communication

JAL516 / JA722A crash at RJTT (Haneda) 02.01.2024

mathias

after reviewing a number of sources presented at different sites, I would like to add a few more points and present my early analysis of the likely causal events for the accident (isolated on this site, without adding to the speculations winding up elsewhere. let’s wait for the official report from JTSB – and compare).

current facts as presented from official sources:

  1. METAR: RJTT 020900Z 33008KT 9999 FEW020 07/04 Q1016 NOSIG
  2. NOTAM J2253/23: [..] STOP-BAR-LGT FOR C1 THRU C14-U/S [..]
  3. ATC transcript (released by Japanese Ministry of Transportation)
    • JAL516 had received landing clearance RWY 34R, positive readback.
    • JA722A taxi to holding point C5 (34R) for #1 in sequence, positive readback.
    • and additionally:
    • JAL166 to continue approach as #2 in sequence, positive readback
    • JAL179 to taxi to holding point C1 (34R) for #3 in sequence, positive readback

Primary question: Why did JA722A, contrary to its clearance, not hold at C5 but entered 34R ? Secondary questions of course relate to: 1) why did TWR (visually or by automated means) not identify the deviation and initiated corrective actions, 2) why was JAL516 unable to identify the abnormal condition and initiated a go-around in time.

While there is a lot to analyze on the environment and procedures related to the secondary set of questions, at this point in time, I would like to solely focus on the primary question. All assertions are speculative in nature and provided with plausible justification:

