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Aircraft Accident Investigation Report

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The investigation for this report was conducted by Aircraft and Railway Accidents Investigation Commission about the aircraft accident of Japan Airlines Boeing 747-400D (an approach to JA8546 of the same airline) in accordance with Aircraft and Railway Accident Investigation Commission Establishment Law and Annex 13 to the Convention of International Civil Aviation for the purpose of determining cause of the aircraft accident and contributing to the prevention of accidents and not for the purpose of blaming responsibility of the accident. This English version report has been published and translated by Aircraft and Railway Accident Investigation Commission to make its reading easier for those who are not familiar with Japan as well as English speaking people. Although efforts are made to translate as accurate as possible, only the Japanese version is authentic. If there is difference in meaning of the texts between the Japanese version and the English version, texts in the Japanese version are correct. Junzo Sato, Chairman, Aircraft and Railway Accidents Investigation Commission ( BLANK ) Abbreviated words Abbreviated words used in this report are as follows: ＡＣ : Advisory Circular ＡＣＡＲＳ : Aircraft Communication Addressing and Reporting System ＡＣＡＳ : Airborne Collision Avoidance System ＡＣＣ : Area Control Center ＡＣＭＳ : Aircraft Condition Monitoring System ＡＦＭ : Airplane Flight Manual ＡＩＣ : Aeronautical Information Circular ＡＩＤＳ : Aircraft Integrated Data System ＡＩＰ : Aeronautical Information Publication ＡＮＯ : Air Navigation Order ＡＯＭ : Aircraft Operating Manual Ａ／Ｐ : Auto Pilot ＡＴＣ : Air Traffic Control ＡＶＴ : Audio Visual Tutor ＢＫＮ : Broken ＣＡ : Cabin Attendant ＣＡＰ : Civil Aviation Authority Publication ＣＡＳ : Computed Airspeed ＣＢＴ : Computer Based Training ＣＬＲ ＣＦＴ : Clear of Conflict ＣＮＦ : Conflict Alert ＣＰ : Chief Purser ＣＰＡ : The Closest Point of Approach ＣＲＭ : Crew Resource Management ＣＶＲ : Cockpit Voice Recorder ＤＦＤＲ : Digital Flight Data Recorder ＥＥＣ : Electronic Engine Control ＥＮＧ : Engine ＦＡＡ : Federal Aviation Administration ＦＡＲ : Federal Aviation Regulations ＦＬ : Flight Level ＦＯ : First Officer ＩＣＡＯ : International Civil Aviation Organization ＪＡＡ : Joint Aviation Authorities ＪＡＲ : Joint Aviation Requirements ＪＡＲ－ＯＰＳ : Joint Aviation Requirements - Operations ＬＯＦＴ : Line Oriented Flight Training - ⅰ - ＭＡＣ : Mean Aerodynamic Chord ＭＣＴ : Maximum Continuous Thrust ＮＤ : Navigation Display ＮＤＢ : Non-Directional Radio Beacon ＯＪＴ : On the Job Training ＯＭ : OPERATIONS MANUAL ＯＶＣ : Overcast ＰＡＮＳ－ＡＴＭ: Procedures for Air Navigation Services Air Traffic Management ＰＡＮＳ－ＯＰＳ: Procedures for Air Navigation Services Aircraft Operations ＰＡＮＳ－ＲＡＣ: Procedures for Air Navigation Services Rules of the Air and Air Traffic Services ＰＦ : Pilot Flying ＰＦＤ : Primary Flight Display ＰＩＣ : Pilot in Command ＰＮＦ : Pilot Not Flying ＱＭ : QUALIFICATIONS MANUAL ＲＡ : Resolution Advisories ＲＤＰ : Radar Data Processing System ＲＰＭ : Revolutions Per Minute ＳＣＴ : Scattered ＴＡ : Traffic Advisories ＴＣＡＳ : Traffic Alert and Collision Avoidance System ＴＨＲ ＲＥＦ : Thrust Reference ＴＲＭ : Team Resource Management