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B747/DC10, Japan Airlines, Suruga Bay Japan, 2001 (Legal Process - Air Traffic Controller)

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Category: Human Error
in Aviation
and Legal Process
Human Error in Aviation and Legal Process
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The Event

Date:31 January 2001

Location: over the Suruga Bay near Yaizu-city, Shizuoka Prefecture

Summary:

Japan Airlines Flight907 was a Boeing 747 with 411 passengers and 16 crew making a domestic flight from Tokyo Haneda International Airport to Naha Airport. Japan Airlines Flight958 was a McDonnell Douglas DC-10-40 with 237 passengers and 13 crew bound from Pusan International Airport to Narita International Airport.

JAL907 had left Haneda at 3:36 PM. JAL907 and JAL958 came to near-collision at 3:55 PM.

JAL907 climbed to 39,000 feet. JAL958 cruised at 37,000ft. Both flights were on an intersecting course near the Yaizu NDB.

The controller noticed confliction alert between them, but instead of ordering JAL958 to descend, he ordered the JAL907 to descend.

Immediately after this instruction, the crew of JAL907 was given an aural TCAS Resolution Advisory to climb in order to avoid a collision, but the captain of JAL907 followed the instructions of the air traffic controller by descending. Both airplanes remained on a collision course, because JAL958 had started to descend as well, following the advisory of his TCAS. Both airplanes were visually recognized by each other. Just before crossing each other’s flight path, the pilot of JAL907 abruptly forced the aircraft to dive based on a visual judgment. A collision was averted when 100 crew and passengers on JAL907 sustained injuries due to the emergency maneuver, while no one was injured on JAL958.

JAL958 continued to Narita, while JAL907 returned to Haneda Airport, and landed at 4:44 PM.


The Non-Judicial Investigations

Carried out by:

The (at that time) Aircraft and Railway Accident Investigation Commission (now the Japan Transport Safety Board)


The Findings:

The Aircraft and Railway Accident Investigation Commission concluded that the air traffic control's error in giving instructions to the wrong flight and the pilot’s decision to follow air traffic control instructions instead of the TCAS Resolution Advisory (RA) were the two main causes.


Action by the Regulator:

Controller (OJT supervisor): Salary cut by 10 percent

Controller (trainee): Reprimand

Chief Controller: Reprimand

The Criminal Prosecution

Persons prosecuted: The two controllers (OJT supervisor and trainee)

The first court: Tokyo district court

The Charges: Professional negligence resulting in injury

The Plea: Not guilty

Prosecutors Sentencing Request:

Controller (OJT supervisor): One year and six months imprisonment Controller (trainee): one year imprisonment

The verdict: Not Guilty

(Prosecutor appeal lodged: 31 March 2006)

The second court: Tokyo high court

The verdict: Guilty

The sentence:

Controller (OJT supervisor): One year and six months imprisonment suspended for three years. Controller (trainee): one year imprisonment suspended for three years.

(The accused appeal lodged to the Supreme Court: 14 April 2008)

The third court: The Supreme Court

No response

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