Precious Lives (Expanded Version)

Japan Airlines Safety Promotion Center compels reflection on solemn responsibilities of aviation professionals.
 

By Wayne Rosenkrans | From Tokyo
AeroSafety World, November 2009

More than 74,000 visitors have toured the Japan Airlines (JAL) Safety Promotion Center since its opening in April 2006. The proportion from outside the company exceeds 40 percent, says Yutaka Kanasaki, director of the museum-like facility near Tokyo International Airport, Haneda. Many are fascinated by the concept, especially the reasoning behind JAL’s decision to prominently recount the story known throughout Japan as the “Osutaka Mountain accident.” On an east-west ridge of this mountain 24 years ago, this crash of a Boeing 747SR-100 resulted in more loss of life than in any single-airliner accident in history.¹

The center is designed, foremost, to provide safety awareness and education for the airline’s employees, Kanasaki said during a November tour for ASW. “Today, 90 percent of our total number of employees — about 50,000 — have never experienced an accident,” Kanasaki said. “People entering our company only know Flight 123 from the viewpoint of history. After visiting our Safety Promotion Center, however, they understand an accident as a real thing. Every visitor, including the JAL employee, studies here what safety is.”

The experience for employees involves historical and technical education, contemplation of aircraft wreckage and personal effects, and examination of their personal role within the airline’s efforts to reduce accident risk.

“Our center has three missions,” Kanasaki said. “The first one is to stop the fading out of the memory of the sadness of the aircraft accidents that Japan Airlines experienced in the old days. We are very sorry but Japan Airlines has experienced eight fatal accidents since the foundation of the JAL Group. The last was Flight 123 in 1985. In each accident, many passengers and crew lost their precious lives. The second mission is to inspire JAL employees to establish safety in their minds. The third is to transfer the lessons learned from these accidents to the next generation of people in the JAL Group.”²

The center aims to tell the story of Flight 123 without distortion, Kanasaki said. Visiting journalists’ questions tend to focus on JAL’s public relations agenda more than any other subject, however. “The real accident must be shown to the public — that is very important,” he said. “There are no other intentions. We instruct visitors based on the 1987 aircraft accident investigation report issued by the Aircraft Accident Investigation Commission of the Ministry of Transport of Japan. I believe it is the most neutral report to show what happened.”

Although some visitors ask how Japanese culture influences the center, Kanasaki only mentions a common experience of aviation professionals worldwide: Safety is invisible in everyday tasks but its absence instantly becomes visible — what he calls “the solid shape of unsafety” — when people personally encounter wreckage and other artifacts of a crash such as Flight 123. Visitors from airlines of other countries have called the center a valuable educational tool, he said. Although exhibits of aircraft wreckage are used elsewhere in training accident investigators, he said he was unsure about their application to safety awareness and training at other airlines.

In January 2007, All Nippon Airways (ANA) opened the ANA Safety Education Center in Tokyo for ANA Group employees. Megumi Tezuka, an ANA public relations representative, told ASW that its basic educational purpose is for employees “to know and learn about aircraft accidents that occurred in the past … to learn and experience how a ‘human error’ can be made by anyone, and how these accidents are something that can happen again.” The facility is open to the public except during hours of use by the company.

Before the JAL Safety Promotion Center was built, the accident airplane’s aft pressure bulkhead, digital flight data recorder (DFDR) and cockpit voice recorder (CVR) were used as visual aids only in JAL safety awareness courses for maintenance technicians. “Other wreckage — for example, the vertical stabilizer and fuselage — was packed and stored in a parts warehouse,” Kanasaki said.

Hideaki Miyachi, a Boeing 747-400 captain and director of the Planning Group, JAL Corporate Safety and Security, said that when new JAL employees arrive, most think they are fully knowledgeable about Flight 123 as a national disaster. “Almost all of the public has been informed through the mass media,” Kanasaki adds.

