacuation deemed nearly miraculous.
The aftermath of the collision led to extensive investigations, and the Japan Transport Safety Board has committed to evaluating broader systemic issues surrounding air traffic control protocol. This unfortunate incident raises larger questions about aviation safety, stressing the importance of ensuring thorough adherence to communication and compliance with the safety protocols necessary for a public airport.
While the investigation continues, the focus remains on preventing future tragedies from similar human errors. The collision has reinforced the need for rigorous air traffic control training and swift response systems for potential emergencies. The interim report, though focused on this collision, serves as both a grave reminder and a guide to re-evaluated operational procedures.
