AvTalk Episode 249: Japan Airlines flight 516

AVT 249 Transcript
EPISODE 249
[EPISODE]
[0:00:07] IP: Hello and welcome to episode 249 of AvTalk. I am Ian Petchenik, here in 2024, as
always with –
[0:00:19] JR: Jason Rabinowitz. It’s been a busy three days of 2024 already.
[0:00:25] IP: Been a long year already.
[0:00:27] JR: A long year comprised of two and a half days so far, let's say.
[0:00:31] IP: Yeah. It's Wednesday, the 3rd of January. Jason and I had planned to start the year
off slow. We were going to talk about some nice things that happened over the break. We were
going to talk about some interesting technological developments that are being pursued. We
were going to talk about orders and deliveries and things of that nature. Instead, we're devoting
at least half the show, probably, to the Japan Airlines and Japan Coast Guard collision in Tokyo.
Here's what we know so far. On the 2nd of January at roughly 5.47 p.m. local time, a Japan
Airlines A350 inbound from Sapporo was landing at Tokyo's Haneda Airport. There was a Japan
Coast Guard, the De Hallivand Dash 8300 on the runway. The A350 touched down briefly and
then collided with the Dash 8, creating a massive fireball at the C5 intersection for runway 34
right. The aircraft, now with a collapsed nose gear, continued on fire for another thousand
meters before coming to rest at the opposite end of the runway, slightly to the right of the
runway in the grassy area.
All 379 people onboard were safely evacuated from the A350. Five of the six crew members
aboard the Japan Coast Guard Dash 8 were unfortunately killed. One was seriously injured. We
understand now that the crew member who was seriously injured was the captain of the flight
and he has been taken to hospital. Those are the quick facts. Jason, I mean, I think we start by
saying, it's incredible that every single person onboard that A350 made it out without serious
injury.
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[0:02:39] JR: It is. We're going to talk a bit about what exactly happened in that evacuation of
the A350. What led up to it? What was a result of it? Some components of the firefighting efforts
that were called into question that we think were probably fine. There's a lot to talk about here.
[0:02:58] IP: Sure.
[0:02:59] JR: This situation, or an exact scenario like this, it's been waiting to happen. We have
seen many, many close calls happen in the last few years that in some cases, have been
averted due to stupid luck, basically. Somebody said something, somebody did something and
crisis was averted at the very last second. Unfortunately, luck always runs out and here, luck did
run out. But fortunately, no passengers on the JAL aircraft, or flight crew were really even
seriously injured, which is an absolute saving grace to this sad story, because there
unfortunately were four deaths, but thankfully, no passengers, or no crew onboard the JAL flight
were injured.
We will talk a bit about why that might be and a lot of that has to do with this being a brand-new
plane with brand-new materials. It's the first, actually, Ian, I'm sure we'll talk about this later, but
it is the first whole loss of an Airbus A350 and the first whole loss, at least of a commercially built
composite frame aircraft. There is going to be a lot of studying of this incident for many years to
come, because I'm sure what we learn from this will influence not only the current aircraft being
built, but the next generation of aircraft, whatever comes next.
[0:04:13] IP: Absolutely, absolutely. Let's back up and talk about what we know so far, and
some of the things that are going to be front and center in this investigation. What we know
based on the ADS-B data, based on radio communications that were both available through our
friends at liveatc.net, but also, transcripts made available by the Japanese Ministry of Land
Infrastructure Transport and Tourism released today on the 3rd of January, we have a better
understanding now of what the aircraft was supposed to be doing compared to what they did. I'll
start the conversation by saying, we don't have position data for the Japan Coast Guard Dash 8,
because that aircraft did not have an ADS-B transponder.
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[0:05:07] JR: Right, and that's not unique in Japan. A lot of aircraft in Japan, unfortunately,
especially smaller domestic aircraft, don't have ADS-B, or they don't have position data,
unfortunately, and hopefully, that changes.
[0:05:19] IP: Yeah. That will certainly be part of the conversation that we have shortly and one
that I think is worth having, especially amongst Japanese governmental agencies, and whether
or not this is something that might be required. But this Dash 8 did not have an ADS-B
transponder. It did have a Mode-S transponder, so we were receiving data from the aircraft, but
there were not enough flightradar24 receivers in positions of reception to get the same signal at
roughly the same time to be able to calculate the position of the aircraft.
We know that the aircraft was operational. We know which receivers it was seeing, so they were
close to the airport, so we know roughly where it was, but we can't calculate the position. That
said, the Japan Airlines A350, of course, did have an ADS-B transponder as nearly all modern
commercial aircraft do these days, at least newly delivered ones. This aircraft was delivered in
2021. So that, we have the standard amount of data for and also the granular data that we
process specifically for this particular flight.
The aircraft was approaching Haneda Airport runway 34 right. The Japan Airlines flight was
cleared to land. It was told to continue its approach and was cleared to land. At roughly the
same time, about 15 seconds later, the tower controller that was talking to the Dash 8 let that
Dash 8 know that they could taxi to the C5 holding position, or the stop bars prior to the runway,
where they would safely be away from the runway and could then take to the runway after the
flight 516 came in.
What we also know, based on the transcript that was put out today by the Japanese Ministry, we
know that the flight that was following Japan Airlines 516, Japan Airlines 166, was told to slow
down by the tower controller, because from what it sounds like, because they include the
phrase, there is a departure plane and this is translated from a mixture of English and
Japanese, because they were – the controllers were speaking to both domestic flights in Japan
using some Japanese, some English, as well as international flights, such as a Delta flight
purely in English.
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AVT 249 Transcript
They told Japan Airlines 166 to slow down, because there is a departure plane. We're taking this
to mean that they were going to allow the Dash 8 to depart from the runway C5 intersection
before Japan Airlines 166 could land.