  1. official sources state that JA722A was a Japanese Coast Guard flight related to Jan 01 24 earthquake disaster relief. It is highly likely that in its flight plan JA722A was given status as a rescue flight and as such was given priority by coordinating stations, including Tokyo TWR.
  2. Consistent with (1) JA722A was cleared to hold for a (non-standard – but acceptable due to the aircraft’s lower requirement on take-off runway available) intersection (C5) take-off on RWY 34R. Tower assigned JA722A as #1 in sequence for runway 34R, relative to #2 JAL166 on approach, behind JAL516 (which has just been given already clearance to land) and to #3 JAL179 on ground for departure, cleared to taxi to (standard) holding point C1, about 30 seconds after JA722A had receive its assignment to C5. Therefore, TWR had indeed prepared a priority sequencing for JA722A, putting it ahead of competing JAL179 (which it would likely have followed to C1) and scheduling it’s departure between landing JAL516 and approaching JAL166. The effective sequence at this point in time was:
    • #0 JAL516: on final, cleared to land 34R
    • #1 JA722A: on ground, to hold at C5, 34R
    • #2 JAL155: on approach, to continue approach 34R
    • #3 JAL179: on ground, to hold at C1, 34R
  3. TWR in it’s communicated sequencing (starting at #1) did not further mention aircraft #0. In fact JA722A and JAL516 obviously being on the same frequency, situational awareness of the JA722A crew would have allowed them to pick up JAL516’s landing clearance right before receiving their clearance to hold at C5. Only in the case that TWR would have considered issuing a conditional “line up and wait” clearance to JA722A (such as: “JA722A line up RWY 34R and wait BEHIND landing aircraft on final BEHIND”) TWR would have mentioned the landing traffic.
  4. On CCTV footage from the airport camera (www.youtube.com/watch?v=6NbVdIoJsHY&t=169, Note: Please enlarge the video to full screen and monitor the faint white dot moving just above the upper edge of the tail of the distant ANA aircraft that just started taxiing from the illuminated area of the apron towards the darker runway area), at video time 3:00 one can see JA722A to enter 34R and wait in a position aligning with the runway as its landing light turns (left) towards the camera and distinctly grows brighter. From this moment on, JA722A is holding position on RWY 34R for an eternity of 48 (!) seconds – apparently waiting for a take-off clearance – before being impacted by the landing JAL516. On the video one can occasionally distinguish the JA722A strobe lights first moving and then holding with the aircraft, but its red flashing beacon is not visible on the recording.
  5. The captain of JA722A was reported to be the sole survivor of this aircraft and (unconfirmed) Japanese Coast Guard sources quote him as being conscious of having received a clearance to (at least) enter RWY 34R. If the captain (LH seat) was pilot flying (PF) and RH seat was pilot monitoring (PM), there is obviously a “connection” between the captain’s statement and the apparent action of the aircraft, but a huge “disconnect” with the ATC clearance (to hold at C5) which was properly read back from the aircraft. In essence, this appears to be a catastrophic disconnect between the mental models of PF and PM. In addition, there are possible physical factors contributing to the fatal actions taken by the crew:
    • (1) If PM was distracted by monitoring ATC (in English language), preparing the aircraft (working the checklists) for priority departure as #1 in sequence, PM (in his RH seat, not being the captain) was likely the only one two have an unobstructed view before line-up towards the arrival end of RWY 34R to spot (in very good visual conditions, see METAR at source 1 above) landing- & strobe-lights of JAL516. PF was likely not in this visual position, and likely not advised by PM, as this would be the case in a cockpit with well established CRM.
    • (2) As stated in source 2, NOTAM indicates that runway stop lights at C5 (and other intersections) were un-serviceable. With regard to the validity of the NOTAM however, additional caution has to be exercised since further provisions in the AIP Japan and possible trigger NOTAMs may be required. If stop-bar lights were indeed not operational, the crew (and specifically PF) would lack an additional clue that the mental model of having received a clearance for line-up was invalid.
  6. Possible causative mental factors, such as disorientation and stress within the cockpit of JA722A could be:
    • (1) night operations at a major international airport, ATC in English language, a non-commercial (coast guard) crew.
    • (2) a sense of urgency and stress perceived by a likely “rescue mission” flight status and an effective priority handling, being assigned #1 in sequence for RWY 34R.
  7. Adding to (6) but being HIGHLY SPECULATIVE in nature, I listened to ATC recordings from Tokyo TWR (remark: I have for myself ICAO English Level 6 printed in my license, but I have to admit that Haneda TWR communications in English by non-native Japanese speakers are EXTREMELY DIFFICULT to follow) on an (amateur) source www.youtube.com/watch?v=LP1xWcyKBDs&t=912s. In fact, those Internet resources usually pool together reception of several TWR frequencies – serving different parts of the airport – in a single audio stream). At the entry point marked (15:13) the recording starts with the C5 holding clearance given to JA722A (note: the documented readback from the aircraft however has not been picked-up on this specific recording – possibly due to low radio signal strength). However, at 15:24, immediately afterwards, one can hear a clearance given to another aircraft on runway 05 to “line up and wait runway zero five”. In a state of mental stress, let’s assume the following:
    • (1) JA722A had initially prepared a radio setup for several possible TWR frequencies, having the one pertaining to RWY 34R selected “active” and another frequency (for RWY 05) selected “stand-by”, possibly monitoring. Depending on the radio equipment of the aircraft, it is possible to simultaneously monitor (listen only) the stand-by frequency while being able to listen & speak on the active one. If this was intentionally or accidentally selected by the crew, then
    • (2) If the mental model of PF was anticipating an expedite #1 departure out of “charlie five” by a soon to follow order to line up, the audible reception of “runway zero five, line up and wait” could be “joined” into the PF’s mental model via the word “five” and his expectation on clearance to enter the runway. The consequence would match exactly the fatal actions taken by the aircraft: line up and wait.
  8. One could speculate that crew communication on board Japanese Coast Guard’s JA722A was obeying to a more military “chain of command” and challenging a decision of a senior party (here: PF, captain) by a junior party (here: PM) is not a strong point in Asia, as this might further be a matter in Japanese culture. This being said, there was perhaps too little room for questioning and corrective action inside the cockpit – sadly within an extensively long waiting time right in the middle of an active runway.

Abbreviations: METAR (meteorological aerodrome report), NOTAM (notice to airmen), AIP (aeronautical information publication), RWY (runway), CRM (crew resource management), ATC (air traffic control), TWR (tower), RH (right hand), LH (left hand)

良药苦口 – good medicine tastes bitter

mathias

In the middle of a global crisis focused on the current developments in Ukraine, the vast ocean of social media is rapidly populated by massive shoals of fish swimming in various directions, occasionally swallowed by trawling (read: trolling) sharks. To stay in calm waters, I chose to sketch my view on the tiny island of my personal website – comments welcome via LinkedIn or contact email !

