Learning from the past

“Look after the children”. These are the sobering words written on a sick bag by a passenger on Japan Airlines (JAL) flight 123 on 12 August 1985. The note was written to the man’s wife shortly before the Boeing 747 crashed into a mountainside, killing 520 people in the worst single-aircraft accident in history.

Today a copy of the note is displayed on a wall of JAL’s Safety Promotion Center, an unusual museum which features reminders of fatal accidents to keep staff aware of the importance of a strong safety culture. The centre is tucked away in a nondescript building in the maintenance district of Tokyo’s Haneda airport, from where the aircraft departed on that fateful day in 1985.

On display are huge pieces of the 747′s wreckage recovered from Mount Osutaka, on which it crashed. At the far end of the main hall are mangled passenger seats, across from the reconstructed aft fuselage. Nearby is a wall featuring notes to loved-ones from passengers who knew they were about to die. Also behind glass nearby are the aircraft’s cockpit voice and flight data recorders, their bright orange exteriors scratched and dented from the crash impact.

The main feature is in the centre of the 622 square metre centre, where the remains of the rear pressure bulkhead are on display just past a huge reconstructed part of the aircraft’s vertical tail.

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The crash was considered a national disaster in Japan and it had a devastating impact on public confidence in aviation safety. Investigations determined the probable cause was the failure of the rear pressure bulkhead following faulty repairs by Boeing seven years earlier. The repairs had been carried out after a tail-strike on landing in 1978 at Osaka Itami airport, which was also where flight 123 was headed on the day of the crash.

Fatigue cracks had been forming in the rear pressure bulkhead but they went unnoticed over the years after the repairs. The pressure bulkhead eventually failed with a bang that was heard on the cockpit voice recorder, blowing pressurised air out into the aft fuselage. This blew off the auxiliary power unit, parts of the tail cone and much of the vertical stabiliser. All four hydraulic systems failed, leaving the aircraft largely uncontrollable.

For 32 minutes the crew struggled to keep the 747 in the air before it crashed into the mountainside. More than 20 years later, the foliage is only now nearly back to what it was before the crash brought down trees and left an eerie scar in the landscape. A permanent memorial was established at the crash site, where wreckage is still being found to this day.

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For many airlines, accidents are things they would prefer to forget. But JAL, after a series of safety-related incidents in 2005 that led to an unprecedented “business improvement order” from the Japanese government, says it wants its staff to remember, rather than ignore, the past.

The safety centre’s director, Yutaka Kanasaki, says more than 18,000 people have visited since the April 2006 opening – many more than expected. He says 40% have been members of the public who have an interest in transportation safety.

Kanasaki says one aim is “to keep the sadness of flight 123 alive”, while another is “to keep the message of safety alive for staff”, particularly younger ones. The final goal is to leave a reminder “for the next generation to learn from”.

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JAL has not had a fatal accident since that of flight 123 and around 60-70% of the group’s current employees joined after 1985. Kanasaki, who was working in the engineering department focusing on cabin pressurisation at the time of the crash, says that rather than pretend accidents are not part of JAL’s past, staff should be reminded of them to learn lessons. The concern is that the majority of employees who have not been working through a crash will not have the same understanding of the need for safety awareness as someone like him who has.

Eventually all of JAL’s employees will visit the centre, which has at the entrance a reference room featuring books on accident investigation and summaries of major accidents that JAL and other carriers have suffered.

There was much debate within the airline before it went ahead with the bold decision to open the centre, which was partly the result of a recommendation of an independent group of safety experts hired in 2005 and partly something that was pushed for by Toshiyuki Shinmachi, at the time JAL’s chief executive and now its chairman.

When plans for the centre were announced by JAL that year it was joked about in some quarters, with some calling it a “Crash Museum” and others describing it as a “Museum of Contrition”.

But JAL says it has already proven a great help in promoting safety, and most of those who have visited, including relatives of the victims of flight 123, have remarked that it has been put together very well. Rival All Nippon Airways has just opened a similar centre of its own featuring reminders of its accidents.

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Kanasaki says he sees the effect the centre has on its visitors every day. Maintenance employees, for example, change their attitude towards their work after seeing the twisted wreckage of the lost 747.

“Of course they are shocked” when they see the wreckage of flight 123, he says, but afterwards “they feel they are no longer just replacing a machine” when carrying out their work as they can see the human impact of a crash.

As one of the minority who was working for the airline at the time of the crash and one who remembers its after-effects vividly, Kanasaki adds: “This is one of our responsibilities – to transfer the lessons learned to the next generation.”

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One Response to Learning from the past

  1. Barry Jocelyn 13 August, 2009 at 4:35 am #

    RE: Rear pressure bulkhead on Boeing 747.
    All of the mechanics and science of controlling pressure that I have learned over time indicates that the bulkhead in the rear of a 747 is facing the wrong way. The dome of the bulkhead should be on the side facing the most pressure. This is how it can withstand high pressure. There are no concave panels on the outside of a nuclear submarine.

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