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All Nippon Airways Flight 140

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All Nippon Airways Flight 140
JA16AN, the aircraft involved, photographed in 2013
Incident
Date6 September 2011 (2011-09-06)
SummaryIn-flight upset due to pilot error
Site
Aircraft
Aircraft typeBoeing 737-781
OperatorAll Nippon Airways
IATA flight No.NH140
ICAO flight No.ANA140
Call signALL NIPPON 140
RegistrationJA16AN
Flight originNaha Airport, Naha, Okinawa Prefecture, Japan
DestinationHaneda Airport, Ōta, Tokyo, Japan
Occupants117
Passengers112
Crew5
Fatalities0
Injuries2
Survivors117

All Nippon Airways Flight 140 was a scheduled domestic passenger flight en route from Naha Airport to Haneda Airport. On 6 September 2011, the plane experienced an in-flight upset over the coast of Kushimoto, Wakayama Prefecture, inverting upside down and diving steeply. Two of the 117 on board were injured, but there were no fatalities.[1][2][3][4]

Background

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Aircraft

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The aircraft involved was a Boeing 737-781, manufactured on January 11, 2008 and registered as JA16AN. It was powered with two CFMI CFM56-7B engines. Before the incident, it had a total flight hours of 7,968 hours.[5][6]

Crew

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The captain was a 64-year-old man. He had 16,518 flight hours, 64 of which on the Boeing 737.[5]

The co-pilot was a 38-year-old man. He had 2,930 flight hours, 197 of which on the Boeing 737. He previously had flown on the Boeing 737-500 from January 24, 2007 to May 8, 2011 and just switched to the Boeing 737-700 on June 10, 2011.[5]

In that flight, the captain was the pilot flying and the co-pilot was the pilot monitoring.[5]

Incident

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At 21:15, Flight 140 took off from Naha Airport and was cruising at an altitude of 41,000 feet (12,500 meters). At 22:46:42, the captain left the cockpit to use the restroom. At 22:48:04, air traffic control instructed the aircraft to change course and the co-pilot performed the operation. During that, the captain returned from the restroom and signaled to re-enter the cockpit.[5] The co-pilot accidentally turned the rudder trim switch instead of the door-lock selector, which caused the plane to bank to the left, reaching a maximum left bank of 131.7° degrees.[7] The aircraft then entered a steep dive, plunging down 6,000 feet, reaching 2.68 G's. The co-pilot was able to regain control of the aircraft at 35,000 feet (10,700 meters). The captain returned to the cockpit and took over the controls. The crew requested to maintain 36,000 feet.[5] At around 23:30, the crew landed at Haneda Airport without further incident.[8] Two cabin crew members sustained minor injuries: one with a sprained neck and one with scratches;[4] and were transported to a local hospital.[9] There were no fatalities among the 117 passengers and crew as the passengers were all wearing seatbelts.[1][10]

In an interview after the incident, the captain said that he was unable to stand during the rapid descent and that he heard an alarm sound from the cockpit.[10] Many passengers did not realize that the aircraft had experienced an upset due to flying at night with no visual references out the window.[11]

Investigation

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The Japan Transport Safety Board (JTSB) conducted the investigation. The cockpit voice recorder (CVR) had been overwritten due to its 30-minute recording time limit and thus no data could be recovered from it.[5]

Similarities between two switches

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Location of door-lock selector and rudder trim switch on the B737-700

Analysis of the data revealed that the upset was caused by the co-pilot mistaking the door-lock selector for the rudder trim switch as the captain requested access back into the flight deck. The two switches differed in shape and size, but were similar in their operation and the angle of rotation.[12]

The placement of the door-lock selector and rudder trim switch on the B737-500 and B737-700.

Manufacturers placed the switches on the assumption that "the Boeing 737-500 shall be retired in the future" and "pilots shall not be on duty aboard both type aircraft in the same period of time." As a result, considering the constraints of available space on the panel and the differences in pilots' physiques, in which it is thought the commonality of the two types may cause adverse feelings, they decided to place the rudder trim switch as far as possible.[5][12]

Training

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Although the co-pilot had completed training to differentiate between the Boeing 737-500 and the Boeing 737-700, the similarities between the two switches were not taught in-depth by the instructor during his training sessions. This lack of training on different cockpit switches may have caused the co-pilot to become unfamiliar with the switches found on different aircraft. As well, the simulator training sessions only involved recovering from inflight upsets below 10,000 feet (3,000 meters) and the activation of stall warnings was not anticipated.[5] Furthermore, no training had been conducted to simulate an aircraft emergency with only one crew member present in the cockpit.[5]

Report

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On September 25, 2014, the JTSB issued the final report stating the cause of the incident.[13]

The report attributed the incident to the co-pilot mistaking the door-lock selector for the rudder trim switch. The action prevented the autopilot from maintaining the aircraft's altitude causing the aircraft to bank and dive sharply. It was also found that the similar design of the two switches may have confused the co-pilot. The inappropriate action was presume to have occurred because the stick shaker unexpectedly activated during the recovery maneuvers, which made the co-pilot to be surprised and confused.[5][9] The co-pilot had not been trained to handle situations where the stick shaker would activate at high altitudes.[7]

The report revealed that the stick shaker had activated multiple times (in contradiction to the simulator training that the pilot trained on, which had no stick shaker or stall warning activation).[14]

Safety recommendations

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The JTSB issued several safety recommendations as a result of the incident:

  1. improve inflight upset recovery training practices to flight crews
  2. airlines be required to conduct inflight upset recovery training from various altitudes
  3. improve the design and placement of cockpit switches and dials.[5][7][13]

Specifically, the JTSB issued safety recommendations to airlines, the Ministry of Land, Infrastructure, Transport and Tourism, and the Federal Aviation Administration (FAA). The recommendations called on All Nippon Airways and the Ministry of Land, Infrastructure, Transport and Tourism to improve their training and recovery procedures. The recommendations suggested that airlines be required to conduct recovery training from abnormal attitudes. The JTSB also issued a safety recommendation to the FAA, calling on it to instruct Boeing to consider improving the similarity of its switches.

