Inadequate interactions between elements of SHEL in JAL516 collision with JA722A – lack of Safety-II approach in safety management

Based on the identified facts, inferences, and doubts about the collision between JAL516 and JA722A on January 2, 2024, this study attempted to explore why the miscommunication between air traffic control (ATC) and JA722A was not compensated by other actors (ATC and JAL516) from the perspective of the inadequacy of interactions between related actors (JA722A, JAL516, and ATC) and each element (Software, Hardware, Environment, and Liveware) of the SHEL model. We also demonstrated that safety management at Haneda Airport was apparently lacking in Safety-II and pre-mortem approaches. Based on such an approach to the interaction analysis of the collision, the progress report of the Japan Transport Safety Board, and the interim report of the CPAC (Committee for Proposing Accident Countermeasures), we discuss why the collision occurred (why the misunderstanding of JA722A was not corrected by ATC and JAL516) and how similar collisions should be avoided during landing and takeoff.