In the past few days, I have analyzed the external factors of some incidents, and today I will talk about what link may have gone wrong and the cause of the air crash?
The discussion here is only to find out the links that may be problematic and to remind everyone that they can be used to prevent similar accidents from happening in the future.
In the land-air call report, it was shown that the controller did not give the Chong-8 plane instructions to enter the runway, which means that the Chong-8 plane broke into the runway where the plane landed without obtaining the runway entry instructions, which is the most likely cause of the accident.
But Japanese media reports said that Captain Okinohachi believed he had received orders to enter the runway.
So where could this have gone wrong?
1 The tower says No 1 Will it cause the Chong-8 aircraft to mistakenly think that it can enter the runway?
During the land-air call, the tower controller told the Chong-8 aircraft, "First, taxi to the C5 waiting point and wait." ”
Is this statement misleading?
In fact, No 1 is very common in airline ground and air calls, and it is used in 3 places in the above short call, such as JAL179 No 3, JAL166 No 2.
For the first few are sorted, it is difficult for the pilot to confuse the command with the command of entering the runway.
The first one is usually used to sequence the aircraft in the same operation, such as taxiing encounter, waiting for takeoff, sequential landing, etc., in this short call, the controller used the sequencing No for the two aircraft queuing up to take off and the one approaching and landing.
Therefore, it is a bit far-fetched to simply think that the Chong-8 plane just heard No 1 and misunderstood it as entering the runway.
After all, instructions are instructions, and sorting is ordering.
2 Links that are more likely to go wrong
1) Answer: It is not the same person who is waiting outside the runway and actually operating the aircraft
We know that whether it is the Airbus 350 that landed or the Chong-8 plane that is about to take off, it is a two-person crew.
The two-person or multi-person unit has obvious advantages, and the two-person unit or the multi-person unit usually has a clear division of labor and strict standard procedures for each member. In this way, the maximum workload of each person is small, and they complement each other, which greatly enhances aviation safety.
But there is also a certain risk, and this is the question of the effectiveness of communication and exchange.
In the case of this flight, usually in a two-person crew, one person is responsible for monitoring the flight - we call it PM, and one person is responsible for steering the aircraft - we call it a PF, which means that the person who is responsible for talking to the controller and the person who is actually operating the aircraft are not the same person.
2) Whether the pilot operating the aircraft correctly understands the controller's instructions
In practice, both the PF and PM are listening to the controller at the same time in the cockpit, and the PM will only repeat the controller's instructions to the controller after the PF confirms the instructions when the controller gives the command.
In Japan, there are two ways for PF to confirm a call: one is for PF to give the PM a thumbs up with a gesture to indicate that the PM can repeat the instructions after receiving the controller's instructions.
On the other hand, when it is not convenient to use gestures, simply answer Roger (understood), and the PM can also repeat the command.
This is where the question arises as to whether the PF really understands or understands the directives correctly.
The picture below is from the Flight Instructor's Handbook of Flying Circles
Suggestion: Normally, after the PM has recited the command, the PF (or PM) should re-express the action to be performed in the language that the two parties normally communicate. For example, in this flight, it is waiting outside the runway or entering the runway.
If there is such a link, it can effectively avoid the possibility of PF (or PM) misinterpreting the instruction.
Although for the Chong-8 aircraft, entering the runway and waiting outside the runway are two completely different common commands, and pilots will encounter them almost every time they take off, even if the PF and PM hear the command to wait outside the runway at the same time, whether the PF mistakenly understands and remembers that "you can enter the runway" is subject to further investigation by the official investigation.
The picture below is from the Flight Instructor's Handbook of Flying Circles
3) The language used in the cockpit
When operating civil airports in Japan, including national aircraft such as emergency aircraft, it is generally stipulated that English is used for air and land calls. In the cockpit, if you are Japanese, you can use Japanese or English, and many countries have similar regulations.
Communicating in your native language increases the effectiveness of your communication.
In the process of language switching, there is often the possibility of misunderstanding, because after all, the conversation is not the native language.
4) Effective supervision by PM
When a two-person or multi-person unit is running, the main responsibility of the PM is not only responsible for auxiliary work such as land-air communication and execution of checklists, but also an important responsibility is to monitor the operation of the PF. When the PF's actions are inconsistent with the instructions or expectations, the PF will be reminded in time, and even the PF can be directly replaced to control the aircraft.
Therefore, assuming that the PM of the Chong-8 aircraft recites and understands the controller's instructions, then if the PF mistakenly executes the action of entering the runway, the PM should raise an objection and even directly use the brakes to stop the aircraft.
However, regardless of China, South Korea, or Japan, under the influence of oriental culture, cockpit culture is not perfectly integrated with the concept of cockpit design.
There is also a possibility that the PM did not warn and prevent the PF from entering the runway, whether the PM also misunderstood, or did they receive instructions from other aircraft to enter the runway? Misunderstood that it was the controller who gave them the instructions, and these are pending official investigation.
5) Cockpit gradient
In the cockpit, there is a proper gradient for effective decision-making in the cockpit, but too large a gradient can have a great negative impact, especially in East Asia.
A typical scenario is when a very junior co-pilot is flying with a very senior, or even a very high-ranking pilot.
In such a cockpit environment, even if a junior pilot finds that the other party has a wrong understanding or wrong action, he will hardly dare or will not easily make suggestions to the pilot with higher qualifications and positions, let alone take over the control.
Only a few of them dare to whisper different opinions and suggestions after a long period of ideological struggle, repeatedly reviewing whether they have misunderstood, lack experience, and whether they have other operational requirements.
A lot will be silent.
There are many, many examples of such accidents.
The investigation into the accident at Tokyo Airport is ongoing, and the questions raised today are just an analysis of some of the possible aspects of the accident and the possible threats that will help us prevent errors and manage risks in our own operations.
We need to wait for the analysis of the official Japanese investigative report on which part of the accident went wrong and caused the collision.
Once again, I regret the loss of life!
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