Gulf of plane Suruga sky near-miss incident, Japan
| Summary of the event | |
|---|---|
| Date | 2001January 31 |
| Summary | Control error |
| The spot |  Gulf of Suruga of Japan, the Yaizu-shi, Shizuoka offing |
| The injured person total number (I remove a dead person) | 100 (crew passenger of Japan Airlines 907 flights) |
| Death toll | 0 |
| The survivor total number | 667 (all the members) |
| The first body | |
| Model | Boeing 747-400D |
| Operation person | Japan Airlines |
| Body sign | JA8904 |
| Departure place | Tokyo International Airport |
| Destination | Naha Airport |
| The number of the passengers | 411 |
| The number of the crews | 16 |
| The death toll | 0 |
| The number of the survivors | 427 (all the members) |
| The second body | |
| Model | McDonnell Douglas DC-10-40 |
| Operation person | Japan Airlines |
| Body sign | JA8546 |
| Departure place | Gold sea International Airport |
| Destination | The New Tokyo International Airport |
| The number of the passengers | 237 |
| The number of the crews | 13 |
| The death toll | 0 |
| The number of the survivors | 250 (all the members) |
Gulf of plane Suruga sky near-miss incident (にほんこうくうきするがわんじょうくう near miss じこ), Japan is a near-miss incident by the Japanese planes which occurred on January 31, 2001.
Table of contents
Summary of the accident
![[icon]](https://upload.wikimedia.org/wikipedia/commons/thumb/1/1c/Wiki_letter_w_cropped.svg/20px-Wiki_letter_w_cropped.svg.png){kind=small} | The correction of this knob is expected. |
Two planes of Japan Airlines flight 958 DC-10-40 (JA8546) which left for the New Tokyo International Airport (the existing Narita International Airport) from Japan Airlines flight 907 Boeing 747-400D (JA8904) and the Korean gold sea International Airport which went to Naha Airport from Tokyo International Airport in 37,000 feet of Gulf of Suruga sky of the Yaizu-shi, Shizuoka offing at about 3:55 on the afternoon of January 31, 2001 woke up near miss, and 907 flights made nose dive for collision avoidance.
Slightly injured serious wound, 37 five among the crew passengers who the dead person did not appear by these a series of swoops with both opportunities either, but do not do a seat belt among 411 crew 16 passengers of 907 flights, and walked the passage (the number of the people with serious or slight injury became 100 people by a later investigation). The injured person did not appear to 237 crew 13 passengers of one 958 flights. 907 flights made an emergency landing to Haneda Airport at 4:44 p.m. Ministry of Land, Infrastructure and Transport appointed this case for an aircraft accident.
Accident cause
When a series of near miss occurred for the wrong instructions of the air traffic controller training of the Tokyo Air Traffic Control Center, according to the accident investigation report of the Ministry of Land, Infrastructure and Transport Aircraft and Railway Accidents Investigation Commission announced on July 12, 2002, I was authorized.
907 flights will originally confront 958 flights because they did not notice it for 907 flights that you must raise first so that they misunderstand flight number, and instructions, the controller whom I supervised more take the wrong descent. The 907th flight TCAS (midair collision arrester) gave the instructions of the rise just after that, but the captain followed this because I was absolutized saying, instructions of the control "were orders of the Ministers of Land, Infrastructure and Transport" in the A.T.C. Control instructions deviation at the time of the TCAS operation was accepted in the Aviation Act-related official regulations, but was not prescribed about priority when control instructions disagreed with TCAS in those days [1]. On the other hand, with the JAL office manual, it was decided to obey TCAS unless I judged that the captain was in danger [1].
Because a warning system of the near miss operated the controller of the Tokyo Air Traffic Control Center approximately 50 seconds before near miss, I touched an altitude difference by letting 958 flights descend and was going to evade it, but, as for 907 flights, it was the dangerous instructions that, as a result, both bodies might collide head-on as for this that started a descent because I started the instructions of the descent that you should originally start for 958 flights for 907 flights by mistake.
TCAS carried just before a head-on collision in both 907 flights and 958 flights operated, and 958 flights started a descent according to this warning, but though the TCAS of the own plane ordered "a rise", they believed control and continued descending because the pilot of 907 flights believed the instructions of the control with a thing to evade near miss.
In addition, as for the instructions contents of this TCAS, all witnesses of the criminal trial testify with foreknowledge impossibility to a controller without being transmitted to the controller who is on the ground [2].