ＵＴＣ : Coordinated Universal Time ＶＨＦ : Very High Frequency ＶＮＡＶ : Vertical Navigation ＶＯＲ : VHF Omni-Directional Radio Range ＶＯＲＴＡＣ : VOR and TACAN（UHF Tactical Air Navigation aid） combination ＶＳＩ : Vertical Speed Indicator - ⅱ - Remarks for usage of terms (1) Directions are expressed by magnetic directions, except for relative directions. (2) "Course" is used in the same meaning with "magnetic course". (3) "Heading" is used in the same meaning with "magnetic course", "course" or "magnetic heading". (4) As for "bank angle", "roll angle" is used in case that the value is cited from "roll angle" of DFDR. (5) "TCAS" is an abbreviation of Traffic Alert and Collision Avoidance System. "ACAS" is an abbreviation of Airborne Collision Avoidance System. Both expressions mean an aircraft collision avoidance system. The term "ACAS" is used in ICAO regulations, AIC issued by Civil Aviation Bureau and the regulations of European authorities. The term "TCAS" is used in the regulations of air traffic control facilities and aircraft operators, etc. and the regulations of the authority of the United States. In this report, the term "TCAS" is used in principle. The term "ACAS" is used in sentences cited from ICAO regulations, AIC issued by Civil Aviation Bureau or the regulations of European authorities - ⅲ - ( BLANK ) - ⅳ - CONTENTS 1PROCESSANDPROGRESSOFTHEACCIDENTINVESTIGATION2……… 1.1SummaryoftheAccident2…………………………………………………… 1.2OutlineoftheAccidentInvestigation2……………………………………… 1.2.1TheOrganizationoftheInvestigation2………………………………… 1.2.2TheImplementationoftheInvestigation3……………………………… 1.2.3InterimReportandProposals3………………………………………… 1.2.4PublicHearing3………………………………………………………… 1.2.5HearingsfromPersonsrelevanttotheCauseoftheAccident4………… 2FACTUALINFORMATION5…………………………………………………… 2.1FlightHistory5……………………………………………………………… 2.1.1FlightHistorybasedontheRecordingsoftheOnboardRecordersand ATCRecorder,etc.5……………………………………………………… 2.1.2StatementsofFlightCrewwithrespecttoFlightHistory……………11 2.1.2.1StatementsoftheCaptainofAircraft-A…………………………11 2.1.2.2StatementsofthePilotUnderTraining()TraineePilotof Aircraft-A…………………………………………………………13 2.1.2.3StatementsoftheFirstOfficerofAircraft-A……………………14 2.1.2.4StatementsoftheCaptainofAircraft-B…………………………15 2.1.2.5StatementsoftheFirstOfficerofAircraft-B……………………16 2.1.3StatementsofAirTrafficControllers…………………………………17 2.1.3.1StatementsoftheControllerUnderTraining()ATCtrainee……17 2.1.3.2StatementsoftheATCWatchSupervisor………………………18 2.1.3.3StatementsoftheCoordinator……………………………………19 2.1.4Situationsinthecabinatthetimeoftheaccident……………………20 2.1.4.1StatementsoftheCPandCAofAircraft-A……………………20 2.1.4.2StatementsofthepassengersofAircraft-A………………………21 2.2InjuriestoPersons…………………………………………………………22 2.3DamagetotheAircraft……………………………………………………23 2.4InformationontheCrewandAirTrafficControllers……………………24 2.4.1FlightCrew……………………………………………………………24 2.4.1.1FlightCrewofJALFlight907……………………………………24 2.4.1.2FlightCrewofJALFlight958……………………………………26 2.4.2FlightAttendantsofJALFlight907…………………………………27 2.4.3AirTrafficControllers…………………………………………………28 2.5AircraftInformation………………………………………………………30 2.5.1Aircraft-A………………………………………………………………30 2.5.2Aircraft-B………………………………………………………………30 --ⅴ 2.5.3WeightandCenterofGravity…………………………………………31 