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ANA pilots unaware for 17 seconds that plane was almost turning upside down

41 Comments

The pilot and copilot of an All Nippon Airways plane were unaware for 17 seconds that their aircraft almost turned upside down during a flight last year, the Japan Transport Safety Board (JTSB) said Friday in a report on the incident.

The ANA flight, with 117 passengers and crew on board, dived 1,900 meters in 30 seconds in the incident off the southern Shizuoka district on Sept 6, 2011.

The maneuver happened when the co-pilot, in trying to unlock the cockpit door for the captain who was returning from the toilet, mistook a command button for the cockpit door lock switch nearby.

A chronology included in the JTSB's report showed that the co-pilot only noticed something was wrong 17 seconds after the rudder was operated.

The plane, which took off from Naha in Okinawa in the south, later managed to touch down at Tokyo's Haneda airport safely.

Two crew members were slightly injured, while four passengers reported health problems following the incident.

Images from the flight recorder on the Boeing 737-700 showed the plane veered to the right and then sharply to the left, before dropping backwards.

The aircraft tipped more than 130 degrees to the left at one point, but the darkness outside meant many of those on board did not realize the craft had almost flipped over.

© Japan Today/AFP

©2020 GPlusMedia Inc.

41 Comments
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Sorry plane captains ... no more toilet breaks for you until the plane has landed safely. If the stewardesses can force the passengers to wait until the craft has landed (which has happened to me), they surely can do the same for the guys up front.

3 ( +5 / -2 )

Pretty big mistake, and could have been a lot more serious. Fortunately it was not -- now time to review the safety instructions.

5 ( +7 / -2 )

What? That just sounds insane. But before for i solidify my opinion on this let me ask has there ever been an accident like mistaking the cockpit door lock with a command switch?

6 ( +7 / -1 )

I remember the story. Because of the path that the plane took, the passengers where not even aware of the aerial acrobatics.

Personally, I think I piolt who mistakes the door lock with a flight control button should be fired and never be allowed to fly again. Sheesh!

3 ( +3 / -0 )

before dropping backwards

How does a plane drop backwards, unless it's stalled?

3 ( +3 / -0 )

Personally, I think I piolt who mistakes the door lock with a flight control button should be fired and never be allowed to fly again. Sheesh!

I have heard designers say that if a product is used incorrectly, it was designed incorrectly. Humans will make mistakes, and planes need to have the common mistakes like this engineered out of the equation.

10 ( +11 / -2 )

A commentator on another site noted something interesting: the two knobs, though different in size, are of the same shape and are also operated in the same manner (turning). The first officer was likely tired, inattentive, and acting on auto pilot, as it were. Still, he'll likely not fly again for quite a while.

A bit more info, including a photo of the control panel, is here: http://www.mlit.go.jp/jtsb/flash/JA16AN_110906-110928.pdf

2 ( +3 / -1 )

Nessie:

" How does a plane drop backwards, unless it's stalled? "

The wording is strange. The plane flew in a kind of parabolic curve. They showed a lot of computer illustrations at the time. I did not know that big passenger jets can even do that sort of thing, but apparently they can.

3 ( +3 / -0 )

It's amazing that only two on board were injured, flying for 17 seconds almost turning upside down. Lucky the plane didn't disintegrate in midair.

3 ( +3 / -0 )

all pilots should have a cup of HOT coffee ( or tea ) between the legs at all time..................that ought to alert them about the plane turning upside down.

1 ( +2 / -1 )

I'm shocked that this was made public and I want to know why it took ONE YEAR to inform us???

1 ( +3 / -2 )

You scared me JT. When I read the headline, I thought they did it again.

1 ( +1 / -0 )

movieguy:

" I'm shocked that this was made public and I want to know why it took ONE YEAR to inform us??? "

It didn´t take one year. It was widely reported when it happened.

2 ( +2 / -0 )

I think I'll try this on my flight simulator and see what happens...

3 ( +3 / -0 )

"All Nippon Airways (ANA) said Wednesday that it will equip all of its approximately 2,500 flight crew with an iPad, in addition to the already equipped cabin crew" -- cause of the incident -- apparently the cabin crew was busy reviewing safety instructions on ipads..

1 ( +1 / -0 )

I really doubt that the IPAD was the cause but I do hope these pilots do not start messing around with their Ipads if they are bored, etc..and really cause a horrible accident!

0 ( +0 / -0 )

Most planes are flown on auto-pilot besides take off and landing which can also be automated. Pilots these are a backup measure as are most subway and train drivers.

I have seen the rooms where the pilots and Cabin attendants sleep during a flight.