The different controller who instructed a charge controller just before one of a collision noticed the aggravation of the situation and was going to order a descent to rise, 958 flights for 907 flights, but misspeaked 907 flights with 957 flights on this occasion. A warning of the TCAS turned into "sinking speed increase" to need a swoop from "a descent" more by 958 flights and increased a sinking speed according to instructions. The captain of 907 flights found the danger of the collision in 958 flights before eyes and decided a swoop and, on the other hand, the captain of 958 flights felt the danger of the collision likewise, too and stopped a descent and rose. As for 907 flights, (there is the testimony of 10m, too) from the 958th flight high difference 20m to 60m was right just before a collision, but succeeded in the evasion by the swoop.
However, it caused 100 injured people in the process of the 907th flight a series of swoops. It was the extremely dangerous situation that the life of 677 people who boarded both passenger planes was threatened, and it might be an aircraft accident of the country, the world worst more than 520 victims of the Japan Airlines flight 123 crash in 583 victims of the テネリフェ Airport jumbo plane collision in 1977, 1985 when it collided.
The following complex factor was considered to be a cause [3].
- Mistake (human error) of the air traffic controller
- Misunderstanding of the flight number
- It having been necessary to evade it, and to direct the lapse of memory of the other party airplane and the emergency by the delay of the CNF (Conflict Alert, near miss warning) operation
- Attention having been suitable for the different plane where was unrelated to the accident
- There having been the communication with similar flight of the flight number just before that
- Having been busy with the adjustment with the adjacent sector and the explanation to a controller training
- A training supervision controller not having received appropriate training instruction
- It is lacking in a function of the radar data processing system
- Judgment error of the 907th flight captain
- TCAS and recognition of the risk that I operated reversely having been insufficient
- Correspondence training in conjunction with the TCAS not having been carried out
- Expression of the official regulations of the country not having been enough
- The seat belt wearing situation having been inappropriate
- Course setting [4] that mixed by Yokota air boundaries.
I it in the progress after the accident
| Supreme Court precedent | |
|---|---|
| Case name | Professional negligence resulting in injury defendant case |
| Case number | 20, Heisei (あ) 920 |
| It is October 26 (2010) for 2,010 years | |
| Casebook | 1,019 pages of collection of punishment Vol. 64 7 |
| The trial point | |
| Both planes continue descending together, and the B machine descends according to the descent instructions with the Traffic Alert and Collision Avoidance System at the same time as an A machine descends according to the instructions of the controller from about the same altitude, and what I did not correct immediately is an act to have the high risk to cause contact, the collision of both planes, and the causation between an error and the accident of instructions is recognized without a plane A machine and a B machine in way/ones/ remarkably approaching it over Gulf of Suruga of the Yaizu, Shizuoka offing, and a passenger recognizing the warning that on-the-job training air traffic controllers tell about both planes being near-missing in the case that got injured in the A machine which made nose dive to evade this, and misspeaking flight number while intending to let a B machine in way/ones/ descend, and a descent directing an A machine rising by mistake, and the air traffic controller who is the instruction director noticing this and air traffic controller both persons near-miss, and, as the thing that there was the fault that neglected on-the-job Sorgfaltspflicht to prevent the outbreak of the accidents such as contact, the collision of both planes to air traffic controller both persons in this matter facts that were able to foresee that I am forced to some kind of measures including the swoop because the captain of both planes evades contact, a collision, a professional negligence charge of inflicting bodily injury is established each. | |
| First Petty Bench | |
| The presiding judge | Mitsuharu Miyakawa |
| Associate judge | Ryuko Sakurai、Seishi Kanetsuki、Tomoyuki Yokota、Yu Shiraki |
| Opinion | |
| Major opinion | Mitsuharu Miyakawa、Seishi Kanetsuki、Tomoyuki Yokota、Yu Shiraki |
| Opinion | Mitsuharu Miyakawa |
| Dissenting opinion | Ryuko Sakurai |
| Reference articles | |
| Criminal law Article 211 preceding paragraph | |
After an accident, I revised the navigation rule, and reinforcement of the development of the system which the operation situation of the TCAS could display on radar screen on the control side and the education training of the controller was carried out. In addition, it was stipulated that I obeyed TCAS when the instructions of the controller and instructions of the TCAS contradicted it.
