Japan's Response to Aviation Accidents as Seen in the Haneda Airport Ground Collision

By Tetsuhiro Hagiwara

1. Overview of the ground collision between a JAL aircraft and a Coast Guard plane at Haneda Airport

On January 2, 2024, while Japan was still in the midst of its New Year holidays, shocking news broke out about an aircraft catching fire at Haneda Airport. Japan Airlines (JAL) Flight 516 landed at Tokyo International Airport (Haneda Airport) and a Japan Coast Guard (JCG) aircraft waiting to take off collided on the runway. This is the first total loss of a JAL aircraft in Japan in 15 years and 2 months since the failed landing of FedEx Flight 80 in 2009, and the first loss of a JAL aircraft in 38 years and 5 months since the crash of Japan Airlines Flight 123 in 1985.

This accident caused a great shock both in Japan and abroad because the Noto Peninsula earthquake of 2024 had just occurred the day before, and the Coast Guard aircraft that caused the accident was on its way to assist with the earthquake relief efforts, and it was a major accident right after the New Year.

A total of 379 people, 367 passengers and 12 crew members, were on board the JAL aircraft. The aircraft caught fire violently after the collision, but all on board were able to escape under the guidance of the crew. On the other hand, the Coast Guard plane had six people on board, five of whom were killed and the captain seriously injured in the collision.

The accident forced a rethinking of aviation safety initiatives and post-accident responses.

(Image Source: NIKKEI)

2. Accident circumstances and causes

The Accident Investigation Committee is currently investigating the cause of this accident, but the following describes the circumstances of the accident and the cause of the accident as far as the media reports.

<Accident History>

JAL516, the airplane involved in the accident, departed New Chitose Airport at 16:00, 10 minutes behind schedule, and was expected to arrive at Haneda Airport at 17:40. A 1.6 meters per second (3.1 kn) westerly wind was blowing at Haneda Airport at 17:30, and the visibility was 30 km at 17:54. Flight 516 circled over Chiba Prefecture and descended over Tokyo Bay directly over Runway C.

Approach

At 17:43, ATC instructed Flight 516, which was approaching Haneda Airport for landing, to continue approach to Runway 34R (Runway C) and transmitted information on wind direction and wind speed and departure aircraft.

At 17:44, ATC informed Flight 516 that the runway was clear for landing and the wind speed information was transmitted, and Flight 516 recapitulated the information. Flight 516 then continued its approach for landing.

At 17:45, ATC instructed Mizunagi 1 (a Coast Guard aircraft) to proceed to C5, the stop position of Runway C, and to indicate Order No. 1. Mizunagi 1 correctly recited the instructions and thanked ATC for giving it priority in the takeoff order. However, Mizunagi 1 did not follow the instruction to proceed short of the runway, and entered the runway beyond stop position C5 before stopping.

Collision

At around 17:47, about 40 seconds after Mizunagi 1 stopped on the runway, Flight 516, which had permission to land, landed on Runway C. Almost as soon as it touched the ground, the nose of Flight 516 hit the vertical tail of Mizunagi 1 from almost directly behind, causing a fire column. The captain of Mizunagi 1 reported to the Japan Coast Guard after ejection that "the rear of the aircraft suddenly exploded," and the flight crew of Flight 516 stated in their investigation that "we did not feel anything unusual until just before landing, but it looked like something crossed over just before impact.

After the collision, Mizunagi 1 exploded and caught fire on the spot, and Flight 516 skidded approximately 1,700 meters with smoke and flames and veered off to the right side of the runway. According to the flight crew, the brakes, rudder and steering wheel did not work during this time, and the aircraft felt as if it was sliding. Passengers in the cabin reported hearing a "crash" with an impact that "lifted them off their backs." The lights went out, and about a minute later white smoke filled the cabin along with a burning smell.

Ejection

At the front of Flight 516, which had stopped by the side of the runway, the cabin crew informed the flight crew of the fire and advised them to evacuate the aircraft, which the captain then instructed them to do. At the rear of the aircraft, the cabin crew decided to evacuate the aircraft because the in-flight intercom had failed and they could not communicate with the cockpit.

Some of the passengers on board screamed and shouted, "Please get me out of here," and "Why don't you just open the door?" but most of the passengers remained calm and did not panic. Since the announcement system malfunctioned due to the collision, the cabin crew guided passengers by calling out with their voices and using megaphones, and about 6 minutes after the collision the emergency escape slides on the forward port (Doors L1, R1) and aft port (Door L4) were deployed to avoid the four middle emergency exits and aft starboard (Door R4), which were unusable due to fire among the eight emergency exits. After completing the emergency checklist, the captain and others entered the cabin to look for and evacuate the few remaining passengers, and all 379 passengers survived, with the captain ejecting last at 18:05 from emergency exit L4, When the passengers were evacuated, about 10 ANA ground handling staff members rushed to the scene and responded in a flexible manner. It was announced that two pets were included in the checked baggage of the JAL aircraft, but could not be rescued.