1 ( +1 / -0 )

Al Stewart

I can easily imagine this.

They fly all sorts of planes, and different size planes made by different makers, with different kinds/ amounts of engines and controls, will all be slightly different.

Like if you are from the US and come to Japan and drive a car, you will signal to turn by mistakenly turning on the windshield wipers b/c they are on opposite sides of the steering wheel than you are used to.

But in the air, and responsible for ppls lives, they should be ultra boy scouts about any move they make, and double check mentally that this is the button they want to touch. Like the JR guys doing their kakunin by pointing and verbally saying aloud what it is they are doing all the time.

2 ( +2 / -0 )

Heck even long-distance Bus drivers got a 2nd dr9iver and a rest-room.

Lowly they can only fly planes that they are certified for, takes months of training to get a new certification.

This is not hollyweird where anyone can pilot a jet or airliner.

1 ( +1 / -0 )

oberst said,

all pilots should have a cup of HOT coffee ( or tea ) between the legs at all time..................that ought to alert them about the plane turning upside down.

That wouldn't work in time to have prevented this. One of the reasons they didn't realize anything was wrong was that even though the plane was in an incorrect attitude, it was still pulling only 1G through the cockpit floor (I guess until about 17 seconds after the start of the maneuver). The coffee likely would have quietly sat in the cup for the 17 seconds the pilots were unaware of the problem. You can do complete barrel rolls (aka "barrel loops") in an aircraft and maintain a steady 1G through the floor of the plane the entire time. You'll lose a lot of altitude in the process, but it is possible to maintain 1G the entire time.

1 ( +1 / -0 )

viking68: "I have heard designers say that if a product is used incorrectly, it was designed incorrectly. Humans will make mistakes, and planes need to have the common mistakes like this engineered out of the equation."

Completely agree! My 2 year old daughter can operate an iPad because it is intuitive. You would think airplane engineers could make airplane controls intuitive enough that someone would not mistake "a command button for the cockpit door lock switch nearby.".

-2 ( +0 / -2 )

I dont know but me thinks they have to MOVE these particular controls! WTF!

-1 ( +0 / -1 )

Heck even long-distance Bus drivers got a 2nd dr9iver and a rest-room

Naha to Narita flights only take around 3 hours. There is no need for a "2nd driver", just a driver that knows what he or she is doing.

Thankfully there wasnt a crash.

0 ( +0 / -0 )

Yubaru, pilots are not bus drivers and what if one of the pilots gets sick or dies? During most flights things are well boring but in an emergency pilot workload is a factor.

-1 ( +0 / -1 )

Geeezzzzzz..... a co pilot mistook a command button for a cockpit door..... WOW and WOW again. I wonder how he became a co-pilot and issued a license but unfamiliar with the plane's control. Bad, bad, bad for ANA business.

0 ( +0 / -0 )

Picking the wrong knob is a big deal. There are hundreds of similar knobs inside every cockpit, so pilots are carefully trained.

As to nearly flipping over, every aircraft should be able to perform this maneuver safely. Here's link to a video http://elsmar.com/Forums/showthread.php?t=26299 of the Boeing Dash-80 (the predecessor to the Boeing 707) doing a barrel roll. I think that is the largest aircraft ever photographed doing a coordinated roll, but there was no way to know many years ago what an aircrew does over an ocean if there weren't any passengers on board and it wasn't reported. These days, monitoring of the aircraft and performance data is pulled constantly to ensure the most efficient use of fuel happens.

Doing it by accident would be odd and dangerous, but doing it on purpose doesn't stress the airframe any more than normal flight maneuvers.

1 ( +1 / -0 )

itsme- the pilots I know usually have more than one plane-type qualification.

Even if they do, they don't necessarily fly a different plane every day, sure. But if they were flying one different from what they're used to, it is just easy to imagine making an error like that.

But my point is, any kind of error is not that hard to imagine. Whethere it's that one or another. When you think you know something and have it down, is when you will make a mistake. Because you think it's ok so you don't check for "not ok". Always double check, even the simplest beginner level stuff.

0 ( +0 / -0 )

theFu, I have known an airline captain who claimed his DC9-30 was put on its back due to wake vortex of a DC-10 in front of him. Said he used elevator and opposite rudder and recovered. Lots of things happen in the skies and are never reported. He also said nobody in the back noticed and why would they? The captain has "flown west" so it is just in my memory and others now.

-1 ( +0 / -1 )

I enjoy my flights on ANA, but there have been a number of disturbing cockpit incidents reported over the years.