Unlike in some major accidents, everyone concerned quickly became aware of the emerging consensus about the most likely causes. “Three weeks after the accident, Boeing informed us that an improper repair had been done for tail strike damage that occurred in June 1978,” Miyachi said. “So everybody knew soon that the aft pressure bulkhead had been damaged and — due to the Dutch rolling and uncontrollable condition — that most of the tail had separated in flight and sunk in Sagami Bay. Boeing reacted very quickly and expressed that their inefficient repair was the major reason.”³

Three factors influenced JAL to create the Safety Promotion Center. From December 2004 to December 2005, several errors during flight operations prompted the Civil Aviation Bureau in Japan’s Ministry of Land, Infrastructure, Transport and Tourism to issue a business improvement order.

“The March 2005 order from the government directed JAL to improve the company’s attitude toward safety,” Kanasaki said. “We established the Safety Advisory Group outside of our company. The group then gave us a proposal at the end of 2005 requesting that JAL exhibit the wreckage of Flight 123 for safety awareness education of JAL employees.”

Another factor was that some bereaved families of Flight 123 many years earlier had requested that JAL exhibit the wreckage for basically the same purpose. Third, the personal sentiments of JAL Group’s former CEO Toshiyuki Shinmachi came into play. He favored permanently exhibiting the wreckage “to remind the JAL employee about the safety mindset.” He also understood that corrective actions for one safety defect at a time would not be sufficient without a strong and pervasive safety culture, Kanasaki said.

Inside JAL, the business improvement order and the independent perspectives of the Safety Advisory Group prompted a critical self-analysis. “What we had been doing, beginning from the Flight 123 accident, was not enough,” Miyachi said. “We took the external criticism more deeply, and we tried to identify what we could do better. As a result, the Safety Promotion Center was built and another big division of safety was added.”

Attendance Required
 

External advice and comments from general visitors, those from outside the JAL Group, influenced a related company policy. Regardless of job title, new employees are required to take the tour as part of the center’s safety awareness course. “Almost all general visitors said that the JAL employee must never forget the pain of the victims and the sadness of the bereaved families,” Kanasaki said. “These are very heavy words to the JAL employee, and we must keep these words forever to keep flight safety, I believe. Awareness of the same feelings as the bereaved family or the victim is the first step to understand safety.”

So far, about 70 percent of JAL employees — including nearly all pilots, maintenance technicians and flight attendants — have taken the course. “Basically, the course gives the same tour to every type of employee,” Kanasaki said. “Minor parts may be different — a maintenance technician or a pilot will know very well the systems of the aircraft, so we skip the parts regarding the systems.”

Some long-time employees also have visited the center in conjunction with evacuation training and ditching training for pilots and cabin crews, Miyachi said. “For example, every single pilot and every single cabin crewmember visited this center in 2008,” he said. “After employees visit the center, their minds may change a lot. They believe they are doing a very important thing working for the company.” Personnel in Safety and Security also use the center for initial and annual refresher training on Flight 123.

One new employee, a maintenance technician, left a comment saying that before his visit, he believed that his job was to “maintain the machine.” “After the visit, he said he understood that his job is not only the maintenance of a machine but also to keep the safety of passengers’ lives — a very big change in his emotion, I believe,” Kanasaki said.⁴

Tour Highlights
 

Operated by Corporate Safety and Security, the center occupies part of the second floor of a mid-rise office building in the Haneda Maintenance Area. Tours begin in the Library Room, containing the official accident report in Japanese and its English translation; historical and technical books about air transport safety and human factors; and documents, reports and nonfiction books associated with Flight 123.

Along one wall, panels summarize 10 major accidents that have occurred worldwide since airlines began operating turbine-engine airplanes. The adjacent panel chronologically shows the JAL accidents alongside 38 other fatal accidents involving large commercial jets. Other panels summarize the airline’s seven fatal accidents before Flight 123, including the probable cause of each and safety actions taken. Computer workstations enable visitors to replay the center’s videos or access digital reference material in English and Japanese.

