Incident Overview

Date: Wednesday 31 January 2001
Aircraft Type: Boeing 747-446D
Owner/operator: Japan Airlines
Registration Number: JA8904
Location: off Shizuoka Prefecture – ÿ Japan
Phase of Flight: En route
Casualties: Fatalities: 0 / Occupants: 427
Component Affected: Air Traffic Control (ATC) ? specifically the controller’s instruction to the 747 and the subsequent decision by the 958 pilot to follow the controller’s instructions.Air Traffic Control (ATC) ? specifically the controller’s instruction to the 747 and the subsequent decision by the 958 pilot to follow the controller’s instructions.
Investigating Agency: JTSBJTSB
Category: Accident
On January 31, 2001, a collision between a Boeing 747 (JAL Flight 907) and a DC-10-40 (JAL Flight 958) occurred near Yaizu NDB due to a miscommunication regarding flight paths. The controller instructed the 747 to descend, prompting the 958 to descend as well. Both aircraft were on intersecting course, and the controller’s order resulted in a collision. The 747, due to the DC-10 captain’s descent, initiated a nose-dive, causing a 105-165 meter lateral and 20-60 meter altitude difference. Approximately 100 crew and passengers on Flight 907 sustained injuries, while no injuries were reported on Flight 958. The investigation attributed the incident to a failure of air traffic control to issue incorrect flight numbers, leading to a disregard for the TCAS system. The commission recommended prioritizing computer orders over controller instructions to mitigate future incidents.On January 31, 2001, a collision between a Boeing 747 (JAL Flight 907) and a DC-10-40 (JAL Flight 958) occurred near Yaizu NDB due to a miscommunication regarding flight paths. The controller instructed the 747 to descend, prompting the 958 to descend as well. Both aircraft were on intersecting course, and the controller’s order resulted in a collision. The 747, due to the DC-10 captain’s descent, initiated a nose-dive, causing a 105-165 meter lateral and 20-60 meter altitude difference. Approximately 100 crew and passengers on Flight 907 sustained injuries, while no injuries were reported on Flight 958. The investigation attributed the incident to a failure of air traffic control to issue incorrect flight numbers, leading to a disregard for the TCAS system. The commission recommended prioritizing computer orders over controller instructions to mitigate future incidents.

Description

On Jan. 31, 2001, JAL flight 907, a Boeing 747 had departed Tokyo-Haneda (HND) for a flight with destination Naha (OKA). JAL Flight 958, a DC-10-40 was en route from Pusan (PUS) to Tokyo-Narita (NRT). A trainee controller cleared flight 907 to climb to Flight Lever 390 at 15:46. Two minutes later JL958 reported at FL370. Both flights were on an intersecting course near the Yaizu NDB. At 15:54 the controller noticed this, but instead of ordering flight 958 to descend, he ordered the Boeing 747 to descend: “Japan air niner zero seven, descend and maintain flight level three five zero, begin descent due to traffic.” Immediately after this instruction, the crew of flight 907 were given an aural TCAS Resolution Advisory to climb in order to avoid a collision. At the same time the crew of flight 958 were given an aural TCAS Resolution Advisory to descend. The captain of flight 907 followed the instructions of the air traffic controller by descending. The 747 now approaching close to Flight 958, because the DC-10 captain descended as well, following the advisory of his TCAS. A collision was averted when the pilot of flight 907 then put his Boeing 747 into a nosedive. The 747 missed the DC-10 by 105 to 165 meters in lateral distance and 20 to 60 meters in altitude difference. About 100 crew and passengers on flight 907 sustained injuries due to emergency manoevre, while no one was injured on Flight 958. Flight 958 continued to Narita, while flight 907 returned to Haneda Airport. PROBABLE CAUSE: The Aircraft and Railway Accident Investigation Commission concluded that air traffic control’s error in giving the wrong flight numbers when asking the pilots to change course and the pilots’ decision to follow air traffic control instead of the computerized Traffic Alert and Collision Avoidance System (TCAS) were two of the main causes. The commission recommended a.o. that the International Civil Aviation Organization (ICAO) put priority on computer orders over instructions from controllers to prevent similar incidents.

Primary Cause

Failure of air traffic control to issue correct flight numbers and subsequent pilot decision to disregard TCAS instructions.Failure of air traffic control to issue correct flight numbers and subsequent pilot decision to disregard TCAS instructions.

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