MONDAY MUSINGS SEASON 2 - EPISODE 243

Obsessive Focus on safety and security

8th January 2024

The freak accident last Tuesday, 2nd January 2024, at Tokyo's Haneda Airport involving a Japan Airlines flight and a coastguard plane was unfortunate and gory. Investigation is ongoing to determine the root cause of the accident. But what is surprising and commendable is the precision with which all the 367 passengers of Japan Airlines got evacuated safely from the burning plane in record 90 seconds. How was that possible? This has already become a case study for emergency response and the lessons from this escape are valuable for emergency response preparations in organizations.  Hence, this takes precedence over our regular MONDAY MUSINGS sessions.  What happened on the second day of the new year?

Japan Airlines flight 516 departed from Sapporo's New Chitose airport at 16:00 local time (07:00 GMT) and landed at Haneda shortly before 18:00 and collided with a coastguard plane which was taking off in the same runway to deliver aid to victims of the powerful New Year's Day earthquake. Japan Airlines flight turned into a fireball after it collided with the coastguard plane and came to a halt on the runway.

Five of the six crew of the coastguard plane died but everyone on Flight 516 survived because of the flawless evacuation by the crew as it filled with smoke astounding the world and winning praise from many. Just one passenger on board flight 516 sustained bruises and 13 others requested medical consultations due to physical discomfort, the airline said. 

The lessons learnt:

1. Take Control when it matters!

The crew took immediate control of the situation and assured the passengers not to get panicky. The crew gave clear instructions with appropriate intonations to identify the exits advising the passengers to evacuate without looking for their hand baggage. 

Emergency protocol stipulates that crew must have permission from the cockpit to open any emergency exits. The captains themselves stood near the two exits up front and gave the go-ahead for evacuation. Leaders must take split second decisions and take control in emergency management situations. 

2. Panic does not but clear communication helps

In addition to a well-trained crew and an advanced plane, the safe evacuation of 367 passengers came down to a relative absence of panic inside the aircraft.

As soon as the Airbus A350 wide-body jet came to a stop, cabin attendants called out to passengers to remain calm as bright-orange flames engulfed large areas of the plane and smoke quickly filled the cabin.

The crew quickly sized up the situation with visual checks of the exterior and decided that only three of the eight emergency exits were safe for use (I was told that we are asked to keep windows shades open during take-off and landing precisely for that reason). They then used short, direct commands, as they are trained to do, such as "leave your luggage" and "not this door".

Tadayuki Tsutsumi, an official at Japan Airlines, said the most important component of crew performance during an emergency was “panic control” and determining which exit doors were safe to use and the crew of the ill-fated flight did that correctly.

3. Passenger’s cooperation

Passengers dashed to the emergency exits, 3 identified exits as instructed by the crew, of the plane without their hand luggage, in compliance with the flight crew's instructions. The simple act of leaving their valuables helped to save precious lives, with the last crew member escaping just before the aircraft was engulfed in flames. All the passengers were seen without their hand luggage in the tarmac and the maximum they took with them were their mobile phones and few winter clothes.

“Even though I heard screams, mostly people were calm and didn’t stand up from their seats but kept sitting and waiting,” said Aruto Iwama, a passenger who gave a video interview after the evacuation. Since the ill-fated flight was a domestic flight, it was easier to secure the attention of the passengers to discipline and the passengers obliged largely.

This is akin to staff cooperation during emergency response procedures in organizations. I get appalled to see the apathy of some staff during the planned simulation exercises. Simulations are for enhancing preparedness and not for ticking-off few checklist items. Simulations become successful only with the active participation of every stakeholder, especially senior management. 

4. Focus on trainings and simulations

The crew's rigorous training was key to the achievement last Tuesday. "You really don't have time to think in a situation like this, so you just do what you were trained to do" acknowledged a flight crew. 

All new crew members of Japan Airlines undergo stringent evacuation and rescue training for up to three weeks before they are allowed to serve in commercial flights. The training - which extends to how you control the tone and volume of your voice so you can be best heard by passengers - is repeated every year.

"We go through a written exam, case study discussions and practical training using different scenarios, such as when the plane has to make a water landing or if there is fire on board. Maintenance staff are also involved in such training," said a former flight attendant. 

“When training for evacuation procedures, we repeatedly used smoke/fire simulation to make sure we could be mentally ready when situations like those occurred in reality,” Yoko Chang, a former cabin attendant and an instructor of aspiring crew members, wrote in an Instagram message.

Incident Response Simulations are essential part of training and preparedness for emergency response. Any amount of training cannot substitute effectiveness of a simulation exercise. 

5. Hope for the best and prepare for the worst

The situation inside the aircraft before the evacuation was far from ideal. The aircraft was nose down, which meant it was difficult for passengers to move," he said.

Only three inflatable slides could be used to evacuate passengers, but they were not properly deployed because of how the jet landed. The rear slide was very steep, which could have been dangerous.

The aircraft's announcement system also malfunctioned during the evacuation, so the flight crew had to convey instructions using a megaphone and by shouting. The crew was prepared for the possible challenges in emergency response. It is very important to think of all the possible issues during exigencies and be prepared with procedures to deal with the exigencies. This applies to Emergency Response procedures and Business continuity Plans in an organization.

6. Focus on metrics

90 seconds has become a very important number in this evacuation exercise. 90 seconds was kept as the target for evacuation during evacuation trainings and simulations. Even aircraft manufacturers must show that everyone aboard can leave the plane within 90 seconds for their planes to be accepted.

Simulations would be objective when they are done with specific targets. 

7. Obsessive focus on Safety

Japan Airlines experienced its own catastrophe in August 1985, when Osaka-bound Flight 123 crashed into a mountain shortly after take-off from Tokyo Haneda. It was later attributed to faulty repair work by Boeing, the aircraft manufacturer. Only four out of 524 people on board survived the crash.

The airline's record has been "blemish free" since then and is a "world leader" when it comes to safety.

Management at the company are so dedicated to safety that in 2006, Japan Airlines opened a museum-like facility near Haneda displaying wreckage from the incident, aimed at promoting safety awareness among its employees.

"In face of the pain and grief of the bereaved families and public distrust in airline safety [after the 1985 crash], we pledged that we would never again allow such a tragic accident to occur," Japan Airlines wrote on the facility's webpage.

"Every member of staff is reminded that valuable lives and property are entrusted to us in our work."

Obsessive focus on safety and security and not attention is essential to drive management’s commitment to all the stakeholders.

___________________________________________________________________________________________  Conceived, compiled and posted every Monday as a newsletter in LinkedIn by Jaganathan T (www.authorjaganathan.com). Read, learn, grow and share your feedback.