Case Study on "Crash of Japan Airlines Flight 123"

Case Study 7 pages (2193 words) Sources: 15

[EXCERPT] . . . .

Crash of Japan Airlines Flight 123

THE WORLD'S WORST SINGLE-PLANE DISASTER

Crash of Japan Airlines Flight # 123

Few can forget the disaster. Japan Airlines Flight 123, a Boeing 747, on its way to Tokyo to Osaka on August 12, 1985, crashed into a forested mountainside (BBC, 2008;

BBC, 2005). Only four of the 520 on board survived. The disaster was attributed to faulty repairs by Boeing, which the airline failed to detect. A series of safety lapses followed the incident (AAIC, 2002). Japan Airlines vowed to firmly maintain safety as its social responsibility (BBC, BBC). This disaster and others before it call for more responsive prevention measures.

On August 12, 1985, Japan Airlines Flight 123 took off from Tokyo International Airport in Haneda bound for Osaka International Airport in Itami (AAIC, 1985; Aviation Safety Network, 2009; NTSB, 2012; JAL, 1985; Kilroy, 2008). The Boeing 747-146SR was 12 minutes into the flight when it crashed into Mount Takamagahara in Ueno, Gunma Prefecture, which is 100 kilometers from Tokyo. The precise crash site was at Osutaka Ridge near Mount Osutaka. All of its 15 crew and 505 out of 509 passengers perished with only four survivors. It is considered the worst single-aircraft disaster in history. In terms of fatalities, it ranks second only to the Tenerife Disaster (AAIC, Aviation Safety Network, NTSB, JAL, and Kilroy).

The aircraft was registered as JA8119 (Article Trend, 2008; Seeman, 1985; Rebok et al., 2009; Magunson, 2005). Most of the passengers were headed for the Obon holiday in Japan when many Japanese conduct yearly visits to their hometowns or resorts. Roughly 12 minutes from takeoff, the rear pressure bulkhead failed. The explosive decompression detached the vertical stabilizer and cut away the aircraft's four hydraulic systems. Loss of cabin pressure at that high altitude resulted in a lack of oxygen throughout the cabin. The aircraft fell uncontrollably into the mountains, hit a mountain ridge and another before swiftly plunging and landing on its back (Article Trend, Seeman, Rebok et al., and Magunson).

The Aircraft Accidents Investigation Commission (1985; Aviation Safety Network, 2009; NTSB, 2012; JAL, 1985; Kilroy, 2008; Article Trend, 2008; Seeman, 1985; Rebok et al., 2009; Magnuson, 2005) identified the official causes. These were the damaged rear pressure bulkhead, the defective repair of the bulkhead, and the rupture of all four hydraulic systems. The disaster drew an intense blow to the airline company. It paid $780 million to the relatives of the victims and led to the resignation of the president, Yasumoto Takagi. Its volume of patrons decreased by 25% the following year (AAIC, Aviation Safety Network, NTSB, JAL, Kilroy, Article Trend, Seeman, Rebok et al. And Magnuson).

James Reason proposes the "Swiss Cheese" Model of Human Error under the Human Factors Analysis and Classification Systems (Shappell & Wiegmann, 2000) in interpreting the basis for the causes of air disasters. The SHELL Model offers additional prevention measures (Aviation HF 2010).

III. Methodology

The study used the descriptive-normative method of research in recording, describing, interpreting, analyzing and comparing data from authoritative and mostly updated sources.

IV. Results

While the aircraft plunged, the pilots sent a distress signal to the Tokyo Area Control Center for heading vectors for emergency landing (AAIC, 1985; Aviation Safety Network, 2009; NTSB, 2012; JAL, 1985; Kilroy, 2008; Article Trend, 2008; Seeman, 1985; Rebok et al., 2009; Magnuson, 2005). Their request for vectors was hindered by control problems. Totally losing hydraulic control and control surfaces, the aircraft oscillated, descended uncontrollably and rapidly plunged at more than 5,000 feet. It took 32 minutes from the bulkhead explosion to the final crash. In addition to the official causes of the accident, rescue operation was delayed. Japanese officials rejected the offer by American forces to guide Japanese forces to the crash site immediately. The Japanese officials, instead, ordered the American forces to stay away from the site and go back to the Yokota Air Base. The Japanese forces said the Japan Self-Defense Forces would tackle the disaster alone. The JSDF reported not seeing any signs of survivors and, thus, did not proceed to the crash site at once. Instead, they spent the night at a makeshift village. Injuries on passengers' bodies later on showed that some of them died from overnight exposure in the mountains without rescue (AAIC, Aviation Safety Network, NTSB, JAL, Kilroy, Article Trend, Seeman, Rebok et al., Magnuson). On June 26, 2002, a Boeing 767-200 belonging to All Nippon Airways and registered as JA8254 (AAIC, 2002) also incurred an accident. It went off into a grass field from the runway and stopped there (AAIC).

