Serious incident Boeing 737-446 JA8996, Friday 9 April 2004
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Date:Friday 9 April 2004
Time:12:26 LT
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different    
Boeing 737-446
Owner/operator:JAL Express
Registration: JA8996
MSN: 28832/2953
Engine model:CFMI CFM56-3
Fatalities:Fatalities: 0 / Occupants: 64
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Kumamoto Airport (KMJ/RJFT) -   Japan
Phase: Approach
Nature:Passenger - Scheduled
Departure airport:Osaka-Itami Airport (ITM/RJOO)
Destination airport:Kumamoto Airport (KMJ/RJFT)
Investigating agency: JTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The Boeing 737-400 JA8996, which belongs to Jal Express Co., Ltd., took off from Osaka International Airport at 11:39 as the company's regular flight 2385 on Friday, April 9, 2004, and when entering and landing at Kumamoto Airport, its destination.
After entering the runway 07 in the opposite direction from the runway used, at around 12:26, just before entering the final entry route, he noticed an error in his aircraft entering the runway due to a report from the Kumamoto Airfield Control Office, and stopped entering. When JA8996 noticed the error of entry, the Beech T-400 (41-5054) belonging to the 41st Education Squadron of the Air Self-Defense Force, which had obtained take-off permission from runway 25 and started take-off, was JA8 on the take-off path of its aircraft. It sighted 996 and canceled the take-off.

JA8996 had 5 crew members and 59 passengers, a total of 64 passengers, and 41-5054 had 5 crew members on board, but neither aircraft had any injuries or damage to the aircraft.


This serious incident is presumed to have occurred because both the captain and first officer of Aircraft A failed to properly listen to communications regarding the designated runway, and continued their approach without realizing they had mistaken the active runway, resulting in an attempted landing on a runway that was already in use by another aircraft.

Regarding the fact that the captain of Aircraft A did not realize the change of the active runway, the following factors are considered to have contributed:

1. There may have been a preconceived assumption that the active runway was "07."
2. The captain was distracted by instructing the first officer, possibly reducing attention to ATC communications.
3. The crew did not voluntarily read back the runway number and traffic pattern, thus missing the opportunity for correction from ATC regarding their misunderstanding.
4. The first officer (who was the PF – pilot flying) may have failed to fully understand the ATC instructions but still responded affirmatively to the captain, thus reinforcing his own misunderstanding.

Regarding the first officer of Aircraft A also not noticing the change in the active runway, the following factors are considered to have contributed:

1. The first officer was focused on flying under instruction from the captain, which reduced attention to ATC communications.
2. Attention may have been diverted by the lower-than-normal altitude when passing over ASONO, reducing awareness of ATC instructions.
3. The first officer was distracted by the captain giving instructions that differed from the landing briefing, requiring more attention to the actual operation than usual.

Additionally, the reason why the Kumamoto Tower controller did not notice that Aircraft A was approaching in the opposite direction from the designated runway until alerted by Kumamoto Approach is believed to be due to the following:

1. The controller had already issued a visual approach clearance for Runway 25, and instructed Aircraft A to report right downwind for Runway 25. Since Aircraft A responded with “Roger,” the controller assumed the aircraft was heading for the traffic pattern of Runway 25.
2. Although the aircraft could not be visually confirmed, the controller received position reports from Aircraft A and believed its location had been confirmed via radar (Bright system).


Accident investigation:
cover
  
Investigating agency: JTSB
Report number: 
Status: Investigation completed
Duration:
Download report: Final report

Sources:

https://jtsb.mlit.go.jp/aircraft/rep-inci/AI2005-1-2-JA8996.pdf

https://www.jetphotos.com/photo/6342900 (Photo)

Location

Revision history:

Date/timeContributorUpdates
16-Apr-2025 12:01 Justanormalperson Added
16-Apr-2025 12:04 ASN Updated [Narrative, Accident report, ]

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