I was born in Germany and identify myself as a European citizen. This is based on my perception of a common European cultural and ethical heritage, i.e. a peaceful co-existence of distinct people and common values of freedom. Having traveled extensively throughout the world, I have learned about different cultures and ethics in both geographically and politically distant countries. While I am – not without difficulties – able to identify myself with nations very much distinct from my own background, I understand that close listening and mutual respect is definitively a good basis to develop friendship and prosperity.

Presently, one is witnessing an outcry to more closely stand together and defend the values of Europe, embodied by the European Union acting as a political organization. I do think that the process of identification and re-alignment of values is very much desirable and vital to the existence and development of any organization. But I admit I do have my issues when it comes to the development and justification of some of its policies and actions:

Defending values routinely seems to translated into a bellicose scheme of identifying “other” values and interests as adverse or hostile and to implement defense as a sole show of (military or economical) force towards the alleged power of the enemy.

To make it crisp and clear, I condemn the invasion of Ukraine by the Russian Federation and there is simply no excuse to not immediately stop this war and to enter into a multilateral diplomatic process of negotiations. Now the house is on fire, it is first priority to put out the flames, then enter into (1) post-fire investigation and the implementation of (2) preventive actions.

Regarding these two actions I am of the opinion that the view has to be considerably enlarged from the narrow perspective of blaming “apparent” ideology or mad man’s action towards a deeper look into the cultural and historical background and developments leading up to the fatal spark igniting a war: Together with culture and history of a nation closely come its identity and pride – but sometimes also humiliation and pain. It is crucial to understand that a dissent or hostile attitude perceived and criticized by one party is frequently rooted in fear or abasement felt by the other side. All these are ingredients to a chemical cocktail that is susceptible to ignite – in contact with a catalyst, which can be as focused as a single political leader. It is important to independently attempt to defuse both sides: the flammable cocktail and its catalyst.

In this post I am aiming at prevention “beyond Russia” and I would like to focus on the cocktail rather than the catalyst.

In several aspects the international curriculum of Russia recalls parallels with China. In their long history, not only both countries experienced periods of impressive geo-political and economic influence, but also had to suffer – for prolonged periods of time – from decay of their glory due to economic and political factors acting from both the inside as well as under foreign pressure. Understandably nations are striving to preserve or restore their self-confidence, identity and global influence. To the present point in time, however, both nations achieved very different levels of development which can be analyzed objectively, i.e. economic prosperity (domestic / trade), civil rights, freedom of press, involvement in amicable international relationships.

With Russia currently being forced into deep political and economic isolation, I regrettably see many people in Europe anxiously looking at China to embody a sort of upcoming “Russia 2.0” which could serve as justification for adopting a rather contentious position in EU – China relationships. In the early days of the Ukraine war, I was initially pleased to see (on 03 March 2022) French president Macron, German chancellor Scholz and Chinese president Xi to engage in a joint video call.

Not being divided by ocean waters and by sharing the same Eurasian land mass bridging from Europe to Asia, I suggest that the current situation should be regarded by both European and Chinese leaders as a unique and huge opportunity to invest into furthering mutual understanding of the historic cocktail and to attempt to speak out and align cultural values and economic interests. “Trade leads to Peace” has been stated as early as by the ancient Greek philosopher Plutarch and since has been repeatedly reflected in EU foreign policies. Of course, I hear people instantly reminding that fair trade might be in danger dealing with a giant China – but c’mon Europe, stop lamenting and boost innovation and competition in lieu of regulation ! China has undertaken a giant and long term effort to re-energize the ancient Silk Road land-based trade routes to Central Europe, rolling out their “Belt & Road Initiative” (one belt one road: 一带一路), facing geo-graphic/political challenges to circumnavigate Caspian and Black Sea waters via either Iran/Turkey or Russia. Eventually, both sides – Europe and China – have a common and vital interest in seeing Russia stabilize and prosper among them in respectful co-existence. Frankly, I think it’s more of a duty and responsibility to the world than a mere opportunity.