“This center has not specialized only on Flight 123,” Kanasaki said. “We exhibit information about other airlines’ accidents in the history of aviation since 1950. They are part of the common knowledge of airmen, and provide a balanced look at experience of our company and airlines all over the world.” The Display Room is the largest area. Its centerpiece is both halves of the recovered aft pressure bulkhead. They are mounted horizontally for close inspection because of the bulkhead’s critical role in the accident. Surrounding panels explain the causes of the accident and measures taken to prevent a recurrence. Other major exhibits of the Display Room include a scale model of the airplane in JAL livery of the time, the vertical stabilizer root section, the vertical stabilizer upper section, the lower rudder’s upper section, sections of the aft fuselage, and four damaged passenger seats.

The introductory wall in the Display Room presents a multi-panel summary of the Flight 123 accident, showing the estimated flight path overlaid with excerpts transcribed from the CVR; a graph of selected data from the 74-parameter DFDR validating the sequence of events; a diagram of areas of the aft fuselage and tail that separated during flight; diagrams of aircraft parts, which have hand-painted numbers, coded to indicate the sites where they were recovered and the parts never recovered; and a cabin layout showing which seats were occupied by the crewmembers and passengers killed, and those occupied by passengers who survived.

The tour begins at a panel on which a white line shows the estimated flight path of Flight 123, a normal departure and climb to Flight Level 240 (approximately 24,000 ft) from Haneda, then a descent to Flight Level 220 and an erratic 32 minutes of uncontrollable flight from soon after the aft pressure bulkhead ruptured to the crash site. Notations indicate key events in the accident sequence and the aircraft position in relation to key geographic features and relevant airports.

“On the day following the accident, part of the vertical stabilizer was recovered from Sagami Bay,” a video narration says. “The subsequent search activities recovered 53 pieces of wreckage from the sea, including part of the lower rudder and the air duct of the auxiliary power unit. Part of the vertical stabilizer was also recovered under the flight path of Flight 123.”

The main point of this reassembly and display of specific pieces of wreckage is to show how they contributed to understanding what happened. “The root section of the vertical stabilizer leading edge connected the tail section with the fuselage, for example,” Kanasaki said. “Parts of the vertical stabilizer leading edge, no. 5 to no. 11, were found and retrieved from the crash site. Pieces numbered 13, 14, 15 and 16 are parts of the vertical stabilizer; no. 13 was found and retrieved from the mountainous area in the Tokyo suburbs. Numbers 14, 15 and 16 were found and retrieved from the crash site. The no. 17 wreckage, the upper section of the lower rudder, was retrieved from Sagami Bay.”

The DFDR-derived graph of aircraft altitude, airspeed, longitudinal acceleration and roll attitude data — along with video narration and a flight crew–air traffic control (ATC) voice re-enactment — give visitors a minute-by-minute sense of what the flight crew experienced while attempting to maintain stable flight, turn, descend and communicate with ATC. “The longitudinal acceleration data continue normally until the data skips, meaning that some impact force was applied in the forward direction,” Kanasaki said.

A video associates this impact force with rupture of the aft pressure bulkhead and air pressure from the cabin destroying the empennage, including the vertical stabilizer and the fuselage tail section. Fifty-five percent of the vertical stabilizer was lost, and the four hydraulic lines — which supplied hydraulic pressure to an actuator for the upper and lower rudders — were severed causing total loss of fluid.

“From this time, all other data show the abnormal situation,” Kanasaki said. “The pitch instability — phugoid motion — and the roll attitude data also showed the [Dutch roll] oscillation from this time, a combination of yawing and rolling.”

A profile diagram marks in amber color which airplane parts had separated during flight. “The fuselage forward of the aft pressure bulkhead was well designed to withstand pressure from the inside,” Kanasaki said. “The fuselage aft of the aft pressure bulkhead was strong enough for the bending and aerodynamic loads applied during normal flight. But this part of the fuselage, including the vertical stabilizer, was not strong enough to withstand the internal pressure when the aft pressure bulkhead ruptured and the air pressure blew into the tail section of the fuselage and the vertical stabilizer through the inspection access hole for maintenance technicians located in the center of the vertical stabilizer.”

On the tour, the exhibit of the upper and lower halves of the aft pressure bulkhead, combined with a video and scale models of repairs conducted after the 1978 tail strike, explain how the instantaneous failure along the joint caused cabin air to open a hole of about 2 to 3 sq m (22 to 32 sq ft) in the bulkhead.