-2 ( +0 / -2 )

Times are so hard for airlines. All these fuel surcharges. ANA literally turned the plane over to get more money out of their pockets. Coins and money clips were never recovered after cleaning the plane.

-2 ( +0 / -2 )

" Ah so, Jesus take the wheel ! "

-1 ( +1 / -2 )

FYI, this video link is dead apparently:

As to nearly flipping over, every aircraft should be able to perform this maneuver safely. Here's link to a video http://elsmar.com/Forums/showthread.php?t=26299 of the Boeing Dash-80 (the predecessor to the Boeing 707) doing a barrel roll.

It's on Youtube however:

Boeing company 707 dash 80 completes a barrel roll during early flight testing to show the aircrafts abilities http://www.youtube.com/watch?v=2Bvhov0nxPQ

0 ( +0 / -0 )

Must be a slow news day, I've mentioned this incident several times when people were complaining about the V22. This stuff happens, and the main reason why auto-pilot is used practically 100% of the time now.

-1 ( +2 / -3 )

This stuff happens

Happens all the time to me. I'm often on flights where the aircraft is flying upside down. And the pilots don't notice.

-1 ( +0 / -1 )

One might wonder why an aircraft doesn't necessarily break up if it turns upside down, but basically there's no reason for it to do so.

(The question of how one flies a large airliner upside down would need an experienced pilot to describe).

However, structurally, the wings and their attachments to and across the aircraft fuselage have to take the load in both directions. Thus the wings flex upwards when flying, but when on the ground they flex downwards. And that's the same load configuration you get when flying upside down.

However, with that reassurance, I definitely don't relish the possibility of ever finding myself being flown upside down!

0 ( +0 / -0 )

Oops, sorry, my first post was not quite correct.

In the air, the wings are designed to support the weight of the fuselage, passengers, baggage, etc. The fuel is usually in the wings. On the ground, the wings only have to support their own weight plus engines and fuel. However, I believe that aircraft designers do design their wing structures to fly upside down, as a safety precaution. But - and this is what I forgot, it's only when flying upside down that the wings have to support the additional weight of the fuselage, etc.

0 ( +0 / -0 )

I've now watched the YouTube video - very impressive.

Of course I should be more careful: whether flying normally or upside down, the wings still have to support the fuselage, etc. It's the direction of wing flexing which changes.

When I was responsible for the fatigue testing of aircraft structures when I worked at Handley Page in the 1950s, one of the specimens was of the main spar boom attachment to the spar across the top of the fuselage of the Victor B atom bomber/air-to-air refueling tanker, as you will. The alternating loading on the fatigue test component took into consideration the fact of the wing taking the load in both directions.

0 ( +0 / -0 )

mike23thurgoodSep. 02, 2012 - 01:05AM JST

Of course I should be more careful: whether flying normally or upside down, the wings still have to support the fuselage, etc. It's the direction of wing flexing which changes

Well, I know you wanted to dumb it down a bit, but could have probably gone into the part where air turbulence forces produce sudden forces far greater, or the fact that the airplane was in a low G spiral and therefore never in negative loading even if it was upside-down. Basically reassure them that the plane never even had larger negative stress than normal operation or higher positive stress.

Seen some footage of the 787/777, but sadly nothing on the 737. Perhaps you have some better contacts for those older models. 787 though has some ridiculous loading capabilities, 150% design load before failure for a design load that is already far greater than anything you would see even in the youtubed 737 spiral above. 737 is probably a bit weaker but still probably stronger than people assume from the movies.

-2 ( +1 / -3 )

Never mind that airplane wings are designed to lift, turn them upside down and you reverse the forces.

Learned as much from R/C planes we as a school project.

0 ( +0 / -0 )

It"S MESep. 02, 2012 - 05:56PM JST

Never mind that airplane wings are designed to lift, turn them upside down and you reverse the forces.

Learned as much from R/C planes we as a school project.

We should have a nice, long talk with your teachers then. That's like saying that driving a race car to the left is the same as just flipping the track upside-down and turning right. The biggest forces involved are lift and gravity, but that doesn't mean that the sum of the forces is always perpendicular to the wings. Also necessary for calculations though is inertia, as in a spiral the inertial forces are quite large compared to normal flying. It's the same as why you don't fall out of your seat in a rollercoaster (aside from safety bars) and why it does nothing normally.

-2 ( +1 / -3 )

Basroil.

No need to talk, a plane has only a limited to perform a roll.

Or you can provide video evidence of a plane upside down for more than a few seconds. Standard physics taught in school.

0 ( +0 / -0 )

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