Meanwhile, on Mizunagi 1, although the captain was seriously injured, he escaped on his own.  The other five crew members, however, were confirmed dead due to general contusions from external shocks and other causes.

Fire Extinguishing

Immediately after the accident, once a fire had been confirmed, more than 100 fire trucks were dispatched to extinguish both aircraft that were in flames, of which the fire on Mizunagi No. 1 was extinguished around 8:30 pm.

The JAL aircraft had both engines and the underside of the fuselage on fire, but the flames soon spread, and five minutes after the captain disembarked as the last individual, flames engulfed the top of the fuselage and spread to the cabin, causing the entire aircraft to catch on fire. In order to extinguish the fire, a large number of water tankers were deployed, and a special vehicle called a "Super Pumper" was used to pump seawater from Tokyo Bay and discharge it to secure a large amount of water for firefighting. As a result of the firefighting efforts, the fire on the JAL aircraft was almost completely extinguished at around 12:10 a.m. on the following day (March 3) and extinguished at 2:15 a.m. The fuselage of the JAL aircraft was almost completely destroyed except for its wings, and the Coast Guard aircraft was also completely destroyed.

 (Image Source: NHK (Originally from the Ministry of Land, Infrastructure, Transport and Tourism))

<Cause of Accident>

As mentioned above, the cause of the accident is still under investigation, but the following is known.

On the night of the accident, the captain of the Mizunagi 1 explained to the Japan Coast Guard that he had obtained permission for takeoff before proceeding onto the runway, but according to communication records between the two aircraft and the tower released the day after the accident, the Japan Coast Guard plane had been issued instruction to proceed to the stop position before it entered the runway, which was recited by the Coast Guard pilot before the accident. It is possible that the JAL aircraft did not see the Mizunagi 1 when it landed, and either the Mizunagi 1 made a mistake in its stop position or mistakenly thought that it had been given permission to take off after the JAL aircraft landed with the instruction of "number 1," the order of takeoff.

On the other hand, the JAL aircraft was instructed to enter the runway. It was also subsequently given permission to land.

The direct cause of this accident was that Mizunagi 1 entered the runway without permission.  However, many questions remain, including:

• Why did it misunderstand ATC instructions and enter the runway?

• Why did it not realize that Flight 516 was about to land?

• Why did ATC not realize that Mizunagi 1 had mistakenly entered the runway?

• Why didn't the flight crew of Flight 516 detect the presence of another aircraft on the runway?

3. Response to the accident by related organizations Tokyo International Airport (Haneda Airport)

All runways at Tokyo International Airport were closed by around 18:00, and more than 100 fire trucks were deployed to extinguish the fire. The Japan Coast Guard dispatched patrol boats and special rescue teams, and the Tokyo Fire Department dispatched a total of 115 units. DMAT (Disaster Medical Assistance Team) was also dispatched. The runway closures were lifted around 21:30, except for Runway C where the accident occurred.

Government of Japan

The Government of Japan established an Information and Liaison Office in the Crisis Management Center of the Prime Minister's Official Residence at 18:05. Prime Minister Kishida gave instructions to "work closely with relevant ministries and agencies and make every effort to rescue and save the victims" and "immediately assess the damage and strive to provide appropriate information to the public.”

Prime Minister Kishida also expressed his condolences to the five Coast Guard officers who died in the accident, saying, "It is a great pity that these officers were killed in the accident, as they were performing their duties with a high sense of mission and responsibility for the areas and people [affected by the earthquake].”

Tokyo Metropolitan Police Department

The Metropolitan Police Department has established a special investigation headquarters at the Tokyo Airport Police Station, and is conducting an investigation, centered in the Special Crime Investigation Section of the Investigation Department, from the viewpoint of filing a charge of manslaughter in the line of duty. They have begun inspecting the scene and interviewing some of the injured passengers. The Coast Guard captain is also being interviewed at the institution where he is currently hospitalized, and the content of his communications with air traffic controllers are being investigated in detail. In addition, autopsies have been performed on the bodies of the five Coast Guard officers who died in the accident, and it was determined that the cause of death was a total body contusion caused by strong external pressure or impact.