Reaction

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On September 28, 2011, All Nippon Airways (ANA) help a conference to apologize.[15] The company has offered refunds for tickets following the incident.[16] An ANA official said: "The figures are unbelievable, even in a case that requires such an urgent maneuver to avert a risk."[17]

Experts said that "It's usually impossible for a passenger airplane to fly in such a position" and that "it could have led to a serious accident."[17]

See also

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References

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  1. 1 2 全日空機、一時ほぼ背面飛行 機首最大35度下向き [ANA flight briefly flies almost upside down; nose pitched down up to 35 degrees.]. Nikkei (in Japanese). 2011-09-28. Retrieved 2026-06-02.
  2. ↑ "Cockpit error sent 737 into Pacific nose dive". CBS News. 2011-09-29. Retrieved 2026-06-02.
  3. ↑ "9月6日のANA140便が重大インシデント-急降下で乗務員2名が軽傷" [Serious incident involving ANA Flight 140 on September 6: Two crew members suffered minor injuries during a rapid descent.]. flyteam.jp (in Japanese). Retrieved 2026-06-02.
  4. 1 2 "ANA Flight Went into Steep Dive Due to Co-Pilot Error". GOLDSEA | Asian American Daily. Retrieved 2026-08-02.
  5. 1 2 3 4 5 6 7 8 9 10 11 12 "航空重大インシデント調査報告書" [Investigation Report on a Serious Aviation Incident] (PDF). Japan Transport Safety Board (in Japanese). 2014-09-25. Retrieved 2026-08-05.
  6. ↑ Ranter, Harro. "Serious incident Boeing 737-781 (WL) JA16AN, Tuesday 6 September 2011". www.aviation-safety.net. Retrieved 2026-08-05.
  7. 1 2 3 Yoshikawa, Tadayuki (2011-09-03). 全日空系機の背面飛行、ラダー誤操作と姿勢回復不十分 [Inverted flight of ANA-affiliated aircraft: rudder misoperation and insufficient attitude recovery.]. Aviation Wire (in Japanese). Retrieved 2026-06-02.
  8. ↑ 全日空機が急降下、副操縦士の誤操作原因 乗員2人けが [All Nippon Airways plane plummets after co-pilot error; two crew members injured.]. Nikkei (in Japanese). 2011-09-07. Retrieved 2026-06-02.
  9. 1 2 Hradecky, Simon (2012-09-01). "Accident: ANA B737 near Hamamatsu on Sep 6th 2011, violent left roll while opening cockpit door injures 2 cabin crew". The Aviation Herald. Retrieved 2026-06-02.
  10. 1 2 "【衝撃事件の核心】"恐怖のミス"「ドア開閉」「方向舵」スイッチ間違え急降下・背面飛行の衝撃…ＡＮＡ機「空中分解の恐れも」" [[The Heart of a Shocking Incident] A "Terrifying Blunder": Confusing Switches for Door Operation and the Rudder Leads to a Plunge and Inverted Flight—ANA Jet Faced Risk of "Mid-Air Breakup"]. Sankei Shimbun (in Japanese). 2014-10-17. Archived from the original on 2020-07-03. Retrieved 2026-06-02.
  11. ↑ "全日空機がほぼ背面飛行、原因はスイッチの押し間違い" [ANA plane nearly flies upside down; cause was accidental switch activation.]. www.afpbb.com (in Japanese). 2011-09-29. Retrieved 2026-06-02.
  12. 1 2 "Air Nippon (now ANA) – Boeing – B737-700 (JA-16AN) flight NH140". Aviation accidents. 2011-09-06. Retrieved 2020-07-01.
  13. 1 2 11年の全日空機背面飛行、誤操作などが原因 運輸安全委 [JTSB: 2011 ANA Inverted Flight Caused by Pilot Error]. Nikkei (in Japanese). 2014-09-25. Retrieved 2026-06-02.
  14. ↑ Pasztor, Andy (2014-10-06). "2011年のANA機急降下、当初の認識以上に危険だった" [2011 ANA plane nosedive was more dangerous than initially realized.]. WSJ Japan (in Japanese). Retrieved 2020-10-01.
  15. ↑ "全日空機がほぼ背面飛行、原因はスイッチの押し間違い" [ANA plane nearly flies upside down; cause was accidental switch activation.]. www.afpbb.com (in Japanese). 2011-09-29. Retrieved 2026-08-05.
  16. ↑ "Special Waiver policy for ANA Flight Award Tickets due to the serious incident of NH 140 on September 6, 2011". www.ana.co.jp. 2011-10-05. Archived from the original on 2020-06-21. Retrieved 2026-08-05.
  17. 1 2 "Japan's ANA: Co-pilot error sent 737 into nose-dive". The Yomiuri Shimbun. 2011-09-28. Retrieved 2026-08-05 – via The Seattle Times.
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