[0:08:13] JR: Right. We know that Haneda at the time was using runway 34 right in what's
known as mixed mode, basically, with both arrivals and departures at the same time. I guess,
we can read a part of the transcript, because there’s not really much to what's actually relevant
here. This would be Tokyo Tower saying, JAL 516 runway 34 right cleared to land wind 310 at
eight. JAL 516 confirmed that, cleared to land, runway 34 right JAL 516. Everything normal
there.
As you said, Ian, this was actually 10 seconds later, the Japan Coast Guard aircraft Juliet Alpha
722 Alpha called the tower. They said, “Tower, Juliet Alpha 722 Alpha C.” I'm not sure if that's a
transcription error.
[0:08:55] IP: They were on the Charlie taxiway.
[0:08:57] JR: Ah, they were on Charlie.
[0:08:58] IP: They were on the Charlie taxiway.
[0:09:00] JR: That probably says Charlie, or maybe it says C. I don't know. But then, they go
into say, Tokyo Tower. They call the Japan Coast Guard aircraft and say, “Tokyo Tower, good
evening. Number one taxi to holding point C5.” The Coast Guard aircraft replies, “Taxi to holding
point C5, Juliet Alpha 722 Alpha number one. Thank you.” It is important to know that not only
did air traffic control tell the crew of the Coast Guard flight to hold short, but they actually did
acknowledge that and read back that instruction. This doesn't seem to have been any air traffic
control, or communication issue. It's nice to see the Japanese authorities put this transcript out
translated into English so quickly, because there were rumors and transcriptions of very
admittedly very staticky ground audio from Haneda. This is one aspect of this incident that is
pretty definitive. It was not at least a communication issue with air traffic control.
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[0:09:59] IP: Yeah. I'm certain that investigators will take a deep, deep, deep look at whether
this was an understanding issue. Was this a understood the instructions, missed the actions?
There's some discussion to be had about the NOTAMs that were available to pilots at that time.
One of the things that is of interest, and I'm sure investigators will look at this as well, is that the
stop bar lights for the taxiway entry into runway 34 right were out of service at that time.
[0:10:37] JR: Yeah, that on its own is not something spectacular, or anything like that. Airports
all over the world, if it's even installed, most airports don't even have this. If it's installed, they
don't seem to have the greatest level of reliability, unfortunately.
[0:10:52] IP: Yeah. The one thing that there are multiple videos of the accident, and one of them
was an extended clip and I timed the video. It was depending on when I tapped my watch and
played with the minimum time and the maximum time, between 20 and 23 seconds from when
you see the Dash 8 take to the runway and the lights shift, so that you can see the lights of the
front of the aircraft. You can see the taxi lights and the runway lights of the aircraft. There's
about 20 to 23 seconds between when those lights shift towards the camera, meaning that the
aircraft is facing down the runway and when the collision occurs.
One of the questions that I have in my mind is there was a good chunk of time there where that
aircraft was sitting on the runway, when it shouldn't have been sitting on the runway. Nobody
said anything. The pilot didn't say, “Hey, we're on the runway. Sorry about that.” The controllers
didn't say, “Hey, you're on the runway. Get off the runway.”
[0:11:57] JR: Yeah. I mean, 20 seconds isn't an outrageous amount of time to be lining up and
waiting if there's traffic crossing down the runway. It's not that unusual. Yeah, as for the go
around, it should be noted, at least if you haven't looked at some of the diagrams, or some of
the photos that the investigators put out so far, the Japanese Coast Guard Dash 8 was not at
the threshold of the runway. It wasn't at the very beginning of the runway. It was at this
intersection, or holding point with C5, which is an intersection of the runway. It was quite a bit
down the runway, not really where you would typically, I guess, see a commercial aircraft at
least holding and waiting to depart. At least that's my take on it. You can tell me if I'm totally out.
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[0:12:43] IP:  I mean, two things here. One, looking at the ADS-B data from other aircraft at the
time, they were all at Charlie 1, which is beyond the displaced threshold. The blog post that we
have includes all of the ADS-B data that we have, the Mode-S data from the Dash 8, the runway
diagrams, and the transcription. If you're wanting to follow along with all this, I should have said
this a few minutes ago, if you're wanting to follow along with this discussion, check out our blog
post. We're adding new data as it becomes available, and anything that seems relevant will
continue to have.
The Charlie 1 entrance is at a displaced threshold. There's the area of the runway where it's not
suitable for landing. It's well before the touchdown point, but it's where aircraft begin their takeoff
roll from that taxiway entry point. If the Dash 8 had been there, this would have been a serious
incident in which an A350 over flew a Dash 8.
[0:13:39] JR: Much like the Austin incident.
[0:13:41] IP: Exactly. At a 100 or fewer feet, but it would have overflowed the aircraft.
[0:13:46] JR: Yeah. There's a lot of human factors issues that are going to come into play here.
There are two I want to call out specifically. One is that at least in the US, air traffic controllers
have to explicitly state to hold short of the runway. What we did not see, and this may very well
just be how Japanese air traffic control works, is that they just said, hold at hold point C5. They
did not say, hold short runway 34 right at hold point Charlie 5.
There is the potential that the Japanese authorities are going to have to amend their policy to
make it much clearer that you need to hold short of the runway at this holding point. That is one
interesting thing that I'm sure they'll take a look at with the air traffic control, really the
communication back and forth with the pilots.
The second is that this comes just a day after a major earthquake impacted Japan out in the
area around north of Kanazawa. I'm sure, the crew of this aircraft was probably working very
hard. They had a lot on their mind. They were possibly fatigued. It's one of those things where,
of course, as we always talk about in this industry, there's not just one thing that happened. It's
always a series of events. Had that earthquake not happen the day prior, this incident likely,
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possibly would not have happened. But we have to think about what was on the crew's mind at
that time. What were they going through? What were they trying to accomplish? It's just a series
of events that unfortunately led to this.