Ministry of Land, Infrastructure, Transport and Tourism (MLIT)

The Civil Aviation Bureau of the Ministry of Land, Infrastructure, Transport and Tourism (MLIT) notified the Japan Transport Safety Board (JTSB) of the accident. Director General Shigenori Hiraoka of the Civil Aviation Bureau stated that the cause of the accident "will be investigated by the JTSB and related agencies.” The JTSB is taking the lead in the investigation, and since the JAL aircraft was made in France, Airbus, the manufacturer of the aircraft, and the French Aviation Accident Investigation Agency (BEA) each sent their own expert teams to the accident. The Federal Aircraft Accident Investigation Bureau (BFU) of Germany, one of the designing countries, and the British Air Accident Investigation Branch (AAIB), which is the manufacturer of the Rolls-Royce engines, also participated in the investigation. Since the Coast Guard plane was made in Canada, the Transportation Safety Board of Canada (TSB) joined the investigation, along with representatives and technical advisors from de Havilland Canada, the manufacturer of the airframe, and Pratt and Whitney Canada, the manufacturer of the engine. The day after the accident, they waited for dawn to begin a full-scale investigation. All black boxes were recovered from both the Coast Guard and JAL aircraft by the 6th. The National Transportation Safety Board (NTSB) of the United States also participated in the investigation, since the cockpit voice recorder on the Coast Guard plane was manufactured by Honeywell and other equipment by L3 Harris Technologies, both of which were made in the United States.

The Ministry of Land, Infrastructure, Transport and Tourism (MLIT) has set up a "Haneda Airport Aircraft Collision Countermeasures Study Committee" of experts, and held its first meeting on January 19. The committee intends to compile an interim report on measures to prevent recurrence by this summer. Ultimately, the committee will take drastic safety measures based on the results of the investigation into the cause of the accident by the National Transport Safety Board, which is being conducted concurrently (Table 1).

Table: Major actions taken by the government to prevent recurrence

(Prepared by the author based on news reports)

Airline Company

Passengers on the JAL plane were told that JAL would pay 100,000 yen to each of them as a lump-sum condolence payment and checked luggage reimbursement, and that any more expensive checked luggage would be handled individually.

ANA gave 2,000 yen for food and drink to passengers whose flights were delayed to Haneda the day after the accident.

Response by Other Transportation Agencies

Since this accident occurred during the year-end and New Year holidays, it hit the peak of return traffic. Therefore, the following measures were taken by transportation companies. Each railway company also responded by operating a number of extra services, including the Shinkansen bullet train.

JR Tokai, concerned about congestion in the Tokyo metropolitan area and the Kansai region due to the accident, increased one round-trip "Nozomi" Tokaido Shinkansen train that departs from Tokyo Station and Shin-Osaka Station after 21:40 on the 2nd as a temporary service. In consideration of the fact that the last trains had already departed on all railroad lines in the Tokyo metropolitan and Kansai areas upon arrival, train hotels were also provided at Tokyo and Shin-Osaka stations until the next morning. From the following 3 days onward, the number of "Nozomi" trains departing from Tokyo Station was increased. JR Hokkaido and East Japan Railway also increased the number of extra limited express trains from Sapporo Station and one each of the Tohoku and Hokkaido Shinkansen trains to Tokyo connecting from the extra limited express trains at Shin-Hakodate-Hokuto Station.

Keisei Electric Railway, which has a line connecting to Narita Airport, was concerned about diverts and congestion to the airport due to the accident, and temporarily increased the number of access express trains from Narita Airport Station to Keisei Ueno Station via the Narita Sky Access Line at 25:00 on the 2nd. JR East also delayed the departure time of the last train on the Narita Line Airport Branch Line for the same reason.

Kanto Railway also operated a temporary bus service to Ishioka Station on the JR Joban Line to accommodate passengers diverting to Ibaraki Airport. Nagoya Railroad also operated a temporary train to accommodate passengers diverting to Chubu International Airport.

Keihin Electric Express Railway, which has a line connecting to Haneda Airport, increased several temporary trains including limited expresses from Haneda Airport to Shinagawa Station after the normal closing of trains from the 4th to the 8th. Tokyo Monorail also increased the number of temporary trains on the 4th and 5th.

On February 27, the Kanto District Transport Bureau of the Ministry of Land, Infrastructure, Transport and Tourism presented letters of appreciation to transportation companies that responded to the accident by increasing the number of extra trains and buses and dispatching more cabs.

4. Media coverage and evaluation of the accident

Evaluation of the Escape of All Passengers

All 379 crew members and passengers on board the JAL flight succeeded in escaping from the accident, which was reported as a "miracle" by CNN and other international media. CNN, in particular, attributed the success to the thorough safety measures and actions taken in accordance with the training that had been amended after the crash of JAL Flight 123 in 1985, and Kuniko Miyajima, executive director of the 8.12 Liaison Committee, which consists of the families of the victims, expressed the same view through a newspaper interview.

