AVIATION ACCIDENT JAL-516 COLLIDES WITH JAPAN COAST GUARD AIRCRAFT

 JAL-516, an Airbus A350-941, collided with Japan Coast Guard (JA722A) DHC-8,on the runway at Tokyo-Haneda Airport, on 02 Jan'24. As per news and few official releases it is alleged (as only the final official investigation report would reveal what happened)that the Coast Guard aircraft misread instructions for hold short on taxiway C-5, and lined up when JAL-516 was already cleared to land. JAL-516 hit the lined up aircraft of Coast Guard. Both aircraft caught fire. All passengers of JAL-516 were evacuated safely while five of the six occupants of Coast Guard aircraft died. Only the captain survived with severe injuries. As per some reports the captain of the coast guard aircraft, post accident, asserted that he was cleared for take-off. As per NOTAMs stop bar lights for the taxiway were unserviceable. 

Some obvious questions are likely to be raised. How could the Coast Guard crew confuse instructions even after reading back correctly. How come the other pilot also could not detect the error of lining up without authorization. Why could JAL-516 not see the coast guard aircraft sitting on the runway with all its lights on. It was night time and visibility was good. How come ATC missed out seeing that the runway was already occupied when JAL-516 was coming to land. Why did the captain of coast guard felt that he had been cleared for take off.

To answer these questions lets go into the background to this accident and understand some aspects of human behavior which could have played to cause this fatal confusion. The Coast Guard aircraft was engaged in relief operations. There had been a massive earthquake just one day before with wide destructions. It triggered a tsunami alert and there was, in the words of Japan's prime Minister Fumio Kishida, a "race against time" to rescue survivors, many of whom would have been trapped under debris. Mental state during such life saving operations changes significantly where the pilots often get into a perceived situation of urgency. They see, correctly, their mission as matter of life and death for people awaiting rescue. It is not unusual for aircrew to be in a hurry for these missions. Minor deviation from well established rules and orders are known to have been compromised during such situations. Author actively participated in the rescue effort post tsunami ,in Andaman Nicobar islands in the year 2004. It was common for the crew to take shortcuts, carry extra passengers and flying without adequate rest. Now, this does not mean they were flying unsafely. Military crew are expected to undertake operational tasks at short notice and in challenging conditions. At such times mission becomes more important and crew are drilled to deliver under trying conditions. They are used to last minute changes and respond to short notice tasking. Checks and procedures and SOPs can be expedited without compromising safety. In multi crew aircrafts duties may be shared in such taskings. However at times the short cuts extend to areas which should not be compromised. During flood relief operations in Uttarakhand in  2013 a chopper MI-17V5 crashed killing all on board. The aircraft entered clouds in hills and collided with high terrain. It can be argued if the pilot had done the same thing in case the pressure of relief operations and saving lives was not on him because entering clouds in hills is never resorted to. Once again an IL-76 undertaking relief operations post earthquake in Bhuj in the year 2001 met with an accident while landing in Agra under poor visibility conditions. The aircraft hit 3 trees at a height of 50-55 feet about 3.5 km short of the landing dumbbell. The crew had been flying long stretches with little rest. 

    Coming back to the coast guard aircraft, it appears that the situation they were in had some role in them landing up on the runway without proper ATC clearance. Expectation bias where they were in the impression that they will be cleared to line up on priority due to the nature of their tasking. It is also possible that they followed an instruction which was meant for other aircraft. It is not uncommon to get confused when two aircrafts have near similar call signs. Lets wait for the inquiry to get over to know what exactly transpired to lead to this fatal error.

    Another question popping up is as to how come the crew of JAL -516 failed to see the coastguard aircraft sitting on the center of the runway during good visibility conditions and with all the identifying lights of the coast guard aircraft. Many accidents have taken place where the crew failed to notice the aircrafts directly in front of their field of vision. Notable among them is the Los Angeles runway disaster on 01 Feb 1991 when USAir Flight 1493, a Boeing 737-300 collided with Sky West Airlines Flight 5569, A Fairchild Swearingen Metroliner turboprop aircraft, upon landing at Los Angeles International airport. The Sky West flight was cleared to line up and hold while the US Air Flight was on approach. The ATC controller lost situational awareness due to distraction with another aircraft and cleared the USAir Flight to land. which landed on the smaller Metroliner. The First Officer Kelly, the only surviving pilot from either plane , stated that the runway appeared perfectly clear. It was like the Metroliner wasn't even there. Another incident happened on 27 Jul 2021. An Airbus-320 took off from Changi airport Singapore with all runway lights off. The crew as well as the controller insisted that the lights were ON. The CCTV and the records of the lighting system clearly showed that all runway lights were OFF when the aircraft took off. The controller had simply forgotten to switch on the runway lights. On 07th Jul 2017, Air Canada Flight 759, an Airbus-320 was cleared to land on RW 28R at San Francisco. It was night and VMC prevailed.  Instead of the runway, the crew aligned the aircraft with it's parallel taxi track which had 4 aircrafts taxying for departure. Air Canada flight went round at 89 feet when one of the taxying aircraft put on its landing lights. Both the pilots insisted that they never saw any airplane on the taxiway. This error of perception is called "Inattentional Blindness" which is defined as failure of observers to notice the presence of a clearly viewable but unexpected visual event when cognitive resources are diverted elsewhere. 

   UPDATE as on 15 Jan 2024. The JAL-516 continues to be in the news. The coastguard plane pilot continues to insist that they were cleared for take-off. The CVR will reveal how and where he misinterpreted the take-off clearance.  It has been clarified that the evacuation was completed in 18 minutes after touch down. This is a significantly long time considering that the aircraft was engulfed by fire all this time. This speaks volumes about the material used for airframe. The reasons for delaying opening the chutes despite aircraft being on fire will be probed. It has also emerged that the captain and the crew displayed exemplary courage and presence of mind during the evacuation by going up and down the aircraft and pulling out few who were incapacitated. They were also the last to leave the aircraft after ensuring that all passengers were out. This was brilliant.

    UPDATE as on 18 Jan 2024. An interesting video taken by a passenger from the time the aircraft landed till evacuation indicates that the evacuation started in about 7 minutes after touch down with evacuation completed soon thereafter (within 90 seconds). Though there are some other versions floating but this appears to be more accurate. The delay in opening the door could be due to the extraordinary situation the crew faced. They were not aware what hit them and must be under shock and startle effect. The communication with the cabin crew appeared to have been cut off. It would have taken time in these circumstances to evaluate which exits are safe and which are not. After the evacuation was completed the captain went to each row and found people and helped them to exit the plane. Probably they were incapacitated by the shock. The captain was the last to leave the aircraft in about 18 minutes after touch down. The cabin crew did extraordinary job in keeping all the passengers calm under extremely serious situation. this also led to orderly and rapid exit when ordered. While there is always scope to improve, under the circumstances the crew did very well. It also , sadly, emerged that two pets, who were checked-in on the flight, perished for which JAL had apologized and offered deep condolences.