[0:15:16] IP: Yeah. To Jason's point, we should note that the Dash 8 was carrying relief supplies
from Tokyo to an airport in the affected area. This was a relief flight. The aircraft was full of
supplies for that effort. That's the reason the aircraft was there to begin with.
[0:15:34] JR: Right.
[0:15:35] IP: The other thing that I want to talk about at this end of the runway before we get to
what happens after the impact is there's been a lot of conjecture and a lot of conversation about
why didn't the A350 go around. Jason, you touched on the unexpected place where the Dash 8
would be. Remember, there's no mention of this Dash 8 to the A350 pilots. One, because it's not
supposed to be there. Two, because the Dash 8 pilots are speaking to another controller on
another frequency in the same tower. The tower controllers are coordinating the departures and
the arrivals amongst themselves. But the pilots themselves are speaking to the two separate
controllers on discrete frequencies.
[0:16:23] JR: Yeah, and that's an interesting point. If the Dash 8 was supposed to have taken
off, the controller talking to JAL probably would have said something like, one departure prior to
your arrival and we did not hear that. They would not have been at all aware.
[0:16:37] IP: Because that information was relayed to the following Japan Airlines flight 166,
because they were told to slow to the minimum approach speed, so that the Dash 8 could
depart after 516 landed. The other thing is that, and I have a photo that slightly conveys this, but
it's blurry, because I took it on a bouncing A330. Seeing an aircraft at night on a runway is
incredibly difficult.
[0:17:07] JR: I don't think we mentioned that until right now. This occurred past sundown. This
was night operations. Like you just said, it is very difficult to discern what blinky light is, what
blinky light that far down the runway. It is very difficult to determine what you're actually looking
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at, especially when this other aircraft is a quarter, a third down the runway. I would be surprised
if they ever did see the Dash 8.
[0:17:31] IP: I mean, the photo I have is a 747. That's a thousand feet down the runway. I knew
it was there, because I watched it begin the take off roll before we crossed the runway behind it.
I could not see the aircraft if I didn't know it was there.
[0:17:51] JR: Yeah. It's a difficult thing. This goes back to, I know we talked about the incident
at Austin, but we do have the technology to avoid, or assist pilots in situations like this with night
vision and all that stuff and synthetic vision. I believe, this is still really just a very high-end
private jet and also, very old FedEx and UPS aircraft where their heads up display for the pilots,
they have what is essentially, night vision and they have much better visibility to what might be
on the runway. Maybe it's time to have this discussion again and should this be something that
commercial pilots have as standard. The technology exists. We know it works. We know it can
save lives, so why aren't we using it?
[0:18:36] IP: Yeah. There is that conversation that I think is certainly worthwhile. There's also,
the other side of things is that we might be leapfrogging that with even better synthetic vision. I
mean, is it worth retrofitting? What is the benefit to retrofitting on an existing technology, versus
developing something even better?
[0:18:59] JR: We'll see what the A360 will have installed.
[0:19:03] IP: There you go.
[0:19:05] JR: We have to shift to the evacuation, because we’ve spent 21 minutes on this and
most of the discussion, at least that's been brought up to me, is the evacuation in what
happened.
[0:19:16] IP: Well, it's what didn't happen at least right away that has come under scrutiny so
far. I would like to stand in front of the crew, because everyone made it out safely. There's no
perfect evacuation. I mean, I think even in some of the training exercises, people have gotten
injured during an evacuation, even when they know what's about to happen.
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[0:19:45] JR: Well, yeah. In a lot of cases, the majority of them, the only injuries you might have
during an evacuation come from the evacuation itself.
[0:19:53] IP: The evacuation itself. Right?
[0:19:55] JR: The slide are no joke. Going down those slides, especially when you have
hundreds of people at once, they are no joke. Injuries do occur, broken bones, sprains from the
mere act of evacuating the aircraft.
[0:20:07] IP: One of the things is that from the time of the incident to the time that the last
person exited the aircraft was about 18 minutes.
[0:20:16] JR: Yeah. 18 minutes. That situation is an absolute eternity. We'll get into why that it
might be absolutely fine that it took 18 minutes. Yeah, 18 minutes is like, that's quarter of the
flight.
[0:20:31] IP: Let's be clear. Once the evacuation order was given, once they popped the slides
and started sending people out, that did not take 18 minutes. What took 18 minutes was the
aircraft stopped. The aircraft was assessed. The crew is trying to figure out what's going on. Fire
crews are reaching the aircraft. They're keeping people onboard. There's fire outside, but there's
not fire inside. Some of the doors are unavailable, whether that's because there's giant pools of
burning jet fuel outside of them, or perhaps, the doors don't work. We don't know. They actually
evacuated the entire aircraft using only three doors; the two front doors, and the left rear door.
[0:21:14] JR: Yes, and that left rear door slide was propped up to the absolute maximum. It's
able to be used –
[0:21:20] IP: The nose gear had collapsed.
[0:21:22] JR: Nose gear collapsed. The aircraft was nose down, tail up. The angle of that slide
was ridiculous. I don't know if I would have opted to use it myself personally. Maybe I would
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have waited and gone to one of the front exits, but that's not going to happen in reality. If you're
at that door, you're going down that slide.
[0:21:40] IP: You're going out. You’re getting shoved out by the flight attendant.
[0:21:43] JR: You're getting shoved out. It looked like, from the pictures I saw, it looked like it
was, I don't know, at a 67-degree angle, it was extreme. If there were injuries, it almost certainly
came from that slide. It was doing exactly what it was supposed to. Everything on the aircraft,
for the most part, did exactly what it was supposed to do. There were a few technical issues,
and we'll talk about that in a moment. Once the order was given, or once the evacuation really
started, it was probably within the mandated maximum of 90 seconds.