JAL President Yuji Akasaka also commented, "The crew really did a good job in achieving the results of their regular training. I think that perhaps they were able to produce results that were even better than their training. I am truly convinced that this result was made possible only with the understanding of our customers." Koji Shibata, president of ANA Holdings, also expressed his appreciation and admiration for the crew, saying, "I think this was truly professional work.

Note that half of the nine cabin attendants (CAs) on board were new hires who had joined the company in April 2023. It was observed that many of the crew members had just received training and were able to faithfully apply the results of their training, and that the fact that the passengers calmly followed the crew's instructions contributed to everyone's escape.

Evaluation of JAL's In-flight Safety Video

Five years prior to the accident, JAL had updated its in-flight safety videos in conjunction with the introduction of the Airbus A350, and the successful evacuation of the passengers in this accident brought the safety videos into the spotlight.

In recent years, an increasing number of other companies in the industry have introduced unique safety videos that guide passengers to tourist attractions in their home countries or introduce facilities and equipment in conjunction with traditional performing arts and sports. However, JAL did not take the risk of incorporating these unique approaches, and instead used a CG animation format based on and improved upon the old video.

When JAL had an engine fire at New Chitose Airport in 2016, a passenger tried to escape with his/her baggage against cabin crew's instructions, and the crew was unable to assist in evacuation due to the time and effort required to pick up the baggage, resulting in three injured passengers. After the accident, JAL included in its old safety video the prohibition of taking baggage off the plane and the request for passengers to assist in evacuation under the slide. Three years later, a new video was produced that stated, "Please do not carry baggage when evacuating! (Leave your baggage when you evacuate!)," the video more strongly prohibits the taking of baggage during an emergency evacuation, and visually explains the risks involved in doing so.

In this accident, which occurred eight years after the 2016 incident, all passengers and crew aboard the JAL aircraft were able to survive, despite the fact that the aircraft was so badly damaged that it burned to the ground. One aviation expert highly praised the safety video, attributing the success of the escape in part to the video's detailed explanation of the emergency evacuation.

(Image Source: JAL)

Reactions to the Accident’s Response

The Japan Federation for Aviation Safety (JFAS), an organization of civil aviation professionals in Japan, issued a statement on January 3 urging the press and social networking service users to exclude speculation and imagination and to use only accurate information in their communications. JFAS also announced that the Metropolitan Police Department will investigate the aviation accident from the viewpoint of filing a charge of manslaughter in the line of duty, that the results of the TSC investigation will be used as evidence in a criminal investigation and trial, and that the persons involved will be punished in criminal court. The committee strongly requested that the investigation of the cause of the accident be prioritized over any criminal investigation.

ALPA Japan, a federation of Japanese aircrew labor unions, also issued a statement urging that, in accordance with Annex 13 of the Convention on International Civil Aviation, the accident investigation, which aims to prevent recurrence, be separated from judicial and administrative procedures such as criminal investigations that impose guilt and responsibility, and that any information disseminated be only confirmed facts. The statement also repeated this sentiment regarding information dissemination, and also emphasized that easy dissemination of information be strictly avoided.

5. Conclusion

The author flew from Haneda Airport to Washington DC the day before this accident, and was greatly shocked by the serious accident that occurred the following day. I would like to express my deepest condolences to the five Coast Guard officers who lost their lives in this accident, and offer my prayers for their repose.

The accident also brought to light the challenges facing the Japanese aviation industry. Immediately after the accident, many experts called it "an accident that would not have happened under normal circumstances," but it was the result of a complex combination of many factors, including the Coast Guard aircraft's accidental runway incursion, the air traffic controller who missed the Coast Guard aircraft, the JAL pilot who did not notice the Coast Guard aircraft, and various background factors that led to the accident, all which must be resolved.

The direct cause of the accident will be investigated by the Japan Transport Safety Board, but as has been reported in some media, measures to prevent recurrence, both in terms of hardware and software, are urgently needed after uncovering the hidden factors behind this accident, such as reducing the burden on air traffic controllers at overcrowded airports and introducing next-generation air traffic control systems.

Finally, the most important lesson to be learned from this accident is to "instill a culture of aviation safety.” As evidenced by the "miracle" of the escape of all passengers on the JAL flight, the Japanese airline industry has a high sense of mission and professionalism for safety that is among the highest in the world. It is sincerely hoped that this culture will continue to be maintained in the future, and that all parties involved will share a common awareness of safety and take appropriate measures. The airline industry will continue to focus on safety more than ever and do its utmost to prevent the recurrence of accidents.

References:

https://vdata.nikkei.com/newsgraphics/haneda-runway-collision/

https://www3.nhk.or.jp/news/html/20240102/k10014307191000.html

https://www.aviationwire.jp/archives/295451