Coming back to the title of my post, I believe that debugging the world shall put considerably more effort on coordinated initiatives involving both Europe and China and that this process will be sort of a bitter pill to swallow for people so far exclusively focused on transatlantic security and trade policies.

covid-19 & air quality

mathias
A couple days after attending the EU Space Conference in Brussels end of January 2020, I got sick with fever and mild respiratory and digestive tract symptoms, and additionally, what I remember as the perception of a strange odor or somewhat misled olfaction. Things improved after about a week and I did not spend a though whether this could have been a sars-cov-2 infection (note: later on, I discovered that the first cases officially identified and recorded in Belgium date back to early February 2020 which indeed made it plausible that my infection could have been the real thing). Covid-19 at this time still seemed to be an Asian “problem” with news gradually spreading on infection rates picking up in the Middle East and eventually Southern Europe. As we all know, the situation got increasingly dynamic in March and April with aggravating reports on high death tolls in Iran and Northern Italy. In the evening of April 27 2020, I had a chat with friends from the bio-medical field who had launched into an analysis of molecular mechanisms and patient phenotypes associated with the disease. As a physicist, I had less to contribute from a solely medical point of view, but I had already undertaken own research on data available on environmental factors – specifically those who seem to relate to pulmonary function, which appears most critically targeted by the virus. Although direct pathogenic impact and the complexity of the human immune and inflammatory response seem to be a rich playground for research, I was not ready to give up the idea that environmental factors, notably particulate matter and ground based (tropospheric) ozone, are contributing factors to a deadly course of the disease.

source: EEA Report No 13/2017 “Air quality in Europe – 2017” Section 5.2 (https://www.eea.europa.eu/publications/air-quality-in-europe-2017)

Particulate matter (PM) in ambient air is commonly recognized as an agent that induces lung damage and aggravation of chronic disease, such as asthma. Ozone (O3), which is known to exercise strong oxidative stress on the pulmonary system, not only occurs in a layer high up right below the stratosphere, but also exists as ground level (tropospheric) ozone catalyzed by the influence of UV radiation on volatile organic compounds (VOCs) and NOx/CO co-emitted with particulate matter. The EU commission had just recently published a survey of European air quality and when I looked at the graphics depicting critical PM and O3 levels throughout Europe, together with similar data available for the Middle-East and China, those maps just looked strikingly similar to the ones depicting covid-19 fatality rates. The disaster was already real for Northern Italy, and I got very concerned about Eastern Europe, specifically Poland.

While I have to admit that my considerations regarding covid-19 are far from a rigorous scientific analysis, in the light of the dramatic situation in spring 2020, I decided that scientific gut-feeling and intuition was enough to let some people higher up know that a political connection between environmental protection and handling the pandemic crisis should at least be given a thought.

Consequently on April 28 2020, I sent an email to EU commissioner for climate action Frans Timmermans and the ambassador of the Polish Republic to Germany, Prof. Przylebski:

Email sent to VP Timmermans and Ambassador Przylebski on 28 March 2020.
Note: The link given in the email has changed: https://www.eea.europa.eu/publications/air-quality-in-europe-2017
I was not particularly hopeful that my message would ever be answered, at most expecting perhaps a pre-formatted reply from the commission’s PR department or an envelope with shiny EU stickers.

When I started to forget about it, on 08 April 2020 I received a message with a letter enclosed from the EU Directorate General Environment – ENV.C3:

Dear Dr. Göschl, Thank you for your message to Vice-President Timmermans regarding the correspondence between the expansion of COVID-19 outbreak and some areas with elevated levels of air pollution in the EU, and your specific concerns about Poland. I have been asked to reply on his behalf. […]

Wow ! My trust was restored and I felt honored that the organization was sharing with me, in an elaborate 1+ page letter, their sympathy for my considerations and their political actions, specifically regarding Poland (for confidentiality reasons, I am unable to publish the full content of the communication). I did not receive any reply from the Ambassador of Poland, though.

Eventually, once more uniting communication with creativity and technology, I started to work on my AirStation project.