[0:22:14] IP: Yeah. I mean, and so, the questions have arisen about why wait so long. There
was also an interesting discussion about why didn't the firefighters put the fire out. I think that's
two parts of the same question. Because what we saw initially was a large presence of airport
rescue firefighting vehicles at the scene, but putting foam down around the fire. I think this is
one of those things where it seems counterintuitive, why aren't you putting the fire out? Just put
the fire out. Well, you don't want people evacuating an aircraft that's on fire into large pools of jet
fuel.
[0:23:01] JR: Right. They were basically giving them an escape path that they knew almost
certainly wouldn't suddenly burst into flames. That's an interesting way to go about doing it. I'm
sure the investigators will look into the actions of the firefighting team, but in retrospect, it seems
like a good move, a good decision.
[0:23:21] IP: Right. Once you have that taken care, and I'm going to call back to QF32. I mean,
they kept everybody on the aircraft for a long, long time after they had landed back in
Singapore. I think it was like, three hours.
[0:23:39] JR: They couldn’t shut one of the engines off, which actually has an interesting
parallel to this incident. We'll talk about that.
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[0:23:49] IP: What you're dealing with is a crew deciding based on the available evidence. Is it
safer for the passengers to remain on the aircraft for the time being? Or is it safer for them to
exit the aircraft where there is a distinct possibility? We know from decades and decades of
experience that if no one's injured yet, people will get injured evacuating the aircraft. It's not a
question of if. It's a question of how many and how badly will be injured?
[0:24:20] JR: Yes. I believe, we've talked about on this podcast in the past years, that there
have been times where pilots have called for the evacuation of an aircraft, and then the airline
goes back and analyzes a situation and says, “You probably shouldn't have done that. You're
fired.” There is definitely thought that goes into the evacuation command, that it's not to be
taken lightly. In this exact situation, 18 minutes is an eternity, but there are some circumstances
that led to it taking an extended amount of time.
The A350 smashed into the Dash 8, and it did the best it could. It held together. The fuselage
didn't break up. The wings didn't break off, but there were system failures. Obviously, the
electrical systems, the electrical power on the aircraft is generated by the engines, that was
suddenly no longer available. But pictures and video from inside the aircraft show that the
emergency pathway lighting came on very bright, all LED lighting now, and the areas around the
exit doors were also extremely bright. That's good. Passengers knew where they had to go.
Unfortunately, a lot of reports that we've read from either JAL or from, I believe this was in Wall
Street Journal as well, said that a lot of onboard systems because of the damage sustained to
the aircraft did not work. Crucially, the public address system and the intercom onboard the
aircraft. In determining in the flight deck, do they need to evacuate the aircraft? It is suddenly
much more difficult if the pilots can't ring back to the flight attendants in the back of the aircraft
and say, “Hey, what's the situation back there? How bad is it? What's going on?” They would
have to go into the cabin, determine that for themselves and issue that command. At the same
time, the flight attendants giving instructions to the passengers wouldn't have the benefit of the
PA system. They had to shout and use the bull horns that are onboard the aircraft for this exact
reason. You've probably noticed them before. Maybe you haven't, but every aircraft, they have
emergency bull horns onboard. Here you go, an actual use of it.
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[0:26:22] IP: An actual use of the bull horns. This is the call back again to QF32, where the
same situation happens, where the cabin interphone was not working and the cabin crew could
not communicate with the flight crew.
[0:26:35] JR: Yeah. Even more eerily, it looked like, we're not quite sure, but it looks like the
right-hand engine of the JAL A350 may not have been completely shut down, or the links to
control it, or put out the fire do something with that engine may not have completely taken effect,
because there were certainly sparks and all sorts of fun things shooting out of the back of that
aircraft, though it didn't look like the fan blades were spinning, or anything like that. But there's
definitely an interesting link to an aircraft that is critically damaged that doesn't lose control of its
engine, but isn't able to completely, promptly, completely shut it down when needed.
[0:27:12] IP: Right, right. I guess, the last thing to talk about of the information that we have, I
guess, so far, as far as the sequence of events is everybody makes it out from the A350. I think
one of the things worth mentioning and worth keeping in mind is that there was also an
extremely large firefighting presence at the opposite end of the runway for the Dash 8.
[0:27:41] JR: Yeah. It's probably not too common that an airport has to fight two completely
engulfed in flame aircraft at the same time on the same runway. They were almost certainly
stretched thin, but this is what they train for. Every time you see at an airport random smoke and
fire trucks doing things, that is the fire crews training for scenarios just like this. They sure were
put to the test. I think they came out quite well at the other end of it since there were no
significant injuries at all on the JAL A350, which is really, if you've seen the pictures, and we
didn't talk about this and we probably should, the aircraft burned down. There is virtually nothing
left of the JAL A350, or the Dash 8 for that matter.
The commercial aircraft here, the JAL A350, you could see a wing, you can see detached from
virtually anything where the flight deck was, because there's some non-composite structural
material there. Then basically, there's nothing left. There is going to be a lot of research into how
the composite airframe of this A350 reacted to the fire. But apparently, it did very well, because
they were onboard that aircraft for 18 minutes before evacuation, and the fire did not manage to
break through that fuselage and get inside the aircraft. It is at least at first, unscientifically, a very
positive result for the first whole loss of an A350, because it was extremely survivable.
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[0:29:09] IP: There's a good article in Aviation Week that came out today. Yeah, Wednesday
today, that I'll link to in the show notes, because it was really instructive about basically, a
confirmation of all of the testing that went into the survivability to fire of carbon fiber composites.
Because the idea is that these carbon fiber composites are able to withstand fire longer.
However, once the fire consumes them, it's going to burn.
[0:29:39] JR: Yeah. That lines up exactly with what we saw, because it withheld. It's burning
down, basically. It restrained the fire as it's supposed to for quite a long time. But once it caught
fire, this isn't hyperbole, there is nothing left really identifiable in the fuselage of this aircraft. It is
not what you likely would have seen from an aluminum-built aircraft.
