Air Busan B734 at Fukuoka on Dec 26th 2010, runway incursion
Last Update: August 31, 2012 / 20:27:43 GMT/Zulu time
Incident Facts
Date of incident
Dec 26, 2010
Classification
Incident
Cause
Runway incursion
Airline
Air Busan
Aircraft Type
Boeing 737-400
ICAO Type Designator
B734
The departing aircraft had been instructed to taxi to the holding point of the departure runway, however mistook the instruction as clearance to line up. The tower controller did not check the contents of the readback leading to the situation that the aircraft moved to line up while another aircraft was on short final cleared to land on the same runway.
The mistake to believe the aircraft was cleared to line up was probably caused by one or the combination of following factors:
1) the query for an intersection departure
2) just prior to the "hold short" instruction tower had queried for the aircraft being ready and was told the aircraft was ready
3) the crew believed they would depart before the arriving traffic
4) an incorrect phrase in the hold short instruction that included the taxi route
The JTSB reported that the Air Busan 737 was already taxiing when ground control queried whether they would accept an intersection departure from taxiway W8, which the crew accepted. About 3 minutes later ground instructed: "ABL141, taxi to W8, contact Tower, 118.4" with the crew reading back "Taxi via W8, contact Tower, 118.4, ABL141"
Upon reporting on tower frequency the crew initially used flight number 142, tower queried and the crew corrected their callsign to flight 141. As an immediate response to the correction tower queried "ABL141, Fukuoka Tower, report when ready", received an instant reply "ABL141, ready" and within a second followed up "Roger, hold short of runway 34 via W8" and received the readback "Runway 34 via W8, ABL141", the aircraft subsequently moved past the hold short line W8. 50 seconds after the readback tower recognized the aircraft had moved past the hold short line and instructed "JAL3530, go around, go around due to traffic".
Subsequently ABL141 queried "ABL141, confirm cleared for take off?", tower responded "ABL141, negative, I said you hold short of runway 34 via W8 due to inbound traffic". ABL141 then apologized stating: "I'm sorry, I heard line up".
The JTSB reported that upon crossing the hold short line the arriving JAL 737 was 1.2nm from the runway threshold at 350 feet AGL, at the go-around instruction the JAL 737 was 1.0nm from the runway threshold at 300 feet AGL, the distance between the aircraft was 1.3nm.
Both flight crew of the Air Busan 737 stated in post flight interviews they never heard the words "hold short", but heard "runway 34 via W8" just as their readback was and thus believed they were cleared to line up runway 34.
The tower controller said he did not expect a misunderstanding and was already thinking about the next departures, then provided updated wind information to the arriving aircraft while overlooking the runway. He said in his interview all the controllers at Fukuoka would use the "hold short of runway .. via .." phraseology.
The JTSB analysed that the standard phraseology to instruct an aircraft to stop before a holding point of a runway, by ICAO, FAA or Japanese standards, is: "Hold short of runway .." without any addition. The JTSB added that the word "via" is to be used only in taxi instructions "Taxi ... via ..."
The JTSB concluded their analysis that if the first few words of "hold short of runway 34 via W8" were missed by the crew, they would hear "runway 34 via W8" and therefore assume a "taxi runway 34 via W8" or "line up runway 34 via W8".
The JTSB further analysed that the term "hold short of" MUST be read back upon receiving any such instruction, and the controller MUST verify the correct read back of "hold short", e.g. "hold short of runway 34" being read back "holding short of runway 34". The controller must not assume that a hold short instruction has been received and understood if the readback does not include that term.
Incident Facts
Date of incident
Dec 26, 2010
Classification
Incident
Cause
Runway incursion
Airline
Air Busan
Aircraft Type
Boeing 737-400
ICAO Type Designator
B734
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Related articles
Engineering the future: The intersection of technology and aviation education
Can you imagine a world without technology? What would have started as something that made life easier has grown to become something we can't live…
Behind the Scenes: Insights into Aircraft Ground Support Equipment
Have you ever wondered what happens when you disembark a plane? The roar of jet engines fades, the plane gracefully maneuvers to a stop, and the…
How to Write Admission Essays for Flight School
Pursuing a career in aviation is a path that demands dedication, perseverance, and an unwavering passion for defying gravity. As you embark on this…
AeroInside Monthly Aviation Safety Review March 2024
March 2024 was a busy month in aviation safety. Please find our summary below.All in all, 94 new articles have been published during last month. 13…
How Private Jet Travel Can Enhance Educational Opportunities
In today's interconnected and rapidly changing world, the landscape of education continues to evolve at an unprecedented pace. As the global village…
Newest articles
ANA B738 at Yonago on Apr 7th 2024, GPWS saves the day
An ANA All Nippon Airways Boeing 737-800, registration JA69AN performing flight NH-389 from Tokyo Haneda to Yonago (Japan), was on a circling…
ANA B788 at Sapporo on Apr 24th 2024, hydraulic leak after landing
An ANA All Nippon Airways Boeing 787-8, registration JA804A performing flight NH-71 from Tokyo Haneda to Sapporo Chitose (Japan) with 213 people on…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways