Japan Airlines Embraces SAFETY FIRST (AND ALWAYS)

Japan Airlines Embraces SAFETY FIRST (AND ALWAYS)

Maintenance personnel, flight crew, and cabin crew are generally seen as carrying the banner of aviation safety. But what if that attitude could spread throughout an entire airline? Japan Airlines is a prime example, as Ian Harbison discovered when he visited the airline’s Safety Promotion Center in Tokyo.

Just under seven weeks after that visit, on January 2, 2024, a Japan Airlines Airbus A350-900 departed Sapporo as JAL 516, a domestic flight to Tokyo’s Haneda Airport, carrying three pilots, nine cabin crew and 367 passengers (the aircraft has a capacity of 369 seats but there were also eight infants, New Year being a peak travel time in Japan). As it left the gate, the ground crew, as always, would have lined up and waved to the passengers to wish them a safe and comfortable flight.

The aircraft landed in darkness at Haneda, with the flight crew following all air traffic control instructions. Unfortunately, a De Havilland Canada Dash 8-300 of the Japan Coast Guard had ignored an instruction to hold short of the runway and lined up preparing for take off. It was carrying relief supplies to a base in Niigata, close to the Noto peninsula, that had been struck by a major earthquake the day before. The A350 hit the Dash 8 from behind, causing a huge fireball and killing five of the six Coast Guard crew members, before veering off the runway in flames.

The evacuation of the A350 is being praised for the efficient way it was carried out — one person suffered a fractured rib, one had a shin bone contusion, one with a sprain and one with bruising, while 12 people visited a medical facility later in the day after feeling unwell — with the captain leaving the aircraft just 18 minutes after the initial impact. It was made more complicated by the nose gear having been torn off and a major fire in the starboard engine. This meant only three slides (two forward and aft left) could be safely deployed, and not all at the right slope angle. In addition, the aircraft’s announcement system failed so cabin crew members had to shout instructions using a megaphone or their voices. For once, the passengers also helped themselves in the evacuation by obeying the crew and leaving their belongings behind. This may be a cultural influence but the JAL safety video does show the consequences of delaying others by trying to collect and carry baggage from the overhead bins.

The professionalism of the ground crew, flight crew, and cabin crew can largely be attributed to excellent training but there is more — a commitment to safety that is an integral part of the airline’s culture. For example, each crew member would have been carrying a card with the airline’s Safety Charter (see box story).

This attitude can be traced back to an accident that happened to another widebody aircraft on a domestic flight with a full passenger load around a public holiday (the Obon Festival, when the spirits of the ancestors return to the family home). On August 12, 1985, the airline suffered what is still the most catastrophic single aircraft accident in aviation history, when a Boeing 747SR-100 crashed, killing 15 crew and 505 passengers, leaving just four survivors.

On June 2, 1978, the accident aircraft suffered a tail strike at Osaka-Itami Airport. It was ferried to the JAL maintenance base at Haneda where it was surveyed by a team from Boeing. It was decided that the lower half of the rear pressure bulkhead needed to be replaced but the overlap between the two halves was less than specified. The solution was to fit a splice plate between them, which would be held in place by a double line of rivets.

For some reason, Boeing supplied a handwritten instruction rather than a proper engineering blueprint and the splice plate ended up being split in two — the bulkhead would be held together by a single row of rivets. In addition, the manufacturer advised JAL that only visual inspections would be required, rather than eddy current testing. Fatigue cracking around the rivet heads where they could not be seen therefore went undetected.

At the JAL Safety Promotion Center the exhibition focuses on the recovered aircraft debris from JAL123, including the aft pressure bulkhead, aft fuselage, part of the tail structure, flight and cockpit voice recorders, newspaper reports and photographs of the crash site. Most of the structure was recovered from the crash site but some parts of the tail were found floating in the sea. Ian Harbison image.
At the JAL Safety Promotion Center the exhibition focuses on the recovered aircraft debris from JAL123, including the aft pressure bulkhead, aft fuselage, part of the tail structure, flight and cockpit voice recorders, newspaper reports and photographs of the crash site. Most of the structure was recovered from the crash site but some parts of the tail were found floating in the sea. Ian Harbison image.

On the day of the accident, the aircraft took off from Haneda as JAL 123, heading for Osaka. The Boeing 747SR-46 was designed for the Japanese domestic market with a very high density layout, hence the high death toll. It took off at 18:12 and, as it reached cruise altitude at 18:24:35, the rear pressure bulkhead failed, blowing a 2m2 hole in the top half — the original structure. The outrush of air blew off the tailcone and APU but inherent design faults in the aircraft then came into play. There was an access panel that allowed engineers to inspect the inside of the vertical stabiliser but there was no cover to restrict the blast, which removed the rudders and about 55% of the tail structure. All four hydraulic systems were located close to each other in the tail area and suffered severe damage, losing all pressure.

This left the aircraft in an uncontrollable state, as it developed a Dutch roll and phugoid oscillations. The only way to change direction was by differential throttle, which the crew attempted to do to return to Haneda. Unfortunately, this was not possible and, at 18:56, it impacted the south ridge of Mount Osutaka near Ueno village, about 70 miles northwest of Tokyo. Search and rescue teams were unable to reach the remote area until the following morning.