[0:30:00] IP: Or maybe there's more. I mean, it's not recognizable. But, I mean, pound for
pound, I'm wondering how much, looking at previous examples of fuselages that have – I also
want to point out, there's the fact that the fire department made a conscious decision to say,
everyone's out of the aircraft safely. There aren't structures around. There aren't other aircraft.
We're not in area where the fire can really spread. Let's contain it and then let it burn itself out.
Because really, once these things get going in such a manner that it did, I mean, anybody who's
seen the video can see that for themselves. At some point, you just have to let the thing burn
itself out and then tamp it down from there.
[0:30:42] JR: That aircraft was a goner. There was no coming back for it, which is just
interesting. When we look at the videos and the pictures from the passengers who had gotten
off the aircraft, and they're now standing in the grass, taking pictures and video of the aircraft, it
is a recognizable aircraft. There is a fuselage, there are wings, there are engines. But by the
time all was said and done, it is unrecognizable to smoldering rubble. Either way, that aircraft
was not going to be repaired. It was not going to be fixed. This isn't the Delta 767 we're talking
about here. It was a goner. So, why not just let nature take its course and let it go? Because
they're not fixing that thing.
[0:31:22] IP: The Japan Transportation Safety Board is investigating as the lead agency. The
French BEA is assisting as the investigative agency for the state of design and manufacture.
Airbus has sent a team of technical experts to provide assistance any way they can. I'm sure
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that there will be more agencies involved by the time this is all over. It's an ICAO Annex 13
investigation, which means that we should see a preliminary report within 30 days. If we can
hope, within a year, we'll have a final report.
I am going to be fascinated by what is found on the flight data recorders and the cockpit voice
recorders. I believe, they have found at least one flight data recorder from the Dash 8. I'm not
sure whether it's the cockpit voice recorder, or the flight data recorder, and I haven't heard
anything about the A350 yet, though, I assume, we will find out soon, and hopefully, they've all
survived what was an incredibly intense fire in both aircraft.
[0:32:27] JR: Yeah. I'd be very impressed if they're able to salvage anything from the A350,
though I don't expect to learn all that much from the A350's recorders. Thankfully, they found at
least one from the aircraft where it probably does matter. Hopefully, it was the voice recorder.
But when they do eventually put out their preliminary and final reports out in Japan, Ian, I look
forward to the authorities faxing you a copy, because this is Japan –
[0:32:51] IP: Absolutely.
[0:32:52] JR: - and it's the only way we're going to get a copy. Dust off your fax machine, and
let's talk about something else.
[0:32:58] IP: All right. We segue with one fatal accident into another, where we do have the final
report. Nepalese investigators released their final report into the Yeti Airlines ATR crash that
happened early last year. That final report, there's not much new from beyond the preliminary
report. The investigators finalized their preliminary conclusions, in which they believe that the
instructor captain, who is the pilot not flying, likely misidentified the propeller condition lever and
moved those to the feather position, instead of moving the flaps lever from flaps 15 to flaps 30.
Flaps 15 had previously been selected as the aircraft is approaching the new airport at Pokhara.
Instead of extending the flaps further for the approach, the propellers were moved into the
feathered position. The flight crew at no time recognized that the propellers had been feathered.
They did recognize that there was no power coming from the engines, but they did not
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recognize that they had feathered the propellers, and so they just ran out of power. They
eventually did extend the flaps to flaps 30, but by then it was pretty much too late.
That's not much new as far as the preliminary report is concerned. What the final report adds to
the cause of the accident was the fact that there was no published approach procedure for this
new airport. The airport had only been open for two weeks, and there was no official published
approach procedures. Yeti had devised their own internal approach procedures. What the
investigators did is they used those approach procedures to conduct approaches and realized
that those procedures did not develop a stable approach.
They lay cause at the fact that it was two stress pilots approaching a brand-new airport without
stable approach procedures. One captain is being trained by the other, and they have an
intense workload landing at this new airport, avoiding high terrain, avoiding the old still operating
airport, and then on top of all that, they pull the wrong handle and feathered the propellers,
instead of extending the flaps, and they just couldn't recover from that combination of events.
Not just one thing, as we always talk about. Not just one thing that led to this. But certainly,
some learning that's going to come out of this accident as well.
[0:35:30] JR: Yup. Always more than one thing. There was certainly a lot going on.
[0:35:33] IP: Way too many things.
[0:35:35] JR: Way too many things. I don't believe we had known this before the final report,
and that's why we read them, and that's why they write them.
[0:35:44] IP: Exactly, exactly. This next story is bizarre, I guess, is the only way to describe it,
and still details are still coming to light. But Salt Lake City Police are conducting a death
investigation, because a man broke through a secure barrier at the Salt Lake City Airport and
made his way into the engine cowling of a Delta Airlines A220. Jason, you've been following this
story a bit more closely than I have.
[0:36:14] JR: Yeah. The Salt Lake City Police Department has thankfully put out more
information to the public. Because initially, it was even more bizarre than that, because it went
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on to say, somebody got onto a deicing pad, was found inside the intake cowling of an aircraft.
Resuscitation was unsuccessful, and he died. Oh, and also, the engine wasn't on, which
obviously, raised all sorts of eyebrows, and had someone in the cowling of an aircraft engine
die, even though the engine wasn't on. None of that really made any sense.
In response, Salt Lake City PD put out some more information, a very nice timeline that says,
this was a ticketed passenger. He was supposed to be there. He was in the terminal. Went
through a secure door, onto the ramp, ended up somehow losing his personal items, including
clothes and shoes on one of the airport's runways, and made his way over to a deicing pad,
where he found a Delta Airbus A220, which I don't know, it was probably there being deiced, no
big deal. They did clarify to say, oh, the state of the aircraft's engines is now unknown. They
were spinning, but they don't believe they were on, which is interesting, because the A220 is a
geared turbofan, so I don't believe those engines’ windmill, like older aircraft engines do. If they
were moving, they must have been on in some capacity. This is a very, very odd situation.
We don't really know what happened here, but they said they, life-saving efforts, including CPR
and the administration of an anti-overdose drug was done, but none of that worked and the man
died on scene. It was just, this is a very, very strange thing to see. Obviously, the flight was
canceled, the aircraft went back to the gate. Just the more we hear out of the story, the weirder
and stranger it gets. I don't believe I've ever heard one quite this strange.
[0:38:09] IP: No. I mean, and we've had naked folks on the runway before. We've had people
who are experiencing acute mental issues on the runway before. This is a weird combination of
all of them. Plus, we don't know. It wasn't the engine that killed them.
[0:38:31] JR: Something happened. Don't really know what.
[0:38:34] IP: But now they've reiterated that they don't know whether the engine was on. Very
strange. Keeping an eye on this one for sure. Okay, we still have a bunch of stuff to cover, so
we're going to do it quickly at least.
[0:38:44] JR: It's going to be a long episode and you're just going to have to deal with it.
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[0:38:47] IP: I think it's a fine way to start the year. I think this is a really important episode. I
hope, it's been a bit enlightening so far.
[0:38:55] JR: All of the rest of this has been fun saving up for a few weeks. We can't just not
talk about it, so let's go.
[0:39:01] IP: We have a fresh multi-operator memorandum from Boeing regarding the 737
MAX.
[0:39:07] JR: Ah, the old one step forward, one step back thing. Yeah.
[0:39:12] IP: Yes. Boeing is telling operators of the newer build 737 MAX. Apparently, there's a
cutoff for this, but I don't know exactly what it is. To inspect specific tie rods that affect rudder
control movement for possible loose hardware. A non-US operator found a missing nut
discovered on a rudder tie rod. Boeing inspected all of the built, but not yet delivered 737 MAX
and found a loose bolt. That bolt was tightened and then Boeing sent out a MOM to all the 737
MAX operators saying, “Hey, check your nuts and make sure they're as tight as they are
supposed to be.” Nothing further. No one's reported that their nuts are loose so far.
On the good news front for Boeing, on December 22nd, after a nearly four-year hiatus, Boeing
delivered its first 787 to a Chinese airline. A direct delivery. Over the course of a few years, there
have been some lessor placements with Chinese airlines. This is the first built by Boeing,
delivered from Boeing headquarters to the Chinese airline directly, 787 delivery. This one went
to Juneyao Airlines.
[0:40:32] JR: Hey, that's great news. That equals out one piece of bad news, one piece of good
news. Boeing is exactly where we found them last week.
[0:40:40] IP: Here's a piece of good-ish news, but we're not quite there yet. There were a
number of reports, both in Chinese media and US aviation press that China was going to clear
the 737 MAX for deliveries once again. We thought that was going to happen towards the end of
the year. The likely candidate for the first aircraft to go home to China would be a China
Southern Airlines 737 MAX 8, registration B20CA. That has not yet happened. I believe, our
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good friend, Jon Ostrower reported that while the China Civil Aviation Authority has given its go-
ahead for 737 MAX deliveries, we are still awaiting the economic authority's approval of the
importation of the aircraft, which has not yet been granted. That is the final step before they can
actually bring those aircraft to China.
[0:41:38] JR: So close.
[0:41:39] IP: Almost there, maybe? We'll see. Jason, I can't remember if we talked about the
New York Times report about the FAA's controller fatigue that was published by the New York
Times. I can't remember if we talked about it in the podcast.
[0:41:52] JR: I don't think we did know.
[0:41:54] IP: We talked about it a lot on Twitter, because the FAA spent a good deal of time
refuting –
[0:42:02] JR: Oh, we did. We did talk about that. Episode 245, we mentioned it.
[0:42:06] IP: Okay. Well before the break. We talked about this, where the FAA spent a good
deal of time refuting the New York Times articles, not even conclusions, just the concept of itself.
[0:42:18] JR: Oh, air travel has never been safer. There hasn't been an incident, a crash, since
X number of years. Anyone paying attention knows that, well, yeah, that's not really by design.
It's by luck at this point. Well, Ian, what's going on now?
[0:42:35] IP: Well, after doing all of that for show, I guess, the FAA has now appointed a
committee on controller fatigue to try and solve the problem of controller fatigue that they said
doesn't exist on a systemic level.
[0:42:53] JR: Okay. Good that they're doing that. Good that they're admitting there's an issue. I
don't know what this committee's impact will have. Ask any controller if there's fatigue and the
answer will be, yeah, only since 1982. There's that.
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[0:43:10] IP: That's a good committee finding. I will note that the FAA did celebrate reaching its
hiring goal for 2023, even though the report that was issued by the independent safety review
committee that we discussed a few episodes ago said, even if they hire all those controllers,
we're still going to end up with just 200 more controllers by 2032.
[0:43:35] JR: Hey, maybe the committee here will find that in some of the conclusions.
[0:43:40] IP: Yes.
[0:43:41] JR: Who knew that six-day work weeks and forced overtime would be fatiguing on a
small, limited set of very important high-stress individuals?
[0:43:51] IP: Yes. Not that we haven't talked about how stressful being a controller is ever.
[0:43:55] JR: No. It's never come up.
[0:43:58] IP: Let's move on to Mexico, where the will they won't they Mexicana saga is a, they
will, kind of. Mexicana started operations as scheduled flying from Mexico City to Tulum, but
they didn't land there on their [inaudible 0:44:19] flight.
[0:44:20] JR: Yeah. It was a bit foggy there at the new airport on the coast. After some holding,
they didn't even attempt to land. There was an aircraft ahead of them. I think it was Viva
Aerobus that tried twice from once from either direction and said, “Nah. We're out of here.”
Unfortunately, the festivities for the first day of new Mexicana version 2.0 was quite dampened
because of that. They eventually repositioned, got back and just was running five hours late for
the rest of the day, because they only have one airplane. If it doesn't make it in, you're not
getting out.