However, it was not able to be said that the aviation industry got an appropriate lesson from this near miss. Ministry of Land, Infrastructure and Transport was dull of the movement of the ICAO to prevent a similar accident in the International Civil Aviation Organization (ICAO) although I demanded an investigation. A passenger plane collided with a cargo plane, and, as for ICAO having accepted a survey by Ministry of Land, Infrastructure and Transport request, all the crew passengers of both planes were after they had the you Berlin gene midair collision accident that died as a result that instructions of the control contradicted TCAS in the same way over Germany one and a half years later [5].
A professional negligence charge of inflicting bodily injury and an aviation danger act sent documents about two controllers of the Ministry of Land, Infrastructure and Transport Tokyo Air Traffic Control Center and captain of 907 flights to Tokyo District Public Prosecutors Office on the charge of violation of punishment method (criminal negligence) on May 7, 2003. But the 907th flight captain denied the criminal liability that the law enforcement authority insisted on saying that I was not able to go against A.T.C. Therefore the Public Prosecutor's Office took non-prosecution action against the fault for suspicion insufficiency saying that I could not authorize it.
Two one air traffic controller were indicted without arrest in the professional negligence charge of inflicting bodily injury for 57 passengers who took out a report of damage on March 30, 2004. This accident was the first case [6], but it sentenced the Tokyo District Court (Presiding Judge Hisaharu Yasui) of the first trial to innocence that the criminal liability of the air traffic controller was called into question in near miss.
The Tokyo High Court canceled first trial judgment on April 11, 2008 and announced the conviction of stay of execution three years to two air traffic controllers for imprisonment one year six months from imprisonment one year [7].
The Supreme Court rejects a final appeal on October 26, 2010, and conviction is established by two air traffic controllers. Two air traffic controllers in this way fell out of employment. Because Ryuko Sakurai not being able to know the instructions contents of the TCAS by just one, a system at the time and the knowledge of the controller among five judges, the judgment of the 907 flights captain are the wrong judgments that lack of reporting of a country and the airline caused, the criminal liability investigation speaks dissenting opinion for the safe improvement of the whole system which descent instructions and causation with the near miss cannot ask the liability arising from negligence of the controller by the reason of not being admitted saying that it is not proper [1].
About a judgment of the Supreme Court, I criticize federation of association of international aviation service controller () (IFATCA) saying, "it is against establishment of the safe culture (Just Culture) that it is the premise of the aviation safety management system, and Japan approved of in the 37th ICAO assembly and is judgment to be safe, and to adversely affect it of the Japanese aviation." [8].
Footnote
- Defendant ^ a b c (PDF) most decision October 26, 2010 20, Heisei (あ) 920 professional negligence resulting in injury case (Report). It is . a court
- ^ "statement (PDF) (press release) that I deal with Japan Airlines 907 flights Supreme Court decision", all transportation labor unions, (October 29, 2010)
- ^ "aircraft accident working papers Japan Air Lines Co., Ltd. position JA8904" (PDF) (press release), Aircraft and Railway Accidents Investigation Commission, (July 12, 2002), p. 160
- ^ "wrestles for the return of the Yokota air boundary". US base measures of Tokyo. The Tokyo Governor main office. October 24, 2012 reading.
- ^ "report outline." ICAO. January 22, 2007 reading. [Broken link]
- I am found guilty for a trial saying that I let an air traffic controller gets a wrong instructions in the All Nippon Airways Komaki Airport collision that occurred in ^ 1960, and a passenger plane and a self-defense machine collide
- ^ [1] [broken link]
- ^ " Japan – Supreme Court Appeal Verdict – 7th November 2010 "(PDF) (press release), IFATCO, (November 4, 2010)
Allied item
- Human error
- Near miss
- Aircraft accident
- Midair collision arrester (TCAS)
- Traffic Alert and Collision Avoidance System (ACAS)
- You Berlin gene midair collision accident (one and a half years after this accident, it is the midair collision that took place by the instructions error of the controller and TCAS disregard on the バシキール side in the same way.)
- JAL dream express (as for the JA8904 machine which was the 907th flight machine parts of this accident, it was "SWEET" of JAL dream express 21 approximately three months later)
Outside link
- Director at airline comment (Ministry of Land, Infrastructure and Transport) (Archive) about the document sending to affect Japan Airlines flight 907 accident
- It is (Archive) about director at airline comment about the civil mediation establishment to affect Japan Airlines flight 907 accident (Ministry of Land, Infrastructure and Transport)
- About a JL907 service accident (Japan Airlines)
- All transportation labor unions
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