LIFE AFTER SQ006 - Orient Aviation

c o u n t r y f o c u sconvention regarding accidents, which is tofind the cause and establish remedies.Society’s goal in Japan is torn betweenfinding out what went wrong, so that it canbe put right in future, and finding someoneto blame and then punish. With the fear ofarrest, trial and detention looming over anyinvestigation there is a natural reluctance onthe part of those involved to comply voluntarilywith a situation that is rigged against them.Hardly surprising when the participants in anaccident case are often treated from the beginningnot as witnesses, but as perpetrators ofa crime – in Japanese, “kagaisha”.Fear of the blame and punishment processcolours attitudes to safety in a disturbing andfundamental way, leading to over-restrictivepractices and excessive limits on operations,which in turn prevent the expansion of servicesand affect the convenience of travellersand shippers.In the “accident culture” in Japan, the firstelements to arise are:• Who is guilty?• Whose fault is it?• Who do we punish?This is in marked contrast to the situationin the United States. The National TransportationSafety Board (NTSB) would investigate anear miss, but a police investigation wouldnever be initiated, unless the NTSB reportuncovered criminal activity.In the case of an aircraft accident in Japan,who is responsible for investigating the case,the Aircraft Accident Investigation Committee,the police or the media?Japan’s Aircraft Accident InvestigationCommittee (AAIC) was established in 1973.It falls under the jurisdiction of the JapanCivil Aviation Bureau, the aviation divisionof the Ministry of Land, Infrastructure andTransportation (MLIF), a newly formed megaministryincorporating the former Ministry ofTransport. It is not independent, as is the NTSB.This puts the impartiality of the AAIC intoquestion. Air traffic control, which is involvedin this near miss case, is also an MLIF-controlledfunction.The AAIC’s role is two-fold. First to determinethe cause and to recommend correction,second to prevent future accidents, save livesand reduce damage and injury.In the case of the police, finding the causecomes first too, but their final goal is to findout who is responsible, then prosecute andpunish.The media focus, apart from initiallyreporting the circumstances of the accident,is to pinpoint blame and call on punishmentof those responsible. To this end they harassand pursue persons involved in the case longbefore responsibility has been established,playing the roles of prosecutor and judge.Often the level of media attention istantamount to persecution and places greatstress on its innocent victims.When air accidents are investigated inJapan, a tacit agreement exists between thepolice and the AAIC. The police have firstpriority to access the accident site or securethe evidence. This includes custody of thecockpit voice recorder and the “black box”or flight recorder. The police ask the AAIC toanalyse these. From the AAIC report the policedetermine the cause of the accident. Duringthe period of the report investigation andcompilation other parties involved are notexpected to make public comments, exceptfor statements of regret or apology.‘The media focus ...is to pinpoint blameand call on punishmentof those responsible.To this end theyharass and pursuepersons involved inthe case long beforeresponsibility hasbeen established’As part of the punishment culture, peopleinvolved in an accident often take responsibilitybefore the official judgement or report ofa case. The most usual form is resignation ofsenior executives.Sometimes the response is more drasticand final. In 1985, during the police investigationinto a JAL B747 accident when 520 peopledied, a Ministry of Transport chief technicalinspector committed suicide, driven to thisdesperate act by incessant grilling by policefrom rural Gumma Prefecture, where the accidentoccurred.The aircraft in question had been in a tailhitaccident seven years before. A Boeing teamhad repaired the aircraft and the inspector hadsigned off on the repair. Part of the repair ofthe lower half of the rear pressure bulkheadwas inadequate, but visually undetectable.The weakened bulkhead ruptured in flight,severing hydraulic lines and damaging thevertical stabiliser, thus leading to the subsequentcrash. The police interrogators put theblame on him.There is a strong sense of taking responsibilityin Japanese society, which expects thosewho have disturbed the harmony or order ofthings to follow custom, apologise and takethe appropriate expiatory measure.In the near miss case, nobody is suggestingthat changing the accident investigationsystem in Japan will do away with the needfor anyone to take final responsibility as theculture demands. Instead, the call is for achange in procedure, to prevent scenes like thecockpit grilling of Captain Watanabe and hisfellow crew and the disruption of a meaningful,expert investigation.Japanese airlines share a common interestin co-operating with civil accident investigations,but would prefer the police waiteduntil the civil investigation is over, instead ofrushing to judgement.Although the role of the AAIC is to findout what happened and then to recommendcorrective action, its report findings often leadthe technically challenged police to the identityof people responsible for the accident.The crash of a China Airlines plane atNagoya in 1994 illustrates how bizarre thiscan become. After a lengthy investigationthe AAIC concluded faulty procedures by thecockpit crew led to the accident. WhereuponNagoya’s ‘finest’ recommended criminal prosecutionof the captain and co-pilot, who wereboth dead!In other industrial societies the processingof accidents involves what we might call the“insurance culture”.In these countries the cost of human errorin an accident is covered by an insurancepolicy. No punishment will be enforced onindividuals unless the investigation resultsindicate wilful misconduct or gross negligence.The other message here is that accidents areto be learned from, so they can be preventedin future.Until relatively recently there was no insuranceculture in Japan. That seems strangewhen you consider in the 17th century therewas already a very healthy and sophisticatedfutures market system in place for handlingrice. But there was no concept of insurance.When things went wrong, events weretreated according to the culture of blame andpunishment.Today, the punishment culture still prevails.With all the talk of globalisation andadoption of international standards, Japan’slaw enforcement authorities should adapt toan accident culture that focuses on remedialinstead of punitive action and enter the 21stcentury rather than continue to apply thestandards of the feudal past.40 | Orient Aviation | March 01