[0:44:56] IP: Good luck to them. We'll keep on that one. Jason, this is an interesting article that
you flagged, mostly because it's one of those things where you're like, “Yeah, it's a problem with
no solution. Good luck.”
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[0:45:07] JR: Yeah. It goes all the way back to 2019. Do you remember 2019? That's so long
ago.
[0:45:14] IP: Honestly, I don't.
[0:45:16] JR: This comes to us from Flight Global. The title of the article is Low Fuel Icelandair
757 Incident Exposed Flaws in Airport’s Diversion Readiness. Basically, what happened here
was an Icelandair 757 was coming into Reykjavik from all the way from Seattle, which is one of
their longest flights. Unfortunately, ahead of the Icelandair flight, I believe a private aircraft, or a
BAE 125 jet had a runway excursion and that ended up closing the runway, the only open
runway at KES, since the cross runway was not being plowed, not being maintained from the
snow at that hour of the day. That would be runway 1028. It hadn't been maintained over the
night and was basically shut down. You can't land in a runway that's that contaminated.
Unfortunately, the Icelandair aircraft had to hold at 6,000 feet for quite a while south of the
airport and they were running low on fuel, but they had nowhere else to go, because there was
some miscommunication, lack of available other runway airports, including the downtown
Reykjavik Airport, which is much smaller, but can facilitate the landing of a 757. There was some
miscommunication about braking action reports. There were some taken, but the approach
controllers were not made aware of it, so they couldn't provide an estimate on when that aircraft
could land. They said, “You know what? We got nowhere else to go, so we're going to land at
Reykjavik anyway on the closed runway,” which is a desperate move of last resort.
Which thankfully, in this case, the runway excursion happened all the way at the end of the
runway and it didn't actually impact it, but their emergency services were tied up in that moment.
Had this Icelandair 75 had any issue, it would have been quite a problem. It did expose a
weakness in Iceland's readiness to deal with a situation like this, where you don't have a ton of
airports in the area. If both of your Reykjavik airports are unavailable, what do you do? Yeah, it
did end here and really, there's no answer.
Hopefully, they tightened up some procedures, communication lines have been improved. Yeah,
disappointing that the report doesn't really say what the improvement should be, or what they
did actually improve. The Icelandair crew did what they had to do.
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[0:47:36] IP: Yeah. The thing was that the controller said, “Well, you can land if you declare an
emergency.” They were like, “All right, we're declaring an emergency.” They all go, “You can
land in the runway, no problem.”
[0:47:44] JR: We'll do.
[0:47:46] IP: That's what they did.
[0:47:47] JR: I did read that they were nice about it. When they approached after landing and
approaching the end of the runway, they turned their lights off as to not blind everyone who was
working at the end of it.
[0:47:56] IP: Oh, well, that's good.
[0:47:56] JR: With the jet that was – the way with jets. So, yay. That's something. One more
thing they did find out, after the fact that the breaking conditions at the other airport, after the
fact learned that, oh, they couldn't have landed there anyway. It ended up not mattering. They
probably would have to do this anyway.
[0:48:13] IP: Okay.
[0:48:14] JR: Moving on.
[0:48:15] IP: Speaking of landing, you're not supposed to land on a frozen river is my
understanding. Unless you're flying a plane that is designed to land on the frozen river.
[0:48:30] JR: Yeah, there is not –
[0:48:31] IP: Am I wrong?
[0:48:31] JR: No, you're correct. It's right there, word for word that I put in the show notes.
There's not much to go on here, but an Antonov AN24 operated by – who operated this thing?
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Polar Airlines. Oh, man. That's almost too good, isn't it? I've never heard of them. But
apparently, Polar Airlines way out in rural Russia landed parallel to the runway they meant to
land on, which is on the waterfront and landed on –
[0:48:58] IP: That counts for something, right?
[0:48:58] JR: Counts for something. They landed parallel to the runway on a very icy river.
Thankfully, there were no injuries, because it's Russia in the middle of the winter. The river was
probably very occupied with some thick ice and there were no casualties. There were no
injuries. I don't know if the aircraft has managed to take off again. But judging from some of the
pictures, I mean, it's flat. It's white. It's by some trees. It looks like it could be a runway, perhaps,
maybe.
[0:49:28] IP: Sure.
[0:49:29] JR: Why not? Yeah. There are more egregious incidents. But thankfully, the ice held
and there were no issues. I don't know, however, the state of the aircraft. It turns out, we can't
track that one right now.
[0:49:42] IP: It's very, very rural. I don’t –
[0:49:45] JR: What is to say? I don't even know how to pronounce it, but it was somewhere very
rural.
[0:49:49] IP: Link in the show notes. You can pronounce it yourself.
[0:49:52] JR: Okay.
[0:49:52] IP: Jason, you flagged this story and I have thoughts.
[0:49:58] JR: Okay, let me go back to the show – Oh, this is a good one. I just put in the show
notes, poo-powered planes? Because it was the week between –
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[0:50:07] IP: We're talking about winning.
[0:50:09] JR: No. It was the week between Christmas and New Year, so I needed to find some
news, but this comes to us from the BBC, and the headline is Firm Develops Jet Fuel Made
Entirely from Human Poo. That's interesting. The chemist at a lab in Gloucestershire, probably
got that right, the CEO of Firefly Green Fuels, James Hygate, demonstrated that, “Hey, we
created this sustainable aviation fuel, alternative fuel, probably not sustainable, get to that in a
minute, but it is virtually chemically indistinguishable from carbon-based fuel. It has a 90% lower
carbon footprint than standard fuel, which is pretty crazy.
Unfortunately, the amount of human poo you would need to power any aircraft for any legitimate
flight is, it's not going to be a large-scale solution. They went on to say that a typical London to
New York flight would require the annual sewage of 10,000 people to get there. It's probably not
going to cut it.
[0:51:19] IP: What you're saying is we're going to need super poo to power these aircraft?