A three-dimensional terrain model depicts three points of impact — the airplane struck a single larch tree, made a U-shaped gouge in a ridge line, then descended at 340 kt into a remote forest of larch trees 1,565 m (5,135 ft) above sea level about 2.5 km (1.4 nm) north-northwest of Mount Mikuni at the boundary of Gunma, Nagano and Saitama Prefectures.

Splice Plate Lesson
 

Explaining this catastrophic failure of the aft pressure bulkhead, Kanasaki said that the splice plate repair — as designed by the Boeing aircraft-on-ground team and approved by JAL and aviation authorities — would have provided a continuous load path except for changes during installation that did not conform to the approved design.⁵

“The stress between the upper and lower halves of the bulkhead was concentrated in the center row of the three rows of rivets,” he said. “An excessive load was applied in the center row and made a small crack around the rivet holes. Due to the repeated application of cabin pressurization during every takeoff and landing, the crack propagated little by little, and seven years later — at the 12,319th flight after the repair — the aft pressure bulkhead ruptured from this repaired area.” A tail compartment pressure-relief vent door functioned as designed “but was too small to relieve the high pressure from the big hole in the aft pressure bulkhead,” he added.

Displays positioned around the bulkhead halves highlight the complex corrective and proactive measures implemented.⁶ International and government-mandated measures focused on enhancement of maintenance programs, aircraft modification and organizational reinforcement for safety enhancement. The earliest came three days after the accident, when JAL “undertook a comprehensive inspection of the vertical stabilizer and rudder of all of its 747 aircraft as an emergency action,” the video narration says.

For example, Boeing design modifications for newly manufactured 747s included the use of reinforced pressure bulkheads and changes to routing of hydraulic lines. Modifications suitable for retrofit included adding a cover plate for the maintenance inspection access hole inside the vertical stabilizer and adding a hydraulic fuse to prevent fluid loss from one line if downstream plumbing ever were damaged. The U.S. Federal Aviation Administration’s Lessons Learned Library lessonslearned.faa.gov/ also has an analysis of international improvements prompted by JAL Flight 123 among 40 worldwide accidents selected for safety education.

After viewing Japanese and English-language newspaper accounts from 1985, and JAL internal magazines from that time, visitors learn that within months after the accident, many of the affected families formed the 8.12 Liaison Association to help each other and communicate. The association issued a publication called Osutaka. Copies are preserved on two display stands.

One corner of the Display Room has glass showcases containing keys, pens, eyeglasses, wristwatches and small debris, and panels showing five final handwritten messages. “Japan Airlines keeps about 2,700 personal items that remained but whose ownership we could not identify,” Kanasaki said. “We selected 17 of these items to show how big the impact of the crash was. The five watches show the correct time of the impact, they stopped at 1856.

“Debris was collected by one member of a bereaved family who picked up items every time he visited Osutaka Mountain. They have been donated by him. Three panels have the actual last messages written by five passengers. One is written on a timetable of Japan Airlines. A sixth message is a memo written by one of the cabin attendants. She expected an emergency landing and wrote the content of the emergency announcement on her notebook.”

Emotional Evolution
 

JAL has been open to suggestions about the center and further refinements. During its first two years, for example, each tour concluded at the personal effects area but some visitors left comments asking for reconsideration of the emotional impact of this order of presentation. “Some employees said they may lose their sense of confidence for their job,” Kanasaki recalled.

In January 2008, the company’s response was to add Display Room 2. “The newer exhibits show how close monitoring of aircraft has succeeded in limiting further damage or loss of lives,” Kanasaki said. “One display is a list of four accidents in which every safety factor worked well due to the best effort by the people involved. The other display is a chronological table that shows the relationship between these accidents and related technical improvements.” The improvements are broken down and graphically linked to subjects such as aircraft structure, warning systems and fire mitigation.