V. Discussion

More than two months before the incident, Flight 123's rear pressure bulkhead was damaged at the Osaka International Airport (AAIC, 1985; Aviation Safety Network, 2009; NTSB, 2012; JAL, 1985; Kilroy, 2008; Article Trend, 2008; Seeman, 1985; Rebok et al. 2009; and Magnuson, 2005). The company tried to repair the damage but did not conform to Boeing's approved methods. The FAA would later say that the repair applied reduced the aircraft's resistance to "metal fatigue" by 70%. The incorrect installation would give way after roughly 10,000 pressurizations. Between this repair job and the final crash, the aircraft made 12,318 takeoffs. And when the bulkhead malfunctioned during the disaster, the explosive decompression ripped the four hydraulic systems. The controls went awry and the aircraft plunged. Moreover, the delayed rescue action could have saved lives if Japanese officials allowed American forces to immediately go to the crash site. A study on this disaster and another revealed the significant cultural differences between Japan and the United States in communication practices (Haruta & Hallahan, 2000). The two countries significantly differed in the use of apology, media strategies, and litigation matters (Haruta & Hallahan).

Public confidence in Japan Airlines' performance was severely eroded by the incident (Magnuson, 2005; AAIC, 1985; Rebok et al., 2009). Domestic patronage was said to have dropped by one-third. Boeing was also said to have admitted to the fault in an attempt at covering up for the airline's faulty inspection procedures. It was a further attempt at protecting the reputation of JAL. For the first time in a decade the following year, fewer passengers patronized JAL's overseas flights during the New Years than before. Some shifted to All Nippon Airways as a safer alternative, although it was the subject of another accident investigation (AAIC, 2002). Japan was reported to have paid out "condolence money" in the amount of $780 million to the relatives of the victims. Not only did its president Yasumoto Takagi resign. A maintenance manager at the Haneda Company took his own life as a way of apologizing for the hundreds of deaths (Magnuson, Rebok et al., AAIC).

Human error accounts for 70-80% of all civil and military aviation accidents (Shappell & Wiegmann, 2000). Despite this, there is no recognized theoretical framework of analysis of human error in this field. This has led to voluminous intervention strategies that miss the mark. The Human Factors Analysis and Classification System was designed for military, commercial and general aviation. It systematically investigates and analyzes human causal factors. One workable approach, suggested by James Reason, is the "Swiss Cheese" Model of Human Error. He enumerates and describes four levels of human failure as unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences. Each level affects the succeeding one. Unsafe acts are either errors or violations. Errors are inherent, while violations are a willful disregard for established rules. Errors are skill-based, decision or perceptual. Violations, on the other hand, are either routine or exceptional. Unsafe acts are basically preconditioned or built into already existing conditions. These conditions are substandard conditions of operators and their substandard practices. Substandard conditions of operators are mainly adverse mental and physiological states and physical or mental limitations. Substandard practices are crew resource mismanagement and personal readiness. Unsafe supervision consists of inadequate supervision, planned but inappropriate operations, failure to correct a known problem and supervisory violations. Organizational influences that affect human error are resource management, organizational climate and organizational process. The development of an HFACS framework has proved to be a valuable first step in the civil and military aviation as a safety program (Shappell & Wiegmann).

The SHELL Model provides a way to understand human factors in aircraft maintenance (Aviation HF, 2010). It is the foundation of the human factors theory. SHELL stands for software, hardware, the environment, liveware as other people and liveware as oneself. It can be used as a practical tool in everyday setting by creating awareness, educating the mechanic, keeping the work environment safe, dealing with stress appropriately, and extending support and encouragement to workers (Aviation HF).

VI Conclusion

The sore details and consequences of the Japan Airline Flight 123 crash raise the question on how many people should be loaded in a single aircraft (Magnuson, 2005; Reebok et al., 2009; Seeman, 1985; Article Trend, 2008; Kilroy, 2008; JAL, 1985; NTSB, 2012; Aviation Safety Network, 2009; AAIC, 1985; AAIC, 2002; BBC, 2008; and BBC, 2002). Despite assurances of plane safety or economic… READ MORE

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