[0:51:24] JR: We’re going to need a lot of power. They estimate that the UK's total sewage
supply for the entire year would meet about 5% of the country's aviation fuel demand. The UK
doesn't have the highest fuel demand in the world. It would only cover 5%. While it's great that
they have seemingly developed a zero waste, virtually emission-free jet fuel, this one does not
look like it will make it into the mainstream, unfortunately. Unless, there's some untapped source
of human poo that you just don't know of, which is, I don't think the case.
[0:52:00] IP: Okay, moving right along. LATAM has ordered five 787s. Their total is now going
up to 45. These five are notable, because they will be powered by GEnx engines.
[0:52:12] JR: That's different.
[0:52:13] IP: That is different. Lufthansa Group has ordered, you ready for this?
[0:52:18] JR: I'm ready.
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[0:52:19] IP: Up to 100 737 Max aircraft.
[0:52:24] JR: Whoa. This would normally be a headlining topic for us. But now it's a couple of
weeks old, so it only gets a footnote. It is 40 firm, 60 options for the 737 MAX 8. We don't know
where Lufthansa will actually end up placing these aircraft. Lufthansa's notoriously opaque
about that, so we don't really know. It is notably the first 737 order for Lufthansa in decades, I
believe. Decades and decades. The last 73 they had wasn't even – was it an NG? I think it was
a 400. It's been a very long time.
On top of that, they're not done. This was the end of year spend your budget, or lose it situation.
They also ordered 40 firm 20 options of the A220-300 for City Airlines, and 40 options for the
A320 for whomever and the Lufthansa Group might need one.
[0:53:16] IP: Excellent. I like it.
[0:53:18] JR: We're not done. There are more orders.
[0:53:20] IP: Not done yet. But wait, there's more.
[0:53:22] JR: Squeaking in before the end of the year, EasyJet says, “We need more.”
Honestly, this would normally be another headlining order. But it came in in that nice, nice spot
at the end of the year where no one's paying attention for 157 more Airbus. I just have written
here 56 –
[0:53:39] IP: Okay.
[0:53:40] JR: to A320neo and 101 A320neo. Sorry. the details before I stopped reading, there’s
a 56 A320 Neo, 101 A320neo, because 100 and even a 100 is just not enough. They also
converted 35 A320neo orders to A321neo. EasyJet –
[0:53:59] IP: Maybe they got free shipping if they go a 101.
[0:54:02] JR: Well, it's a deal. End of year blowout sale, order a 100 321neos, get one free.
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[0:54:08] IP: Well, there you go.
[0:54:09] JR: Yeah.
[0:54:10] IP: We will end the show with news I did not expect to begin the year with. To be fair, I
didn't expect most of this news. But this news I really didn't expect, because Schiphol is not
cutting slots for the summer. They're adding them. What?
[0:54:29] JR: Oh, which is airlines love this uncertainty about can they fly to a specific
destination? This seems quite opposite of the last few weeks. Hey, I'm flying to Amsterdam in a
few days. This is good news. I'll make sure to thank them for not making really weird decisions.
But who knows? Check back two weeks later. It might be the opposite.
[0:54:49] IP: There you go. Yeah. What we know so far is that Schiphol is going up to 293,000
slots for the summer season, rather than the slated 280. They were trying to bring things down
to 460,000 flights for the year. Instead, there will be more than those.
[0:55:09] JR: All right. Someone in the boardroom at Schiphol had to say like, “Are we still in
the airport? Do we do that?” Someone said, “Yeah, we are. We should have flights. It's good.”
[0:55:20] IP: This comes after the European Commission and the US Department of
Transportation suggested that the unilateral slot removals by Schiphol violated a number of
international and European-wide agreements, including open skies agreements that the US is
party to. There might be repercussions if you go through with the slot cuts. Not long after that,
Schiphol said, “No, we're not doing anything.” Then this week, they said, “Hey, you know what?”
We'll add slots. Why not?
[0:55:52] JR: All right. Well, if nothing else –
[0:55:53] IP: There you go.
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[0:55:54] JR: - we're on the right path for Schiphol, I guess. But we are on notice now. We are
on notice that this is what they want to do.
[0:56:02] IP: Sure. All right. That's what we know to start the year. It's the 3rd of January. By the
10th of January, when we record next week, who knows what will have happened and what we'll
know by then? This has been episode 249 of AvTalk and the first of 2024.
I want to first, thank everyone who wrote in over the break, suggesting stories and ideas to talk
about on the podcast over the next year. Some of those were absolutely fantastic, and we'll be
getting back to you on those. Some were a little interesting, and some of you just wrote your
name in an email. I'm not sure why, but thank you for that. Yeah, I'm not sure. Maybe they want
us to talk about them. Maybe that's –
[0:56:52] JR: Hey, if you are an interesting person and you do something interesting for work –
[0:56:56] IP: Hey, let us know.
[0:56:57] JR: Let us know. Just include more than your email, please.
[0:57:01] IP: Exactly. Then to close the show, Jason and I want to say, job well done and best
wishes for a long and happy retirement to our good friend, Lou, who retired as an air traffic
controller at the Chicago Center. Dealing with aircraft mid-flight. He's been there for the better
part of two decades and has been an air traffic controller between, working at the FAA, as well
as working in the US military for the better part of three decades. His last shift closed out 2023.
He is now officially retired, but he is not leaving entirely. He will be training some of the new
controllers that will be guiding aircraft through the skies over the US. Please, join us in wishing
Lou a wonderful and happy retirement. We hope to have him on the podcast in the near future.
Lou, congratulations, enjoy your retirement and come talk to us soon.
[0:58:02] JR: Yes. They should put him on the committee. Come to think of it.
[0:58:03] IP: That's a great idea. This has been episode 249 of AvTalk. I am Ian Petchenik,
here, as always with –
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[0:58:13] JR: Jason Rabinowitz. Thanks for listening.
[END]
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