Policy updates on recurrent training at JAL recently have directed employees to participate at their earliest opportunity in the center’s updated two-day safety promotion course, which includes a day trip to historically important sites outside Tokyo that are associated with the Flight 123 accident.⁷

Notes
 

1. JAL Flight 123 crashed at approximately 1856 local time Aug. 12, 1985, among the mountains of Ueno Village, Tano County, Gunma Prefecture, during a scheduled passenger flight from Tokyo International Airport, Haneda, to Itami International Airport, Osaka, Japan. A total of 505 passengers and 15 crewmembers were killed in the accident, and four passengers received serious injuries. The aircraft was destroyed, and a fire occurred at the crash site.

2. On the tour for ASW, Kanasaki did not mention his own memories of the night of the accident or the following day. He was then a junior-level aircraft maintenance technician suddenly called back to work at his maintenance section at Haneda where Flight 123 was expected to return after a sudden decompression, possibly caused by a door opening, Miyachi said. Kanasaki soon was advised that the flight crew had reported their aircraft was “uncontrollable.” Next, he heard a television news announcer tell viewers that a JAL 747 was missing in the mountains of Gunma Prefecture. Confirmation of the crash followed, and Kanasaki gathered heavy jackets, boots, gloves and other equipment for a first-response team. When JAL leaders learned the next day from the Japan Self-Defense Forces that debris floating in Sagami Bay was drifting to the shore of Yokohama, Kanasaki was dispatched to the location, where he sketched the recovered parts and faxed his drawings to company specialists, enabling accident investigators to identify some of those missing from the crash site.

3. The English translation of the final report of the Aircraft Accident Investigation Commission of Japan’s Ministry of Transport, released June 19, 1987, contains the following statement of cause: “It is estimated that this accident was caused by the deterioration of flying quality and loss of primary flight control functions due to rupture of the aft pressure bulkhead of the aircraft, and the subsequent ruptures of a part of the fuselage tail, vertical fin and [hydraulic] flight control systems. The reason why the aft pressure bulkhead was ruptured in flight is estimated to be that the strength of the said bulkhead was reduced due to fatigue cracks propagating at the spliced portion of the bulkhead’s webs to the extent that it became unable to endure the cabin pressure in flight at that time. The initiation and propagation of the fatigue cracks were attributable to the improper repairs of the said bulkhead conducted in 1978, and it is estimated that the fatigue cracks having not [been] found in the later maintenance inspection is [contributory] to their propagation leading to the rupture of the said bulkhead.”

4. Two other new employees of JAL Group left comments saying, “The most important meaning [was] to find that our job has strong linkage with the passenger’s life,” and “I will visit … again whenever I forget a mission of my job.”

5. The repairs were conducted by a 40-member team of Boeing engineers, inspectors and other members, from June 17 to July 11, 1978. JAL conducted an acceptance inspection of these structural repairs in accordance with the company standard, the official accident report said. The inspection comprised verification that each repair item had been accomplished as contracted, attendance at system function tests, confirmation of post-repair functional performance by test flight and a check of work records submitted by Boeing. Test flights were conducted by JAL and were attended by airworthiness engineers from the Japan Civil Aviation Bureau (JCAB). JCAB representatives inspected the repair plan, the process of repair by Boeing based on work records and the post-repair aircraft condition.

6. The accident report said that by 1987, the following safety improvements had been identified, begun or completed: empennage design changes so that 747 and 767 aircraft would have protection against catastrophic failure if a significant pressure buildup occurs in the normally unpressurized empennage; protection of the integrity of all four hydraulic systems under this condition; re-evaluation of the fail-safe validity of aft pressure bulkhead designs on transport category airplanes; evaluation of aft pressure bulkhead repair procedures; revision of visual inspection programs for the aft pressure bulkhead to add other methods to detect the extent of possible multiple-site fatigue cracking; and bulletins to increase awareness of people responsible for engineering approval of repairs about potentially catastrophic consequences of concealed and undetected human errors.

7. Sites include the Ueno Village Memorial Park, which contains an interment vault, engraved names of passengers and crewmembers killed, and a another monument sculpted to represent hands pressed together in prayer; the Osutaka Mountain trail, marked with a plaque containing excerpts from commemorative remarks by former U.S. National Transportation Safety Board Chairman James E. Burnett Jr.; the Flight 123 monument at the crash site; and a prayer bell.

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