Safety Promotion Center

Masato Mukoyama, senior specialist in the Safety and Security Promotion Department of the Corporate Safety and Security Division, who has worked at JAL since 1987, said the airline was traumatized but management adopted a protective attitude, determined to preserve the reputation of the airline. Added to this, Japanese law made the investigation a criminal matter, which Boeing found unacceptable.

As a result, in subsequent years there was insufficient emphasis and communication on safety from top management, with punctuality seeming to be the main focus. However, in March 2005, the airline received a Business Improvement Order from the Ministry of Land, Infrastructure, Transportation and Tourism warning that it had to improve the quality of its operations. This wakeup call followed four incidents in the previous four months caused by human error, the situation being complicated by moves to consolidate the smaller Japan Air System into the JAL Group.

The immediate response was to form a Safety Measure Council that would meet on a regular basis. It was headed by the president and included vice-presidents, safety supervisors, safety directors, and a representative from each of the airline’s divisions. Five months later, a Safety Advisory Group was established, chaired by Kunio Yanagida, a well known writer and critic specializing in aviation, medicine, and disaster management.

The group came up with four recommendations:

• establish a central body responsible for safety

• establish a Safety Promotion Center

• consider the viewpoint of passengers and their families in the wake of accidents

• improve communications.

In April 2006, a Corporate Safety and Security Division was formed, reporting directly to JAL’s president. It consists of an Operation Group, Safety Planning Group and a Casualty Care Office. One of the duties of the latter is to provide assistance at the annual memorial ceremony in Ueno village for the families of the JAL 123 passengers and crew – 272 people turned up for the 2023 event.

The structure has changed over the years, with a chief safety officer now between the President and the Corporate Safety and Security Division. A group safety enhancement council is composed of the president (chair), the chief safety officer, executive officers appointed by the president, and presidents of group airlines while the Group Operational Safety Promotion Committee, a sub-committee of the Group Safety Enhancement Council, is composed of the vice president of JAL’s Corporate Safety and Security (Chair), vice presidents of JAL safety management departments appointed by the chair, and the chief safety officer or executive officer in charge of safety of each group airline.

Also in Aprill 2006, the Safety Promotion Center was opened at Haneda. Every JAL Group employee passes through the Center when they join the company and it has been used by other airlines, the nuclear industry and train, bus and trucking companies as a way to reinforce safety as part of their own businesses. It is also open to the public.

The introduction covers the early years of the company and its safety record. From its foundation in 1951 to 1977, as it moved from propeller-driven aircraft to jets, it had six fatal accidents that killed 315 passengers, crew and people on the ground. All were caused by pilot error or not following procedures rather than technical issues.

At the end of the exhibition is a library that features the history of aviation safety, describing safety improvements based on lessons learned from accidents and a panel describing actual cases of severe accident mitigation. Also shown are message cards containing personal ‘My Safety Pledges’ of JAL Group staff.

However, the heart of the exhibition is aircraft debris from JAL123, including the aft pressure bulkhead, aft fuselage, part of the tail structure, flight and cockpit voice recorders, newspaper reports and photographs of the crash site. Most of the structure was recovered from the crash site but some parts of the tail were found floating in the sea. In addition, there are mangled passenger seats — it is estimated the aircraft hit the ground at 300mph with a force of 100g. Wall-mounted displays show the transcript of communications between the pilots and ATC and announcements to the passengers by cabin crew. One started writing an announcement in a notebook that matched the circumstances, as the usual script would not apply. The notebook survived the crash and is on display, they did not.

Part of the exhibition shows the aft pressure bulkhead of JAL 123, which was held together by only a single row of rivets due to numerous contributing factors. Ian Harbison image.
Part of the exhibition shows the aft pressure bulkhead of JAL 123, which was held together by only a single row of rivets due to numerous contributing factors. Ian Harbison image.

Passengers also wrote messages to their loved ones in the 32 minutes from the bulkhead failure to impact with the mountain. Most poignant are personal effects such as car keys and a calculator and, most powerful of all, five watches stopped at the time of impact. None of these items could be attributed to a particular passenger and, says Mukoyama, there are still 2,500 similar items in storage.

Yanagida, perhaps as he was outside aviation, came up with a unique concept that runs through the airline’s current thinking about safety — the 2.5th-person perspective. The first- person perspective is that of the passenger, the second-person perspective is that of the passenger’s family and friends, while the third-person perspective is that of the airline employee carrying out their job. Unfortunately, as in the case of JAL 123, that can lead to an attitude that appears to be cold an uncaring. Yanagida’s insight was to suggest a perspective that avoids being swayed by emotions that hinder impartial professional judgement while showing empathy and understanding.

The concept can be seen in the press release relating to the A350 accident: “Sincere apologies are offered for the considerable concerns and inconveniences caused to our customers, their families, and everyone involved. Full cooperation will be provided in the investigation of the incident.”

He also felt it was important, as a 2.5th person, to reach out to the families. In particular, to someone who lost a sister in the crash and made an annual pilgrimage to the site on Mount Osutaka, retrieving small pieces of wreckage and cleaning them. Yanagida told this story to a JAL executive who pleaded for the gentleman’s permission to donate the collection to the Safety Center, where they are shown in a large case, again demonstrating the violence of the impact.

The airline’s response to the JAL 516 accident, from the perfect evacuation to engaging with the public, demonstrates that safety really is at the heart of everything it does. The Safety Promotion Center is an important tool in promoting that message but it can also be seen as a lasting memorial to the people on JAL 123 — they did not die in vain.