2.5.4FuelandLubricatingOils……………………………………………32 2.6MeteorologicalInformation………………………………………………32 2.6.1WeatherSynoptic………………………………………………………32 2.6.2SatelliteCloudInformationChartovertheAsiaPacificRegion……32 2.6.3AerologicalObservationData…………………………………………32 2.6.4ShizuhamaAirportAviationWeatherObservations…………………33 2.7AirNavigationFacilities……………………………………………………33 2.8Communications……………………………………………………………33 2.8.1OperationalConditionofRCAG………………………………………33 2.8.2ATCRecorderBackgroundNoiseLevel……………………………34 2.9InformationontheAircraftRecorders……………………………………34 2.9.1CVRRecording………………………………………………………34 2.9.2RecordingsoftheDFDR,ACMandAIDS…………………………34 2.9.3TimeCorrectionofRecordings………………………………………35 2.10MedicalInformation………………………………………………………37 2.10.1ThenumberofCabinAttendantsandPassengerssustainedinjuries…37 2.10.2DetailsofSeriousInjuries……………………………………………37 2.10.3DetailsofMinorInjuries……………………………………………39 2.11InformationonSearch,RescueandEvacuationrelevanttoSurvival, DeathorInjury……………………………………………………………40 2.11.1SituationinthecabinofAircraft-Aaftertheaccident………………40 2.11.2CorrespondenceofJALandRelevantFacilityontheGround………43 2.12TestsandResearchtoFindFacts…………………………………………44 2.12.1InvestigationoftheAircraft…………………………………………44 2.12.1.1TestsonAircraftEquipmentandAvionics……………………44 2.12.1.2InvestigationintoDamagetotheInteriorofAircraft-A's PassengerCabincausedbyGalleyCarts…………………………45 2.12.2InvestigationintotheOperationoftheTCAS………………………46 2.12.2.1OutlineofTCAS…………………………………………………46 2.12.2.2AnalysisoftheTCASAlerts……………………………………47 2.12.3TestFlightusingFlightSimulator,etc.………………………………50 2.12.3.1EngineThrustResponsetoMovementofThrustLevers………50 2.12.3.2FlightSimulatorTests……………………………………………50 2.12.4InvestigationintoATCRadarSystem………………………………56 2.12.4.1RadarDataProcessing()RDPsystem…………………………56 2.12.4.2CNF()ConflictAlert……………………………………………57 2.12.4.3RadarHand-Off…………………………………………………58 2.13OrganizationandManagementinformation………………………………59 --ⅵ 2.13.1Flightcrewproceduresatthetimeoftheaccident…………………59 2.13.1.1Standardflightcrewcomplements………………………………59 2.13.1.2Flightcrewdispositionandtaskassignmentatthetimeof theaccident………………………………………………………60 2.13.1.3Qualificationrequirementsofflightcrewmembers……………60 2.13.2Airroutecontrolservicesatthetimeoftheaccident………………62 2.13.2.1GeneralinformationofKantoSouth-Csector…………………62 2.13.2.2ControllerConsolePositionsandTaskAssignment……………63 2.13.2.3Qualificationrequirementsforcontrollers………………………63 2.13.2.4RequirementsforaATCwatchsupervisor……………………65 2.14Otherinformation…………………………………………………………66 2.14.1RegulationsrelatedtoTCASoperations……………………………66 2.14.1.1JapaneseRegulations……………………………………………66 2.14.1.2ICAORegulations………………………………………………68 2.14.1.3Aircraft-A'sManuals……………………………………………70 2.14.1.4Aircraft-B'sManuals……………………………………………74 2.14.1.5Regulationsappliedtoairtrafficcontrol………………………75 2.14.1.6U.S.A.Regulations………………………………………………76 2.14.1.7EuropeanRegulations……………………………………………77 2.14.2TrainingforTCASprocedure………………………………………78 2.14.2.1Trainingforflightcrewmembers………………………………78 2.14.2.2TrainingforAirTrafficControllers……………………………81 2.14.2.3Studymaterialscompiledbytheaircraftmanufacturers………82 3ANALYSIS……………………………………………………………………84 3.1General………………………………………………………………………84
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